The New York Times has a new article "At Many Nursing Homes, More Profit and Less Nursing." The article describes how consortiums of private investors such as Warburg Pincus and the Carlyle group are buying up nursing homes, and in the process, harming the residents of the nursing homes they acquire.

These private investment companies are even more profit-driven than the large publicly traded corporations that sold them the nursing homes. The Times’ analysis of records collected by the Centers for Medicare and Medicaid Services shows that “at 60 percent of homes bought by large private equity groups from 2000 to 2006, managers have cut the number of clinical registered nurses, sometimes far below levels required by law. . . . During that period, staffing at many of the nation’s other homes has fallen much less or grown.”

“The first thing owners do is lay off nurses and other staff that are essential to keeping patients safe,” says Professor Charlene Harrington, a professor of nursing at the University of California, San Francisco. Nursing home owners have made “a lot of money by cutting nurses, but it’s at the cost of human lives,” she says.

The typical nursing home acquired by a large investment company scored worse than the national averages on 12 out of 14 quality indicators that government regulators use to evaluate nursing homes. These privately owned homes also have far higher rates of citations and deficiencies than do homes owned by publicly held corporations.

One nursing home profiled by the Times is Habana Health Care Center in Florida (formerly owned by Arkansas-based Beverly Enterprises, Inc.). Within a year of being bought by a private investment group, the investors had cut the number of clinical registered nurses in half. They also slashed budgets for nursing supplies, resident activities and other services, and cut staffing and 48 other nursing homes. A former nursing manager of the home told the Times that “the [new] owners wouldn’t let us hire people. . . . We told the higher-ups we needed more staffing but they said we should make do.”

One of the victims was Mrs. Alice Garcia (pictured here with her grand-daughter). Within months of moving into Habana Health Care Center, she sustained repeated falls. The staff would also reportedly leave her seated in wet adult-diapers, and ignored her daughter’s repeated complaints that they were neglecting her care. Five months later, her daughter discovered “that her mother had a large bedsore on her back that was oozing pus.” The doctor at the hospital to which Alice was taken reportedly said she should have been given treatment for the pressure ulcer “much earlier.” Three weeks later, she passed away.

When her daughter (Vivian Hewitt, pictured here) sued the nursing home for neglecting Alice, her lawyer found out that the private investment group had set up layer upon layer of corporate structures that insulated the investors from legal liability for the injuries to their residents. These corporate shell games “unjustly protect investors who profit while care declines.” The corporation who is listed as the owner with the licensing agency does not have any assets, so even regulators cannot collect fines that are levied at the nursing home.

Although only 10 percent of nursing homes nation-wide are estimated to be owned by private investment groups, this is an alarming trend that demands action from our elected officials. Most of these nursing homes are paid with government funds, by Medicare or Medicaid, and the government needs to demand accountability. In fact, the government pays nursing homes an estimated $75 billion a year, under Medicare and Medicaid programs, according to the article. If a company receives government money for care provided at a nursing home, the company should be responsible for paying any fines levied by the government regulators and for any court judgments entered on behalf of neglected residents and their families.

What can you do? If you or your loved one lives in a nursing home, skilled nursing facility, or assisted living facility, find out from the licensing agency who the owner of record is. Compare that with the names of the corporations on the door, the names of the corporations that manage the facility, and own the building or land where the nursing home is located. Ask the nursing home employees the name of the company that writes their payroll check. If there are multiple corporations involved, that tells you that a shell game may be going on to insulate the owners from liability. Corporations who feel that they have nothing to lose are more likely to cut corners on care.

To read the Times article, click here.

Felicia Curran
www.ElderAdvocacyLaw.com

Do you know what a pressure ulcer is? I didn’t, until my mother acquired a Stage 4 pressure ulcer during a hospital stay ten years ago. I had no idea what they were, or how they were formed. I learned quickly, though, and helped my mother get appropriate care that got her back home with my Dad -- though only after a two-month stay at a convalescent hospital.

Pressure ulcers can be a red flag of poor care at a hospital or a nursing home. A pressure ulcer is an area of skin that breaks down when you stay in one position for too long without shifting your weight. The constant pressure against the skin reduces the blood supply to that area, and the affected tissue dies. Also referred to as “wounds,” "bed sores” and “decubitus ulcers,” a pressure ulcer starts as reddened skin but gets progressively worse, forming a blister, then an open sore, and finally a crater.

