FRAIL ELDERLY AT MERCY OF SYSTEM
Lack of affordable choices, low staffing lead complaints
By Jim DeBrosse and David Gulliver
Dayton Daily News (OH) - Sunday, December 5, 1999
(C) 1999 DAYTON DAILY NEWS
When 80-year-old Grace Blankenship could no longer live on her own, her family found a good alternative: the assisted living wing at Wood Glen Nursing Center in Miami Twp.
There, she could move about as she pleased, decorate her room with her own furnishings, bathe herself, eat meals when she felt like it and find fellow residents who could talk about one of her passions: the Cincinnati Reds.
Then her money ran out.
Blankenship was transferred to Wood Glen's nursing home unit for severely demented and often combative patients - a place she insisted she didn't belong, but one where the state would pay her bills. Within six months, a male resident attacked her in her room, threw her against a wall and broke at least three of her ribs.
Blankenship was put on painkillers. Two weeks later, on the evening of July 4, 1993, she began vomiting and lapsed into shock from severe dehydration. Not until after 6 a.m. the next morning - eight hours later - did the home notify her family and physician.
She died, at age 81, at 6:40 a.m. July 5, 1993.
"If she'd had enough money, she could have stayed in assisted living, and she would still be alive today," said her son, Victor Blankenship of West Carrollton.
Grace Blankenship died because Ohio's $2 billion publicly funded system of caring for the elderly is itself seriously ill.
An eight-month Dayton Daily News examination found the state's frailest citizens are at the mercy of a system that gives companies few incentives to maintain quality homes and limits choices primarily to those who can afford them.
The Daily News analyzed more than 100,000 Ohio Department of Health records on complaints, inspections and enforcement actions over a five-year period, examined regulatory systems in three states and conducted more than 200 interviews with government officials, industry representatives, consumer advocates, caregivers and patients and their families. Among the findings:
* Those without means have few choices in Ohio's system of elder care. Of every Medicaid dollar Ohio spends on care for the aged, nursing homes receive 92 cents, leaving most alternatives to those with healthy pensions or bank accounts.
* Nursing homes that neglect or abuse patients face few penalties, even if they violate standards repeatedly. Four of five homes the state targeted for enforcement since 1994 escaped fines, and the typical fine was less than what many homes receive in state Medicaid payments in a single day. Fifty-six homes avoided any fines despite facing proposed penalties three or more times in a five-year span.
* The nursing home industry is increasingly dominated by for-profit companies that typically have more health and safety violations and fewer staff members per resident than non-profits.
The most recent Ohio Department of Health data available show that for-profit homes in 1995 and 1996 averaged more than twice as many serious violations than non-profits, and they made up a disproportionate number of the state's worst-performing nursing homes .
* The state has eased enforcement of health and safety standards even as the number of facilities and programs grow to meet the booming demand for elderly services. The number of inspectors who monitor Ohio's facilities for the aged has dropped by a third since 1995, and overworked inspectors are writing fewer citations. Last year, Ohio long-term care facilities averaged 6.6 citations per inspection, down from 10.2 in 1994. State officials acknowledge that short-staffing has meant less vigilant surveillance.
* Despite the growth of assisted living and other alternatives to nursing homes , state regulators have little control over the quality of care in those programs. Ohio is one of 11 states that won't pay for assisted living facilities - apartments where residents can arrange the services they need - and it is one of nine states that doesn't license home health agencies. State regulators can threaten to shut down an assisted living facility by pulling its license; they can't impose fines or deny new admissions.
* Staffing problems have reached epidemic levels in the elder care industry. Nursing home aides make an average of $8 per hour, and the work can be back-breaking and stressful. A major Dayton-area nursing home operator said qualified help is so hard to find his company is starting a program to import workers from Jamaica. A recent ad in the Dayton Daily News listed these qualifications for a home health aide: Basic First Aid, a current cardiopulmonary resuscitation card (obtainable following a four-hour course through the Red Cross), negative tuberculosis test and reliable transportation.
