From Reader’s Digest
The shocking truth about what’s going on in America’s nursing homes.
By Andrea Billups, Additional reporting by Fran Lostys
Loren Richards, an 84–year–old Kentucky farmer, spent his last days bedridden and in intense pain. A bowel impaction that went neglected and untreated for several days finally caused a fatal heart attack, after a morning spent screaming for a doctor who never came.
His family didn’t know the truth of his terrible demise at the Beverly Health and Rehabilitation nursing home in Frankfort until weeks after he’d been buried. Daughter Jan Richards was at a church service when a man in front of her, who drove the city’s handicapped van and had transported local nursing home residents, turned around to offer his condolences. It was so sad, he said, that her father had to die "suffering like that and nothing was done for him."
Suffering? Nothing done? Richards, her brother Phil and sister Wanda Delaplane, had been told by the nursing home staff that his passing had been perfunctory. He’d had a history of heart problems and a stroke, after all. They believed his care had been good throughout his five years at the home, although after recent staff cuts, the family had noticed he wasn’t always as clean as they’d hoped.
But finding out their father –– one of 11 children born in hardscrabble Appalachia, a man who’d worked his entire life tending his crops and later driving a forklift –– died pleading and screaming to no avail was enough to make them heartbroken. And furious.
They sought answers from the nursing home’s staff but learned little. So Delaplane, an assistant attorney general in the state’s consumer affairs office, went straight to the state agencies charged with regulating care facilities and asked them to investigate. Two found independently that the nursing home had neglected her dad’s condition, and each cited the facility for failure to provide proper care. Among other things, Delaplane learned that 11 of the 13 staff on duty that day were on break at the same time.
Four years later, on May 4, 2006, a seven–week trial ended with a Frankfort jury returning a $20 million verdict against the home. The facility appealed, maintaining that its treatment was appropriate, and agreed to an out–of–court settlement. Delaplane attended the proceedings faithfully. "I had to live my dad’s death over each day, but it was worth it," she says. "It was a way of honoring him and having the truth of his death be known."
She also hopes it will help call attention to a growing nationwide problem –– the serious, sometimes fatal neglect of nursing home residents. While many cases become public only through lawsuits, there’s compelling evidence that thousands of seniors suffer injury and death each year from preventable causes like malnutrition, dehydration and infected bedsores.
Data from the U.S. Centers for Disease Control and Prevention, analyzed by the Detroit Free Press, show that these conditions were the combined cause of nearly 14,000 deaths in nursing home patients between 1999 and 2002. And that figure is likely low, since government agencies rely heavily on nursing homes to self–report such incidents. Consider these findings from recent studies:
- In 2003, the National Research Council estimated that one to two million Americans 65 and older were "injured, exploited or otherwise mistreated" by a caretaker.
- Also in 2003, the Government Accountability Office –– the investigative arm of Congress –– released data that showed more than 300,000 nursing home residents live in facilities where they are at "great risk of harm due to woefully deficient care."
- In 2006, a report issued by the University of Kentucky on behalf of the National Committee for the Prevention of Elder Abuse revealed that, in one year alone, adult protective services investigated 461,135 reports nationwide of neglect and abuse (the latter includes physical, sexual and emotional harm) and substantiated 191,908 of them. Of these cases, 26.1 percent were from caregiver neglect.
In Incredible Pain
Behind this appalling care is a familiar problem in the nursing professions: too few staff assigned to too many patients. "Everyone should know there is a certain amount of neglect that goes on in every nursing home because they simply don’t have hands–on staff to take care of people," says Barbara Hengstebeck, who was Florida’s nursing home ombudsman for six years before becoming executive director of the nonprofit Coalition to Protect America’s Elders. In fact, the Department of Health and Human Services found that more than 90 percent of nursing homes don’t have enough staff to provide proper care.
Janet Wells, a policy expert at the National Citizens’ Coalition for Nursing Home Reform in Washington, D.C., says, "We frequently get calls from nursing assistants who say they are taking care of more than 30 residents a night." Yet Wells’s organization warns that this is more than twice the number of recommended patients per certified caregiver.
