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An Unthinkable Crime
Neglect and physical or sexual abuse of the elderly are crimes that are often times hidden
from the public. None of us want to believe it happens, and yet it does, every single day, countless times a day. Despite federal and state regulations intended to protect these vulnerable citizens, and regardless of the best
efforts of dedicated care providers and advocates, neglect and abuse in long-term care facilities remain widespread. Unfortunately, South Dakota is not immune from these problems.
The number one reason neglect and abuse persist in our long-term care facilities is a
chronic lack of enough well-trained and well-supervised direct care staff. The vast majority of daily care in nursing homes is given by nurse aides who struggle to do their jobs with little training, low pay, few benefits, minimal
professional supervision, and limited resources.
According to the 2006 South Dakota Health Professional Workforce Report, the turnover rate for certified nursing assistants in nursing facilities in South Dakota was 45.3% overall. That turnover rate is higher in our urban areas (population over 50,000) and according to the same report in 2005 reached 61.1%. There are individual nursing homes in South Dakota where the turnover rate exceeds 100% in a year. It is a sad commentary that the very same people who are charged with chiefly providing basic care to nursing home residents can and often do make more money working at fast food restaurants.
Repeated lack of basic care or failure to provide enough competent, well-screened
employees can transform neglect into abuse. Neglect becomes abuse when residents who cannot move independently are not repositioned often enough, causing painful pressure sores to form.
If they are not immediately detected and treated with proper diet, medications, and pressure relieving devices, they multiply and deepen until the tendon or bone is exposed. Malnutrition and dehydration occur because the residents are not assisted with eating, or their food is not properly prepared so that they can eat it (for instance, a resident with no teeth is given a whole pork chop to eat) or they are not provided with liquids on a regular basis. Poor nutrition contributes to the worsening of pressure sores.
When residents with dementia are poorly supervised and wander from the facility through
unlocked doors, they may fall and break bones or die from exposure. When sexual predators are allowed to enter facilities through those same unlocked doors at all hours of the day and night to prey upon helpless residents, neglect
becomes abuse. Neglect becomes abuse when facilities hire workers without doing criminal background checks and residents are physically or sexually abused.
The long term care industry has repeatedly blamed the government, stating that low
reimbursement rates under Medicare and Medicaid are to blame for their inability to provide adequate staffing. The majority of nursing home care in South Dakota is paid for by the state's Medicaid program.
In 2003 the United States General Accounting Office issued a report to Congress on Medicaid nursing home payments. They reviewed 19 states, including South Dakota. They found that all the states they reviewed base payment rates on nursing homes' actual costs and develop rates specific to each home. These states also update payment rates regularly to reflect changes in nursing homes' costs due to factors such as inflation or residents' changing care needs. Although each of the 19 states reviewed experienced recent fiscal pressure, their nursing home payment rates remained largely unaffected. In over 3/4 of the states nursing home per day payment rates grew, on average, by an amount that exceeded the changes in the price of nursing home goods and services.
The fact is that many facilities don't put that money into staffing, choosing instead to
use it to finance takeovers and boost profit margins.
This is especially true of the for-profit long term care facilities and chains. For instance, only a few months ago the Carlyle Group acquired nursing home chain HCR Manor Care, which does business in South Dakota as well as many other states, for $6.3 billion. Manor Care's CEO made approximately $186 million from the deal, and sixteen other executives received an additional $68 million. In March of 2006, Golden Gate National Senior Care Holdings acquired the former Beverly Enterprises, which also operates in South Dakota, for $2.29 billion. These transactions would seem to suggest that providing long term care is hardly a struggling industry.
Here are some steps you can take when considering long term care for parents or other
loved ones to help guard against neglect and abuse. The internet is a good place to start your research. Here are some helpful websites:
- www.medicare.gov/NHCompare/ --The U.S. Department of Health and Human Services Nursing Home Compare website allows you to search for nursing homes by name, or within a specific geographical area. It provides basic information on the nursing homes, such as type of ownership, number of residents, etc., but it also provides information gathered by state inspectors during annual inspections and from resident records regarding such things as the number of residents who developed pressure ulcers, the percentage of residents who are physically restrained, and the percentage of residents who experience a deterioration in certain quality of life indicators.
- www.cms.hhs.gov/CertificationandComplianc/12_NHs.asp – From this page, which is part of the Centers for Medicaid and Medicare Services (CMS) website, you can download the list of facilities which have been identified by CMS as "special focus facilities." Those facilities have had a history of serious quality issues.
- www.MemberoftheFamily.Net – This website
provides information about 16,000 Medicare/Medicaid-certified nursing homes in the United States, including easy-to-understand reports based on recent government surveys. They also compile a of homes recently cited for violations or that have had substantiated complaints made against them. Additionally they maintain an of facilities found to be deficiency-free.
- www.nccnhr.org –T his is the website of the National Citizens Coalition for Nursing Home Reform, which is a grassroots organization made up of advocates of quality long term care nationwide. Their website contains a wealth of information about what to look for in quality long term care.
- www.aperfectcause.org – This website is devoted chiefly to educating the public regarding the dangers of sexual predators in our nation's nursing homes. There is a search tool on the website which will identify whether there are registered sex offenders living and/or working in particular facilities. Unfortunately, South Dakota is one of the few states which has not allowed access to this information.
