A Hawaii nursing home that sent a frail resident away in a Lyft is one example of the risks to patients across the country
By: Jill Riepenhoff, Daniela Molina and Lee Zurik
Originally Published: September 3, 2020
(InvestigateTV) – According to the federal government, a nursing home in Selma, California is the worst of the worst.
Residents of Bethel Lutheran Home have been subjected to seclusion, manhandling and verbal abuse from staff members.
One woman was confined to her room for days at a time on two separate occasions because she gifted a Gideon bible and $2 to a facility custodian who was tearful about becoming a grandmother.
Another woman was involuntarily confined in her room for more than a week because of “episodes of coughing.” Yet the nursing staff never provided any medical treatment or testing to see if she had an infection.
An elderly man was left without his motorized wheelchair for days as a punishment for not following facility rules.
The wrongful punishments, abuse and neglect were so severe and pervasive that inspectors cited the nursing home with the most serious violation – one that causes immediate jeopardy of harm to residents.
The harrowing details are spelled out in a January 2019 Centers for Medicare and Medicaid Services inspection report.
Over the past three years, Bethel Lutheran Home has had so many serious violations that it scores by far as the worst nursing home in the country. Those weighted scores are used by CMS to target 88 poor performing nursing homes for extra oversight.
Yet Bethel Lutheran Home is not one of them. It is only a candidate for the Special Focus Facility program. Run by CMS, the SFF program brings increased inspections and heightened enforcement to troubled nursing homes, but participation is limited to 88 facilities because of a lack of resources.
Bethel Lutheran did not respond to requests for comment.
A nursing home in Hawaii evicted a 76-year-old man with dementia and sent him away in a Lyft without any money, identification or medication. A facility in Kentucky didn’t know how to safely evacuate residents during a flood. A nursing home in Washington was in so much financial trouble that it hadn’t paid bills for food and medical care of its residents.
These are just a few examples of the 445 nursing homes that are waiting for a slot to open in the oversight program as of August. Two dozen of them have been on the list for at least three years.
Created in 1987, the program subjects up to 88 facilities with persistent poor quality of care to increased inspections and enforcement actions.
But those on the candidates list receive no additional oversight or inspections even though many of them have had serious problems for years.
The American Health Care Association, which lobbies on behalf of the nursing home industry, says the Special Focus Program should be expanded to include the bottom 10% of the nation’s long-term care facilities as rated by CMS.
“What they don’t need is more fines and regulations,” said Mark Parkinson, the association’s president and CEO. “They need someone to come in and help them.”
Nursing homes are identified by CMS as meeting the criteria for the SFF program. States then select which become an SFF or a candidate. Each state has a limited number of slots for each list.
That selection process means that the worst of the worst don’t always make it into the stricter enforcement program.
Nearly 450 poor-performing nursing homes are on a federal government waiting list for the Special Focus Facility program, which provides additional inspections and enhanced penalties for the worst facilities. These nursing homes on average have four times as many substantiated complaints as all other facilities in the U.S. The Centers for Medicare and Medicaid Services revises the list each month. But some have been on the so-called candidate list for years.
California, where Bethel Lutheran is located, and Texas are limited to having six SFF nursing homes – the most allowed – and 30 candidates.
Twenty-nine states including Kentucky, Louisiana, Virginia and Washington are limited to one SFF and five candidates.
“Many more facilities need to be in the focus program,” said Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy, which pushes for nursing home reforms. Candidates for the SFF “provide equally poor care.”
Until last year, the identities and locations of the SFF candidates were kept secret by CMS.
Pennsylvania Sens. Bob Casey, a Democrat, and Pat Toomey, a Republican, persuaded CMS to make the names of those facilities public after issuing a scathing report about the SFF program and its candidates.
CMS now issues a monthly report naming the participants and candidates.
But the candidate designation is not noted in the Nursing Home Compare data, the public website created to help the public make informed decisions about long-term care.
The website allows the public to read inspection reports, check staffing levels and learn about any fire or safety hazards at individual facilities.
CMS flags on the website those nursing homes with histories of abuse and neglect, and it labels facilities that are SFF. But it doesn’t flag candidates.
Asked by the senators last year why there is no candidate designation on Nursing Home Compare, CMS Administrator Seema Verma said that information is available elsewhere.
The public can see this, she told them, “by accessing the data.medicare.gov website and downloading the Provide Info file. By sorting the column names Total Weighted Health Survey Score in descending order, the facilities with the highest survey scores, which could be SFF candidates, appear at the top of that list.”