"We're paying teen-agers more to flip burgers than we are to care for our elderly," said Robert Applebaum, associate director of the Scripps Gerontology Center at Miami University in Oxford. "That raises some very serious questions about our societal values."
The system of caring for the aged couldn't be failing at a worse time. Seniors 65 and older will soon become the fastest-growing age group in Ohio, doubling in size by 2030. And the frailest and most vulnerable among them - those 85 and older - will quadruple in that time.
Half of all baby boomers eventually will spend time in a nursing home , sociologists predict. If the system can't handle the existing elderly population now, what will happen when hundreds of thousands more need services? Who will take care of them?
"We are really at a crossroads when it comes to dealing with the elderly, particularly when you look at the baby boomers," Applebaum said. "We have about 10 years to figure it out."
Nursing home industry representatives and the state officials who regulate the industry defended the quality of care, insisting there is plenty of punishment in Ohio's enforcement system.
Some even said the system focuses too much on penalties and that regulators should work together with homes to improve quality.
Tougher enforcement hurts nursing home quality by making the homes look bad, and thus making it harder to recruit and retain good employees, said Peter Van Runkle, spokesman for Ohio Health Care Association, the state's largest nursing home trade group representing some 760 institutions.
"What do you expect people to think that are looking for prospective employment in this industry if all they hear is the negative?" he said.
Nursing homes get an undeserved bad rap, said Catherine Hawes, a nationally respected researcher at the Menorah Park Center on Aging near Cleveland. The attention focused on badhomes has led to a near-phobia toward all nursing homes , she said, resulting in low expectations that stifle further reform.
"People have unreasonably negative views of nursing homes ," she said.
"They don't realize that, one, there are some really good nursing homes and, two, you can demand that any nursing home you're in respect your dignity, your privacy and your choices."
Nursing homes also have had to cope with cuts in Medicare, an average of $50 less per day from the federal program that pays for short-term acute health care.
Those cuts come at a time when homes are caring for sicker patients discharged earlier from hospitals while also struggling to attract workers and residents against increasing competition, said Ohio Health Care Association President William B. Levering.
"Never before has the business been faced with all of these factors at the same time, and that has put tremendous pressures on operations today," he said.
`CRUISE SHIPS WITH NURSES'
Many states, including Ohio, offer a rapidly expanding list of choices for the elderly, allowing them to live at home or in home -like comfort and freedom until they require around-the-clock care.
But the choices are much more limited for those who need both personal care and financial assistance. Their choices are basically two: spend themselves deep into poverty and hope they are selected for subsidized in- home care, or enter a nursing home , where Medicaid will pay the bills.
Unlike many states, Ohio devotes little state funding beyond Medicaid for the elderly. In 1996, Ohio spent about $8 per elderly resident on home and community-based services for those over 65. Illinois that same year spent more than $80 per resident, while Pennsylvania spent $57.
"I'm very frustrated," said Julie Griffie, a Germantown resident who recently placed her 86-year-old mother in a nursing home . "I would much prefer, and I know my mother would much prefer, some kind of assisted living situation, or somebody to come in to her own home . But they cost more than we can afford."
Assisted living is the Cadillac of long-term care in Ohio. Targeting the swelling ranks of the affluent elderly and their families, the glitzy centers aren't equipped to care for the sickest among the elderly, but they can make life very comfortable for those who still have a measure of independence.
Assisted living facilities can feature lobbies with grand staircases and chandeliers, sitting rooms with fireplaces and libraries and private dining rooms with linens and table service. They generally provide residents with their own apartments, furnished in their own way, with private baths and kitchenettes. They can sport in-house clinics, beauty salons, ice cream parlors, drugstores, even banks.
Most offer free transportation and activities nearly around the clock. In some cases, residents can pay extra for their own private duty nurse or therapist, so they can "age in place" without going to a nursing home .