The most common places for pressure ulcers are over a bony prominence such as the shoulders, back of the head, elbows, sacrum, hips, heels, and ankles.

Residents of nursing homes who are immobile are at high risk for developing pressure ulcers because they may sit or lie for long periods of time in one place or position. They may be too weak or too ill to move themselves, and they are totally dependent on nursing home staff to help them reposition.

Pressure ulcers are preventable. For pressure relief, immobile individuals need to repositioned at least every two hours in bed, and at least every 15 minutes if they are sitting in a chair or wheelchair. The nursing home should use a written schedule, posted on the wall for verification, for systemically turning and repositioning the resident.

At poorly managed nursing homes and rest homes, residents develop pressure ulcers because they are left unattended sitting or lying in bed for long periods of time, due to staffing shortages or because staff are poorly trained.

Poorly trained nursing home staff may cause pressure ulcers by even dragging the resident’s body across the bed onto the chair, instead of using a lifting device, such as a trapeze, to move the resident. Shearing of the skin can occur when a resident is pulled up in bed, instead of using a technique such as placing a half sheet under the person’s torso to lift the resident up off of the bed.

Another red flag of poor care at a nursing home is when the pressure ulcer gets worse, and not better, or multiple ulcers develop in different locations. Signs that the ulcer is getting worse include:

the ulcer gets wider, deeper, longer;
the ulcer develops dead tissue (usually black);
the ulcer develops “undermining” (a thin lip of tissue around the edges of the wound);
the ulcer turns black (indicating dead tissue);
the ulcer has drainage (watch out for yellow, green, or grey drainage);
the ulcer has a foul odor.


Pressure ulcers are staged 1 to 4 according to the degree of tissue damage involved, with Stage four being the worst.

Stage 1: A reddened area on the skin that, when pressed, is "non-blanchable" (does not turn white). This indicates that a pressure ulcer is starting to develop.



Stage 2: The skin blisters or forms an open sore. The area around the sore may be red and irritated.

Progression of a pressure ulcer beyond Stage 2 most likely means that the nursing home or care home is not providing appropriate care, or that they have not fixed the problem that caused the pressure ulcer in the first place - for example, they are still dragging the person across the bed, or they leaving the person sitting in a chair all day.


Stage 3: The skin breakdown now looks like a crater where there is damage to the tissue below the skin.







Stage 4: The pressure ulcer has become so deep that there is damage to the muscle and bone, and sometimes tendons and joints.


If a pressure ulcer becomes infected, the infection can spread to the rest of the body and cause serious problems, including blood infection (sepsis) and bone infection (osteomyelitis). Either of these are life-threatening conditions.

A red flag of poorly trained staff at a nursing home is that the staff does not know the signs and symptoms of infection.

Signs of an infected ulcer include:

A foul odor from the ulcer
Yellow, green, or grayish discharge from the ulcer
Redness or tenderness around the ulcer
Skin close to the ulcer is warm and swollen

Fever, weakness, and confusion are signs that the infection may have spread to the blood or elsewhere in the body.

The pressure ulcer that my Mom had was able to heal because, after two months of failed treatment at the convalescent hospital, we found out about a new technology, a vacuum pump, that helped draw the fluid out and close the wound up. She was able to go home with the pump, and her wound completely healed in another three weeks. Previously, the wound had been so deep that you could see her sacrum bone.

Don’t let pressure ulcers happen to your Mom or Dad. Educate yourself on the causes of pressure ulcers. If your loved one develops a pressure ulcer, be pro-active in getting appropriate treatment, and don't let them tell you that it can't be healed. A general guide to prevention from the National Pressure Ulcer Advisory Panel (NAPUAP) is available online, in PDF format.