Right now, inclusion on the SFF’s candidate list is virtually meaningless.
They aren’t inspected any more frequently than 5-star rated nursing homes. Nearly 40% haven’t had a regular inspection in at least 16 months, outside the limit set by CMS.
“We have not done a good job across the board protecting nursing home residents,” Casey told InvestigateTV. “We’ve needed a much more definitive strategy.”
These nursing homes “are indistinguishable from the [SFF] participant list,” Casey said.
Many have equal – or even worse – quality of care problems. Nearly a third have histories of abuse and neglect.
“Those who have done so much for us and for our nation deserve quality care,” Casey said. “It’s that simple.”
A 110-mile Lyft ride leads to serious deficiencies
Legacy Hilo Rehabilitation & Nursing Center in Hawaii is one of the facilities with a history of abuse and neglect.
In September 2017, the nursing home discharged a resident with dementia and sent him in a Lyft to a hotel, with no money or medication.
By day’s end, the 76-year-old man was in a hospital, and the nursing home had set itself up for a serious citation from government inspectors.
The nursing home has been on inspectors’ radar since at least 2015 because of its persistently poor quality of care. What happened to that one resident on Sept. 8, 2017 is a prime example.
In more than 1,600 Lyft rides, driver Rex Riley never thought he’d drive a nursing home patient 2 hours across the island of Hawaii in the dark pouring rain.
When Riley arrived at the nursing home he was greeted by a female supervisor and was told that he would be taking the man to Manago Hotel & Restaurant in the city of Captain Cook, 110 miles away.
Riley said that the nursing home supervisor said that Legacy Hilo had made reservation for the patient stay at the hotel.
The staff loaded the man and his belongings – two boxes and a wheelchair – into the back of Riley’s car. Riley said it was clear that the man was confused about what was happening as soon as they left the nursing home.
“I’m not going to the hotel, I’m going to go see family,” the man told Riley.
Riley, a former paramedic and respiratory therapist, thought something about this situation seemed off.
“It was strange that he didn’t know where he was going. It didn’t match what I was told,” he said.
He turned the car around and returned to the nursing home where staff again confirmed that the man was to be taken to the Manago Hotel.
Riley arrived at the hotel about 7:30 p.m. and wheeled his passenger into the hotel lobby and spoke with the owner.
He confirmed that a reservation had been made by the nursing home but no plans for payment had been made.
The patient arrived at the hotel without identification, money, credit cards or any paperwork from the nursing home.
The hotel owner and Riley each called Legacy Hilo hotel and asked to speak with the manager. Neither received a call back.
“I started talking to the patient and I noticed that his feet were in very bad condition and that he could not stand up to make a meal, or take shower, or take care of himself,” Riley said. “Here I was 110 miles of where I picked up the gentleman and the hotel won’t take him, I won’t leave him, and in my opinion as a paramedic and respiratory therapist, he needs additional medical care, because his feet were in really bad physical shape.”
Riley couldn’t come to terms into leaving the patient at the facility with a visibly purple foot.
He called 911. Medics immediately took him to a hospital.
Riley recalls that on the way back home he was called by police officers and interviewed about what had occurred that night and that the state had picked up the incident for further investigations.
“They have endangered this man’s situation. They put him in a car, drove him 110 miles and expected me to drop him off and that was the end of it,” Riley said.
For hotel staff and Riley, it came as a surprise that the nursing home would put a patient in danger.
“I’m very happy it was me who he was assigned to, because less medically trained individuals may have just done their job and dropped him off,” Riley said.
The man spent five months in the hospital, the inspection report shows.
After years of troubling inspections, Legacy Hilo graduated from the SFF program this spring only to be immediately placed on the candidates list to return to the oversight program.
Graduation, CMS reports say, “does not mean that there may not be problems in quality of care but does generally indicate an upward trend in quality improvement compared to the nursing home’s prior history of care.”
CMS says that graduation indicates an upward trend in compliance. However, there still could be problems in the quality of care.
“They aren’t graduates with honors,” said Edelman, who has studied the revolving door of the SFF program, a goal that is was supposed to achieve. “These facilities don’t come back and stay in compliance.”
Legacy Hilo did not respond to requests for comment.
COVID-19 inspections uncover problems that put lives at risk
As the coronavirus continues its attack on nursing homes, CMS had suspended regular inspections until Aug. 17.
Inspectors only visited nursing homes to assess their infection control plans and policies or to investigate complaints of serious harm to residents.