"Cruise ships with nurses," one industry observer calls them.
But like cruise ships, they aren't available to everybody. Assisted living costs anywhere from $2,500 to $4,000 a month, and government programs in Ohio won't cover any of it. That puts assisted living out of reach for most Ohioans. About 36 percent of those 75 and older are either poor or "near poor," according to the Ohio Department of Aging.
Assisted living facilities also are virtually unregulated. Anyone can pay to enter an assisted living center without first undergoing an independent assessment to determine if the facility can properly care for them. The state also lacks licensing standards and staffing requirements specific to assisted living.
"Anyone can hang a shingle outside and call themselves an assisted living facility," said Lisa Heermans, who heads the long-term-care ombudsman office for the Miami Valley.
Lack of state guidelines didn't help Mildred Barrett in 1996.
Barrett, then 94, fell from a second floor window of The Laurelwood, an assisted living facility in West Carrollton, after wiggling her small frame through a gap between the screen and the window frame. She had tried to leave the facility at least five other times in the month before her fall, explaining she had "to get to the highway." Four days before her death, she rammed and bent out another screen with her head, according to a state inspector's report following her death.
The report cited The Laurelwood for failing "to take immediate and proper steps to see that this resident was supervised and received necessary interventions, including, if needed, transfer to an appropriate medical facility." In the end, though, the state took no action against the home . It has no remedies under law short of pulling the facility's license.
Diane Jergens, admissions and marketing director at The Laurelwood at the time, said Barrett had been moved to the second floor and placed on a 15-minute watch by staff just days before her fall because she had tried several times to leave the building from the first floor. Barrett had been at the home only 29 days when she fell, Jergens said. "We were going to have a care conference with her family to decide what they wanted to pursue," she said.
Charles H. Bellmyer, 70, walked away from the Washington Manor assisted living facility in Washington Twp. one Sunday last March and was found drowned in a nearby creek the next morning. Bellmyer, who suffered from Alzheimer's disease, left claw marks on the muddy embankment where police investigators believe he tried to pull himself out of the water.
Ohio Department of Health officials found no reason to penalize Washington Manor for any violations of its license. However, Bellmyer's family filed a lawsuit against the home , accusing the facility of ignoring a physician's recommendation the previous summer that Bellmyer be evaluated for a higher level of care.
Bellmyer, who had relied on his wife, Dorothy Jean, for supervision, remained alone in their one-bedroom suite after his wife was transferred to a nursing home in September 1997. At that point, "someone at Washington Manor should have asked, `Does this man need a higher level of care?' ' said Deborah Hunt, the family's attorney. "Alzheimer's is not a disease that improves. We can only suspect that he got worse as time went on."
The home has denied responsibility in the death in court documents. Terry Duffy, administrator at Washington Manor, declined to comment while the case is pending.
`IT'S BEEN HELL'
For 80 percent of the elderly who need assistance, care is not provided in a nursing home or at an assisted living facility. It's provided at home , either by family members or home health aides. But Ohio pays for in- home care only for those elderly frail enough to qualify for nursing home care and poor enough to live well below the federal poverty level.
That excludes thousands of Ohioans like Tom and Renate Lilly of Centerville. The Lillys are caring for Renate's 81-year-old father and 75-year-old mother at home . While Tom's insurance pays for medications and doctor bills, it won't help cover the in- home assistance that would give the Lillys a break from their constant duties. "We rarely get the opportunity for a social life," said Renate Lilly, 50.
Recently, the Lillys were forced to cut their in- home assistance by half, from 24 hours a week to 12 hours, because they could no longer afford the extra hours for aides. Even so, it still costs them $1,500 per month.
Renate Lilly has paid a steeper price - damage to her elbows and shoulder joints from the repeated lifting of her mother. She's receiving cortisone treatments, hoping to avoid surgery on her rotator cuffs. The condition also means she can no longer baby-sit her 8-month-old grandchild, who has grown too heavy for her to lift.