Felicia Curran
www.ElderAdvocacyLaw.com

The U.S. General Accountability Office recently filed a report where it reviewed federal oversight of a group of 63 nursing homes nationwide that have a history of repeatedly harming nursing home residents. In 1998 and 1999, GAO had issued reports reviewing the oversight exercised by the Centers for Medicare & Medicaid Services (CMS) over nursing homes. Those reports found that sanctions CMS imposed on bad nursing homes often did not take effect, because CMS had adopted a policy of giving nursing homes a “grace period” to correct deficiencies before sanctions would be imposed. The prior reports found a “yo-yo” pattern where the nursing homes would cycle into compliance just long enough to avoid the sanctions, and then revert to a pattern of serious violations - avoiding sanctions while continuing to harm residents.

In response to the GAO reports, CMS was supposed to adopt an “immediate sanctions” policy for nursing homes found to repeatedly harm residents. Did they? According to the current GAO report, the answer is “no.” The CMS “immediate sanctions” policy is in name only. More than half of the 63 homes that had serious violations that had harmed residents as of 1999 continued to have serious violations during 2000-2005.

GAO attributes the continuing yo-yo effect to CMS' lax enforcement policies, including failure to impose fines, delaying imposing fines, and levying fines in such small amounts that it is more profitable for the nursing homes to pay the fines (which averaged $350 to $500 per day) than it is for them to provide good care to nursing home residents. An example is:

“A significant medication error occurred when resident #8 was administered the wrong medication over a three day period. The resident experienced hypoglycemia and required hospitalization. Upon return from the hospital there was evidence of actual harm: a decline in the resident’s ability to perform activities of daily living.” The fine for this citation could have been anywhere from $1,000 to $10,000. CMS only fined the home $1,500.

GAO says that CMS terminated from Medicare or Medicaid reimbursement only 2 of the 63 bad homes. What incentive would a nursing home have to do things differently? These bad nursing homes are actually being paid by Medicare or Medicaid to provide the very care that CMS has determined merits a citation. The nursing homes can actually pay the fines with the money that they are receiving from Medicare for the resident’s care.

As long as the federal government makes it cheaper for nursing homes to violate the law than it is to comply, elderly residents will continue to be neglected by nursing homes. For the big corporations that own the nursing homes, it’s just more cost-effective to neglect the residents and pay the paltry fine if they get caught.

And, if you’d like to know the names of the 63 “repeat offender” “yo-yo" nursing homes studied in the GAO report, you’re out of luck: GAO won’t disclose their names. You or your parents could be living in one of these homes (which were in Texas, California, Michigan and Pennsylvania).

To read the GAO report, click here.

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Felicia Curran
www.ElderAdvocacyLaw.com

Sen. John Edwards recently spent a day at a nursing home, working with a certified nursing assistant, taking up a call made by Service Employees International Union members, to "walk a day in my shoes."

Edwards' day with Elaine Ellis began at a 3 a.m. early morning breakfast and continued with rounds at the nursing home where Elaine works. Edwards helped nursing home residents dress, helped serve meals, and helped out a nursing home resident who needed a shave.

She said that he seemed like a very nice person and she felt grateful that he took the time to find out what her world is like. He said that she seemed like a caring person and that she treated the home residents like family.

Elaine actually works two jobs, from 7 a.m. to 3 p.m. at one nursing home, and then from 3:30 p.m. to 9 another nursing home. When Edwards left, Elaine went to work at her second job.

She works two jobs because she does not make enough from her first job to support herself.

You have to wonder how she could possibly be doing a good job for the residents at either home, given how exhausted she must be. She's been doing this routine for more than 17 years.

Edwards was not there to critique her or the nursing home, however. He was there to watch and learn. Let's face it: neither the nursing home or the union would have let him in the door if there was any chance of that happening! At another time, Edwards needs to address the issues of understaffing, poor training, and low wages at nursing homes if this visit is to be more than a photo-op.

SEIU represents nursing assistants and some licensed nurses at the few nursing homes that are unionized. SEIU has invited all candidates for president, Democrats and Republicans, to experience firsthand what the employees' lives are like by spending a day with an employee.
Sen. Clinton, Sen. Dodd, Gov. Richardson, and Sen. Biden have all accepted the invitation. None of the Republican candidates have responded.

For more on the Walk in My Shoes Challenge, check out the SEIU website.

Click here to watch a short video clip from Edwards' day with Elaine.




