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Complaints up against county care facilities since 2004 law
Ventura County Star
Complaints against Ventura County nursing homes that lean heavily on Medi-Cal increased nearly twentyfold over six years despite a California law designed to provide better care by injecting $880 million into facilities across the state.
Over 10 months ending in May, a Ventura County ombudsman program filed 194 cases with state agencies for possible violations against nine nursing homes funded for at least half of their patients through Medi-Cal. The complaints, many still being investigated, range from alleged physical abuse to using medication as a chemical leash to control patients.
Six years earlier, when nursing homes began to receive increased Medi-Cal funding through the Nursing Home Quality Care Act of 2004, ombudsmen filed only 10 complaints against the facilities.
"The numbers show that (the law) did not do what it was supposed to do: increase the quality of care for residents in nursing homes," said Sylvia Taylor Stein, executive director of the Long Term Care Services of Ventura County ombudsman program, blaming the lack of checks and balances in the law.
"They were given a checkbook with no oversight," she said. " The numbers don't lie."
A statewide investigation by the California Watch investigative reporting group showed 131 nursing homes across the state cut staffs despite increased Medi-Cal funding that was designed to boost nursing care. Those homes also reported dramatically higher profits than other facilities.
Shoreline Care Center in Oxnard received $877,356 in Medi-Cal funding increases from 2004 to 2008. But the 193-bed home that includes a unit for Alzheimer's patients provided less nursing care after the funding came, according to the investigation. Its staffing ratios fell from slightly above California's mandated 3.2 nursing hours daily for each patient in 2004 to 3.14 hours in 2008.
The home collected $4.1 million in profits after the law was passed, from 2005 to 2008, though the rate of increase fell off in 2008, when net income was only $132,537.
In 2004, state public health inspectors investigated six complaints as well as four possible violations reported by Shoreline staff. Two cases were substantiated. In 2009, 20 complaints and possible violations were investigated. Eight cases were substantiated, including an incident in which the same bedpan was used by more than one patient.
"There's a lot of alarming indicators," said Mike Connors of the California Advocates for Nursing Home Reform. "Staffing levels, using money for profits instead of care are all indicators of facilities that are putting money before care for residents."
'Single largest expense'
Shoreline is operated by Covenant Care, an Orange County company with 13 nursing homes that cut staffs despite $15 million in increased Medi-Cal funding, according to California Watch.
Cindy Poulsen, Shoreline's administrator, responded to repeated inquiries by e-mailing a reporter a statement from the California Association of Health Facilities. That organization's CEO, James Gomez, said the California Watch investigation focused on what he called a small number of nursing homes with fluctuating staffing and falsely blamed the problems on a widespread misuse of state funding.
He said the investigation ignored how the 2004 law has helped nursing homes, citing data that show turnover is down and wages are up. Nursing homes spent 96 percent of the increased funding to pay for expenses and provide care and services, he said, noting the law also allowed for a modest increase in income.
"Reasonable profits allow owners to hire more staff, provide better care, make physical improvements, borrow money and maintain stability," Gomez said.
Others argue Shoreline and other homes that reduce staffing ratios do so for an obvious reason: to make money.
"The single largest expense of every skilled nursing facility's budget is staffing," said Greg Johnson, a Ventura lawyer who is suing Shoreline in a case involving the lack of nursing staff at the home. "The more money a skilled nursing facility makes, the more likely it is to receive complaints and bad surveys."
As part of its statewide investigation, California Watch gathered data on how the 2004 funding law affected nine Ventura County nursing homes where Medi-Cal funded at least half of the patient days.
'Losing less money'
According to the findings, the biggest raise went to the Thousand Oaks Health Care Center. It received about $1.13 million more in 2008 than in 2004. The Camarillo Healthcare Center, in comparison, received $333,340 less in funding over the five years because of an ownership change that apparently affected the number of Medi-Cal patients.
The nine homes combined took in about $4.99 million in new funding. All of the homes except for Shoreline increased their staffing levels over the five years though in some facilities, staffing dipped one year and increased the next.
Some homes have improved. A year ago, public health inspectors documented 34 deficiencies at the 188-bed Victoria Care Center in Ventura, from overuse of restraints to not checking credentials of outside contractors. The regulatory issues brought worries the facility might be shut down.
But the concerns have faded. An annual health inspection in February revealed the 34 deficiencies have been diminished to two in a survey a new administrator called the best in the facility's history.
The home received about $977,801 in increased Medi-Cal reimbursement from 2004 to 2008. The money has helped Victoria Care maintain consistent day-to-day staffing and slow down turnover, said John Albrechtsen, the home's administrator.
Albrechtsen rejected the perception that the Medi-Cal funding represents a windfall. He said the government's reimbursement levels before the 2004 law were far too low to cover costs.
"I'm not aware of a single nursing home that makes a profit on a Medi-Cal patient," he said. "Basically you went from losing huge amounts of money (on Medi-Cal patients) to losing less money on them."
Staffing 'most important'
If profit drives quality, Ventura lawyer Johnson hasn't seen it in his decade of litigating against nursing homes for elder abuse and neglect. He said about half of his cases involve homes where staffing doesn't meet state minimum requirements.
Understaffing means employees are overwhelmed with patients and responsibilities, Johnson said. Call lights don't get answered. Diapers don't get changed.
"The single most important predictor of patient outcome in a skilled nursing facility is staffing," he said. "It's more important than diagnosis."
Johnson is suing Shoreline in a case where two certified nursing assistants moved Betty Jean DeWitt of Ventura from a shower chair to her bed. Paralyzed from the neck down, the 78-year-old woman was totally dependent on caregivers. Instead of using a mechanical lift, each nursing assistant grabbed DeWitt by an arm and lifted her, according to the complaint.
The woman's shoulder broke with a loud crack, said Johnson, who argues the nursing assistants took a shortcut because the nursing home was short-staffed.
"We're talking about the difference between a 20-second transfer versus a five-minute transfer, and that adds up," he said, blaming the institution as much as the employees. "I do not believe that these people who work in these facilities and work their butts off are uncaring because if they were, they wouldn't work there. I've had CNAs cry when I say 'How do you feel when you go home at the end of your shift?'"
DeWitt's family moved her from the nursing home after the incident, which led to a citation from the state Department of Public Health and the termination of one of the CNAs. DeWitt died in November at a skilled nursing facility in Santa Paula. The case was filed in May, and Shoreline has not yet responded.
The additional funding expires next year, but Gov. Arnold Schwarzenegger wants to extend the plan five years with increased audits and fines for understaffing.
Local nursing home representatives support the extension but are wary of increased regulation. Albrechtsen argues nursing homes scrambling to survive can't afford to spend money on patient care. "In order to provide quality, you have to have a viable business," he said, then referring to the 2004 law. "AB1629 will help us be viable."
Stein likes the concept but isn't sure she trusts the follow through. If there are provisions that force nursing homes to invest new funding on quality and not profit, she thinks the law could be a boon. It could deliver more nursing, more dignity to people in a place where they don't want to be.
"These individuals are tucked away," she said. "They're invisible to the community."