"If you require outside help (with your parents), and we do, it just becomes overwhelming," she said.
Home health care allows the elderly what they want most: to stay in their own homes as long as they can. But it can be frustrating. Home health aides are in short supply, often underqualified and - residents complain - unreliable.
"It's been hell," said Charlotte Jewett, a 65-year-old Trotwood resident who was left a quadriplegic by a car accident in 1962. Until she switched to an independent home care aide this summer, Jewett said she was often left stranded in bed during the day or in her lounge chair at night, sometimes with her doors unlocked, because an agency worker missed an appointment.
Doug McGarry, executive director of the Area Agency on Aging, said the shortage of reliable home health aides is a national problem, especially with the country in the midst of an economic boom.
`The better employees are gravitating to other areas where the pay is higher and the work isn't as hard,' he said.
`WHERE DID GEORGE GO?'
The lack of qualified help is crippling the entire system of care for the elderly.
Rashanna Hunter was one of two nursing assistants assigned to 44 patients last June when a confused resident walked out of a south suburban nursing home and into a busy thoroughfare.
Hunter had been supervising the man, who suffers from Alzheimer's disease, after escorting him to the smoking room. But another patient pressed her call button for help and Hunter was the only aide who could respond.
When she returned to the smoking room, the man had vanished.
Hunter was panic-stricken. Just two weeks before, another patient had walked out the front door of the same home and was struck by a car and severely injured.
"I asked the nurse at the nurse's station, `Where did George go?' ' Hunter said.
Minutes later, George was found wandering in the street in front of the home . Luckily, this time, a passing motorist retrieved him before he was hurt.
"There are times when you just feel like throwing up your hands and saying, `I quit,' ' said Hunter, a 23-year-old Dayton resident who has been a nursing assistant for six years.
"I have bills to pay or I wouldn't work there. They're very understaffed ... but when something happens, the blame always falls back on us."
Hunter's lament is common among nursing home aides, who make between $7 and $10 per hour, usually with limited benefits.
Nationally, the turnover rate among aides in a typical nursing home exceeds 100 percent in a single year, according to the National Academy of Sciences, a private non-profit group in Washington, D.C., that advises Congress on science, technology and medicine.
"The nursing home industry is putting profits before patient care, by keeping staffing levels to the bare minimum," says a lobbying brochure produced by the Service Employees International Union, which represents thousands of nursing home aides and nurses across the country.
Nursing homes , once primarily run by churches, government agencies and other non-profit organizations, are now dominated by for-profit companies; four-fifths of Ohio's 940 nursinghomes are private, for-profit companies, and an increasing number are chain-owned.
There are some excellent for-profit nursing homes , but overall their staffs have a higher patient load, a Daily News analysis of staffing ratios shows.
For-profit homes typically have 15 residents per registered nurse, compared to 13 per nurse at non-profits.
For-profits also average about 1.5 residents for every member of the nursing staff on all shifts, including aides, compared to about 1.3 per nursing staff member at non-profits, the data show.
The staffing disparity may be hurting patient care. The Daily News analysis found for-profit homes averaged twice as many serious health and safety violations than non-profits, and they are nearly four times as likely to have three or more serious violations.
"There are a lot more violations in the for-profit homes ," said Charlene Harrington, a nationally known researcher at the University of California at San Francisco who has examined national data on nursing homes over the past five years.
"They're trying to cut corners too much."
But the Ohio Health Care Association, which represents primarily for-profit homes , says a study it conducted comparing state and federal data on Ohio nursing homes shows for-profit and non-profit homes had "very similar" violation rates in 1998-99.
"In some ways, non-profits get more citations," said Van Runkle, the chief legal counsel to the health care association.
Clay Reedy of Springboro, a nursing student who has worked three and a half years as a nurse's aide in four nursing homes , said reduced staffing is a problem in the for-profit homes he's worked in, particularly on nights and weekends.