Felicia Curran
www.ElderAdvocacyLaw.com

File this under “IF YOU’RE NOT OUTRAGED, YOU’RE NOT PAYING ATTENTION.” The Foundation for Taxpayer and Consumer Rights, a consumer watchdog group, made public last week internal memos and secret agreements between the Service Employees International Union (SEIU) and large nursing home chains in California. These contracts were supposedly signed in 2004 and are still in effect. Under the contracts, nursing home workers lost the right to strike and to complain to regulators about quality of care problems in exchange for wage increases. Nursing home operators got the unions’ agreement to lobby for more Medicaid dollars, for measures limiting nursing home residents’ legal rights (aka "tort reform"), and to refrain from seeking safe staffing requirements.

Instead of providing the residents living in their nursing homes good care, the home operators would rather buy the silence of their employees. They would rather restrict the laws that protect elders' ability to sue nursing homes for abuse and neglect. How outrageous is that? The contracts say that union officials are forbidden from publicizing or discussing the contracts.

As FTCR President Jamie Court said, “Nursing homes are a sector where care givers are the eyes, the ears, and the witnesses when there is abuse. To tie their hands and to tie their tongues is to let people die. That’s immoral and a terrible thing for a nursing home worker to have to live with.”

Besides the SEIU International, the contracts state that Locals 250 (Oakland), 434B (Los Angeles), and 2028 (San Diego) are parties to the agreement, along with the following nursing home chains in California:

Beverly Enterprises California, Inc.
Compass Health, Inc.
Country Villa Health Services
Covenant Care
Evergreen Healthcare LLC
Golden State Healthcare
Horizon West Inc.
Independent Quality Care
Kindred Healthcare, Inc.
Longwood
GranCare, LLC aka Mariner Healthcare Inc.
Meritcare Inc.
Ocadian Hospitals & Care Center4s
Pleasantcare
Sun Mar Healthcare
Sunbridge Healthcare Corporation
The Chase Group
Skilled Healthcare, LLC


The “gag” provision of the contract provides that the union will not use “voluntary adverse reporting to any regulatory or other oversight agency having jurisdiction over operations; provided, however, that this provision shall not apply to any employee mandatory reporting of suspected abuse or neglect which shall continue to be reported consistent with the requirements of California law.”

Nursing home employees are mandated reporters of any suspected elder abuse or neglect in nursing homes under California law. The catch is that California’s mandated reporting laws for elder abuse and neglect require reporting only when an elder has actually sustained harm or injury. What these gag provisions do is prevent employees who are union members from reporting potentially hazard conditions or unsafe practices which pose a threat of harm and which need to be corrected.

These contract provisions would be void and unenforceable as against public policy if the nursing homes ever tried to enforce them against employees who report unsafe conditions. But most employees would not know that. The mere presence of these contract provisions would have a chilling effect on employee whistle-blowing on elders’ behalf.

The documents also discuss how the nursing homes will receive more than $900 million in new Medicaid funding as a result of union lobbying on their behalf. Yet, “despite this huge cash infusion, union workers will see only $21 million in increased wages and benefits through the 2006-2007 rate year.”

The contracts, which were signed back in 2004, are also the subject of a San Francisco Weekly article about SEIU International President Andy Stern [http://www.sfweekly.com/2007-04-11/news/union-disunity/print ).

Union representatives refused the reporters’ requests to be interviewed, which is really all the confirmation we need that the contracts are in existence.

To view the contracts, go to:

Agreement to Advance the Future of Nursing Home Care in Washington http://www.consumerwatchdog.org/resourc ... CareWA.pdf

Agreement to Advance the Future of Nursing Home Care in California http://www.consumerwatchdog.org/resourc ... CareCA.pdf

CA Alliance to Advance Nursing Home Care, Inc. Board Meeting Agenda http://www.consumerwatchdog.org/resourc ... Agenda.pdf

To see union members' critique of the contracts, go to:
CA Alliance Agreement: Lessons Learned -- Union Members Own Criticism of The Agreements. http://www.consumerwatchdog.org/resourc ... eement.pdf

Report on Alliance Negotiations. http://www.consumerwatchdog.org/resourc ... ations.pdf

To read Jamie Court’s article, click here.

To read Matt Smith’s article in SFWeekly, click here.


Felicia Curran
www.ElderAdvocacyLaw.com