After you have done your initial research to identify facilities you're
interested in, there is absolutely no substitute for visiting the facility in person. These visits ideally should be done over a several day period, at all different times of the day and evening. During those visits you should
observe such things as:
- Resident appearance:
- Are residents up and dressed for breakfast?
- Are residents well-groomed (shaved, clothes clean, hair combed, nails trimmed and clean)?
- Do residents appear alert, content and occupied, or are they lethargic, listless or dazed?
- Are residents comfortably positioned in comfortable chairs? Are they restrained in their chairs or beds?
Are they in chairs that have a tray or "lap buddy"?
- Staff:
- Is there adequate staff? What is the staff-to-resident ratio? Are resident requests responded to in a timely manner (5 minutes or so)?
- How does the staff address the residents? Are they courteous to the residents, treat them with dignity and respect, or is the attitude
condescending? Are childish or otherwise inappropriate nicknames used when speaking with residents?
- Do the administrator/manager and director of nurses appear to know residents' names and personalities?
- Are there therapists on staff or does the facility contract out for therapy?
- Is there a licensed social worker on staff? Full time?
- Does the facility have permanent fulltime nurses and CNAs, or are contract or registry nurses and aides used? Is there a full-time RN in the nursing
home at all times, other than the Administrator or Director of Nursing?
- Does the same team of nurses and CNAs work with the same resident 4 to 5 days per week?
- Facility environment:
- Is there an obvious odor in the facility? Urine and body odors may indicate poor nursing care or poor housekeeping.
Heavy air freshener, deodorants and other temporary chemical cover-ups may be substitutes for care and maintenance.
- Is the facility clean, well-lit and free of hazards? Do you see soiled linen?
- Are floors clean and non-slippery?
- Are entrance and exit doors locked and/or is there a facility staff person monitoring who enters and leaves the facility?
- How many lounge areas are available for residents and visitors? Are they clean and comfortably furnished?
- Resident rooms:
- How many residents share a room? Are there privacy curtains around each bed?
- Is there a bedside stand, reading light, chest of drawers, and at least one comfortable chair for each resident?
Is there adequate storage space, separate from other roommates?
- Are call buttons accessible to residents?
- Is there fresh drinking water at the bedside?
- Are residents allowed and encouraged to bring their own belongings or furniture? Have residents personalized their rooms?
- Bath and shower rooms:
- How many residents share a bathroom?
- Do bathrooms have handgrips or rails near all toilets and bathing areas?
- Are bathrooms conveniently located?
- Kitchen and dining areas:
- Is the kitchen clean and well-organized?
- Is the dining area pleasant, clean and comfortable?
- Does it appear that residents who need extra encouragement or assistance in eating are receiving it? Are they given adequate time to consume their meals?
- Buy a meal and sample the food. Is it served at appropriate temperatures? Does the food appear and smell appetizing? Is it nutritious?
Are fresh foods used? Do residents appear to enjoy their food?
- A menu for the current and following week should be posted. If it is not, ask to see one.
Is the meal listed on the menu actually the food being served? How often are meals repeated?
- Is a professional dietician on staff?
- Are dishes and silverware used, or are disposable plates and utensils used?
- Activities:
- Are activity calendars posted? If not, ask for a description of the activity program. Meet or arrange to meet the Activity Director.
- Do activities cover a broad range of interests?
- Do volunteers visit the facility?
- What arrangements are made for residents to participate in religious services of their choice?
- What is done for holidays and birthdays?
- Is there a resident council or family council?
When does it meet, and what is its function? If there is a family council, arrange to attend a meeting and talk with other family members.
- Miscellaneous:
- How long has the facility been operating under the present management? Are there any plans to change in the near future?
- How often do residents' physicians visit the facility? It should be at least once every 30 days.
- How will the facility notify the resident and family members of the time and place of required quarterly care planning meetings?
- Is the Ombudsman Program's phone number posted, as required?
- Are the results from the last inspection by the Department of Health posted, as required by law?
- Is there a system to protect wanderers? Is it operational? Ask for a demonstration.
- Are copies of the Resident's Bill of Rights available?
- Will you and/or the resident be asked to sign an arbitration agreement upon being admitted to the facility which in effect signs away the resident's right to
address any complaints in a court of law with regard to deficient care, abuse, or any other matter.
The decision to move a loved one into a nursing home is almost always an
extremely difficult one.
When we make that decision for our grandparents, our parents, our spouses, we do so because we want them to be in a safe environment where they can receive care we are not able to provide for them ourselves. When some in the long term care industry choose to place their profits above the lives and safety of our loved ones by not providing the services that are needed, it is a betrayal of our trust. It dishonors and disrespects the people who are dearest to us, and robs them and us of what should be happy memories of those precious last years of their lives.
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(Greg Eiesland is an attorney with the Rapid City firm of Johnson
Eiesland Law Offices, P.C. Eiesland's practice includes the representation of victims of nursing home neglect and abuse.
Dennyce Korb is a certified paralegal working with Eiesland. Both are active members of the Nursing Home Litigation Group of the American Association for Justice.)
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