"When you're short-handed, sometimes you have as many as 20 people (to care for) on second shift," he said. "It's intense all the time. It's just shut up and move on . . . . You can work all day and you don't feel like you've accomplished anything when you walk out of there."
A nurse who quit working at a for-profit nursing home in Kettering this year said poor staffing levels there left as many as 43 patients in the care of a single nurse and nurse's aide.
"I've seen patients lying in urine overnight and stuck in wet diapers for most of the day," she said. "And many of them are not getting proper nutrition and hydration. You can tell just by looking at them - their skin is dry and flaky and their eyes are sunken."
For the frail elderly, dehydration can kill.
Barbara Frantz of West Milton, a registered nurse, said fluids could have saved her husband's 100-year-old grandmother, Helen Bice.
After breaking her hip in a fall at home , Bice entered Carriage Inn of Dayton Nursing Center last February.
Carriage Inn is operated by Integrated Health Services Inc. of Maryland, one of the largest for-profit chains in the country.
Bice was still alert and otherwise healthy when she entered the home , Frantz said, but two weeks later, and just hours before her death, it was a different story.
"I never saw anyone so dehydrated in my life," Frantz said. "She was pasty. Her oral (cavity) was dry. Everything about her was dry."
Carriage Inn of Dayton officials would not comment on Bice's care but defended the quality of the home .
"The care we have here is exceptional," said Dan Like, who took over as administrator of the home in September.
"We are well-staffed, and that's rare for a long-term-care facility in this day and age."
`NOTHING WAS EVER DONE'
Under federal regulations, the Ohio Department of Health can use three main penalties to enforce standards in nursing homes : deny government payments for new patients, impose fines or terminate a home 's eligibility for Medicare and Medicaid payments, effectively closing the facility.
However, in nearly all cases, homes can escape penalties if they correct their problems within an allotted period of time, usually 50 days.
Critics say that's the crux of the problem. "It's no enforcement system at all if all you're doing is saying, `Gee, do better next time, guys,' ' said Toby Edelman of the National Senior Law Center, a non-profit advocacy group in Washington, D.C.
Between May 1994 and September of this year, the state began enforcement actions against nursing homes 1,251 times.
In four of five cases, no fines were imposed, primarily because problems were fixed in time.
Even when homes were fined, the typical amount - $7,963 - was less than what many homes receive in state Medicaid payments in a single day.
Weak enforcement leads to a yo-yo pattern among bad homes .
A recent national study by the General Accounting Office, the investigative arm of Congress, found that although most homes corrected their problems to avoid sanctions, nearly half - 40 percent - again showed serious violations within three years.
Lenore Kiln of Centerville complained to state authorities about the care of an 88-year-old friend at Manor Care in Centerville. Kiln said her friend was sometimes left to lie for hours in a soiled bed and developed bed sores that were rarely bandaged.
"I filed a complaint with the Ohio Department of Health, and other than an inspection (of the home ), nothing was ever done," Kiln said.
Health department officials say the home was cited, and the state recommended a denial of Medicare and Medicaid funds. But the home corrected its problems in time and escaped any penalty.
HCR-Manor Care, the for-profit chain that owns Manor Care, declined comment on the case.
`SHE COULD BE ALIVE TODAY'
In the living room of his West Carrollton home , Victor Blankenship keeps a framed picture of his mother Grace, looking the way he would like to remember her.
The vivacious smile, he said, captures what she was like at age 79: an active, outgoing woman who loved to cook, entertain and crochet, who faithfully supported her church and who regularly made the rounds of garage sales and flea markets. Like Grandma Moses, she had begun painting oil pictures for the first time in her life the year before.
`She was so active it was unbelievable,' Blankenship said. `I could hardly keep up with her myself.'