Between March and July 31, inspectors visited nearly 90% of the 445 nursing homes listed as SFF candidates to survey their infection control practices, according to an InvestigateTV analysis of federal inspection data.
At 17 of these troubled nursing homes, inspectors discovered other serious problems, deficiencies that posed immediate jeopardy of harm to residents.
CMS has yet to release any of those inspection reports to the public. The limited descriptions available show that these nursing homes endangered residents.
The failures include:
Ridgewood Center in Bedford, New Hampshire, an SFF candidate, was cited by inspectors on April 22 for failing to provide basic life support.
Without the inspection report, the details of that violation are unknown or if it was related to the coronavirus. However, COVID-19 swept through the 148-bed facility, sickening 66 residents and killing 31, CMS data shows.
Ridgewood Center did not respond to requests for comment.
Fifty of the SFF candidates have not had these targeted infection-related inspections. In fact, one candidate, Fort Scott Manor in Kansas, hasn’t seen an inspector since the fall of 2017, CMS data shows.
“That is a serious problem,” Edelman said. “The worst facilities haven’t been looked at.”
Parkinson, of the nursing home association, said that the 5-month suspension of regular inspections was the right decision.
“Until there is a vaccine, I don’t think we should restart regular surveys,” he said before the moratorium was lifted. “I’m completely comfortable with the total focus right now being on infection control.”
Some candidates have been on the “waiting” list for years as problems pile up
A Kentucky nursing home has languished on the candidate list for more than six years even as inspectors documented serious, life-threatening incidents at the facility, reports show.
In February 2019, as a flood threatened Salyersville Nursing and Rehabilitation Center, inspectors said that an administrator at failed to act until water began rushing into the facility and that staff did know how to safely evacuate.
As staff scrambled to evacuate more than 100 residents in the middle of the night, they placed liquid oxygen tanks in portable beds with patients. At least one resident ended up with frostbite-like burns because liquid oxygen is stored at minus 300 degrees.
A month later, another resident was given too much pain medication and overdosed. She was incoherent and couldn’t say her own name, but the nursing home only called 911 after her daughter insisted.
In October, the staff nearly killed a resident because they didn’t know how to properly care for a catheter in his abdomen – nor did they ask for help from a doctor.
In the past three years, Salyersville has been cited 18 times for serious problems that jeopardized its residents, federal inspection records show.
Salyersville, which did not respond to requests for comment, is one of nine nursing homes that have been on the candidate list for more than six years.
Thirty-four others have been on the list for more than two years.
“It doesn’t make any sense that that would persist that long,” Casey said.
He said that Congress needs to inject $20 billion into long-term care facilities in order to combat these serious, life-threatening conditions.
“This is definitely affordable if your priorities are straight,” he said.
The money would help surge resources and interventions into these poor-quality nursing homes.
Parkinson agrees these nursing homes need help in the form of special quality improvement teams that can effect change. The current structure of inspect and fine doesn’t work, he said.
He’s not surprised that dozens of homes have languished on the list for years.
“Surveying them more doesn’t make them better,” he said.
Nor does fining them help, he said, because many of these nursing homes already are “underwater, underfunded and don’t know what they are doing.”
In February, a complaint led inspectors to University Place Rehabilitation Center in University Place, Washington.
They found a facility in disarray and disfunction, the inspection report shows.
The nursing home had not been paying its bills. It owed more than $21,000 to its food vendor, had not paid its medical director in more than 15 months and was in jeopardy of losing its medication vendor because of an $170,205 balance.
All totaled, it owed more than $276,000 for medical services and supplies to keep residents healthy and safe.
The inspectors also found that the staff was incompetent and neglected residents – then failed to report these incidents to state authorities as required by law.
One family’s complaint to the nursing home administrator about their father’s condition fell on deaf ears. He had lost weight, had not been bathed and had not had dressing changes, the woman told inspectors investigating the issues.
She told inspectors that the staff argued with her father and bullied him.
It was the fourth time in three years that inspectors found violations so serious that residents’ well-being was in immediate jeopardy.
The nursing home did not respond to requests for comment.
Over the past three years, University Park has been fined a total of $153,102. It didn’t improve the quality of care, according to CMS data.
Regulators added University Place to the candidates list in April.
It joins four other facilities in the state of Washington waiting for the its one allocated SFF slot to vacate.
As many as 56,000 residents live in these nursing homes with long histories of persistently poor care.
“Many more facilities need to be in the (SFF) program,” said Edelman, the lawyer who has been advocating for nursing home residents since the 1970s. “It’s not trivial problems. We’re talking about people’s lives.”
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