The photo was taken more than a year before Grace Blankenship was transferred from an assisted living wing to a nursing home unit for severely demented residents at Wood GlenNursing Center.
It was there on the morning of June 20, 1993, that the staff failed to notice when a male resident - a man who had been a boxer in his youth and who had a history of fighting with other residents - wandered into her room. In the confrontation that ensued, Grace Blankenship, who weighed just 112 pounds, got the worst of it, including three broken ribs.
To help control the pain, Blankenship's physician prescribed 100 milligrams of Darvocet to be repeated every four hours. However, there was a standing order to notify him if she became nauseous or began vomiting.
At 5 p.m. on July 4 - a holiday - she complained of pain in her right side, according to a state investigator's report. Then at 10 p.m., and again at 11 p.m., she began vomiting large amounts of fluid.
Exactly how many times she vomited that night is unclear, but by midnight, she was cold, clammy and unable to walk without help. By 6 a.m., her blood pressure had plummeted to dangerous levels and her speech was slurred, the report states.
During those eight hours in which her condition had changed dramatically, no one at the home called her family or her physician for a consultation or to order a transfer to a hospital emergency room, state investigators found.
Nor was she given fluids that might have prevented the severe dehydration that sent her into shock and killed her at 6:40 a.m. that same morning, according to the home 's nursing notes.
Marietta Houchins, the nurse's aide assigned to care for Blankenship starting at 11 p.m. that night, said she was told by her supervising nurse, "Grace is dying, and I want you to stay with her the whole night on your shift." But at no time during her shift did Houchins give Blankenship fluids or did the nurse start an IV, she said.
Houchins said Blankenship never asked for water. "She was dying. I always know when they're dying. Before people die, they talk about the people they've seen, or they're going to see," she said. "They're not wanting anything to drink."
Greg Nelson, president of the Kettering-based Centurion Management Group and owner and operator of Wood Glen at the time, said the home was not responsible for Blankenship's death.
He said her family had placed a "no code" order in her file, asking that she be given only "care and comfort measures" in the event of a sudden downturn.
"A no code order is a no code order," he said. "We allowed her to die with dignity."
A statement released by Nelson's attorney, Brant Poling, also said that Blankenship's "medical and mental condition had progressed to the stage that she required nursing home care. She was seen and evaluated by her physician prior to admission in the nursing center."
"Grace Blankenship died suddenly of natural causes on July 5, 1993," the statement says.
Victor Blankenship insists he never signed a no-code order. Such a request wouldn't have applied to his mother anyway, he said, because simple, not heroic, measures could have saved her.
And he said he knows of no doctor's evaluation prior to her transfer to the nursing home unit for severe dementia patients.
Blankenship said it was understood when his mother entered her apartment at the assisted living wing that she would be transferred to a nursing home bed when her savings ran out. But, he said, he assumed she would be placed in a unit for residents with the lowest severity of dementia. Instead, she was moved to a vacant bed in Wood Glen's Pine unit, where many of thehome 's most confused and combative patients resided.
"She was very uncomfortable in that setting and was quick to say so,' Blankenship said.
Billy Stratton, an aide who cared for her on second shift and no longer works at the home , agreed that Grace Blankenship did not suffer from dementia.
"She was as lucid as we are," Stratton said. "We used to talk about the Cincinnati Reds. She knew all the players' names and how they were doing."
The state fined Wood Glen $5,842 for violations in the handling of Grace Blankenship's death. Victor Blankenship said that's not enough of a penalty.
He filed a $30 million lawsuit in Montgomery County Common Pleas Court against the former owners and managers of the home , including two of Nelson's firms, Centurion Management Group and GNWT Inc. A trial date has been set for early next year.
Blankenship said much of his bitterness is aimed at Ohio's system of elder care, a system that he feels gave his mother only one choice - a nursing home unit where she didn't belong and where she didn't get the care or protection she needed.
`All I know," he said, "is that with some very simple treatment she could be alive today.'