It’s shameful that facilities are routinely understaffed, given that the majority of nursing homes are for–profit enterprises and operating in the black. Nonetheless, staff tend to be overworked and poorly paid, leading to a high turnover rate of caregivers.
According to a GAO study, replacement rates at some facilities approach 100 percent a year. What’s lost, of course, is institutional memory and the continuity of care that goes with it.
The family of Glen Macaux learned the terrible price nursing home residents can pay when staff are inattentive. Macaux, a father of five who ran a life insurance office in Green Bay, Wisconsin, was fairly robust when he entered a nursing home for rehabilitation after knee surgery at age 82. He’d been diagnosed with Parkinson’s disease and had diabetes, but both conditions were stable. "It wasn’t like he was in bad shape," daughter Carol Macaux, 52, recalls. "The expectation was that after he had his physical therapy, he could use his leg."
After the first week, though, things went very wrong. Glen Macaux seemed groggy and was becoming unresponsive. According to Carol, when the family questioned the nursing home staff, "they just said, Well, he’s on antibiotics." Then a physical therapist noticed redness near the surgical bandages on his knee.
"It turned out they didn’t change [the bandage] or inspect the surgery wound for six days," Carol says. "When they moved him into his wheelchair, I could see him wince. My eyes were just bugging out because he was in such incredible pain."
Rushed to a hospital, Macaux was already suffering from septic shock and renal failure, with a pressure sore now growing on his heel. "He was literally at death’s door," his daughter contends. His knee incision required three painful debridements, which meant doctors had to detach ligaments and tendons to remove the infection. He would never regain use of his leg. "The surgical nurse started crying because of the state of the wound," Carol says. "Everyone was just mortified that [the nursing home] had allowed this to happen." (The family ultimately settled with the nursing home, which denied any responsibility.)
Part of the shock for families who experience poor nursing home care is that they’re usually paying a bundle to keep their loved one in a facility. The average cost of an annual stay is $71,000 for a private room and $62,500 for a semi–private room, according to a national study released in March 2006 by Genworth Financial, which sells long–term care insurance.
It’s especially galling that these prices don’t guarantee basic care, leaving older people vulnerable to very preventable illnesses. "Dehydration is extremely common," says Wells, whose organization briefed Congress last April. "It’s a terrible problem, people just being thirsty and not getting access to water."
Malnutrition and weight loss are also common, she says. "It’s not atypical for a nurse to bring the food tray and come back in half an hour and take it away. There are heartbreaking stories of people who need help eating and drinking and don’t get it."
And that can trigger a string of complications, says Dr. Loren G. Lipson, a geriatric physician who teaches at the University of Southern California. "Once you are malnourished and dehydrated, you are much more susceptible to pressure sores and at risk of compromising your immune system," he says. "The potential for infection is greater, and in severe cases, these conditions can lead to delirium."
Ed Armstrong learned his mother’s pressure sores were severe only after an emergency room doctor roused him one morning and told him to get to the hospital. Emily Armstrong, 84, who had been in a St. Petersburg, Florida, nursing home after suffering a stroke, had not been moved or turned enough by staff while she was in bed. Sores had developed, and the doctor stunned Armstrong by showing him a leg wound on his mother that was so hideously infected, the hospital needed to amputate immediately.
Emily had been in the upscale Carrington Place nursing home for less than two months –– but that was enough time for her to develop a massive stage 4 infection that had eaten clean to her sacrum and ankle bone.
When Emily recovered from the amputation of her left leg, Armstrong sued Carrington Place and later reached a settlement with the facility, which has denied any wrongdoing. He then moved his mother to a Catholic facility, Bon Secours–Maria Manor, across the street from his home, where he felt sure her care would be better.
Yet during her stay at Bon Secours, her right ankle was broken. Armstrong suspects it happened when she was being moved in –– but he has received no answers from the home. The break did not heal, and before long, a sore developed and became infected. Once again, Armstrong found himself at the hospital making a second decision to amputate. Armstrong has also decided to sue Bon Secours. The nursing home is contesting the complaint, denying any culpability.
"She was like a carcass at that point," says Armstrong, his voice trembling as he recounts picking up his mother’s legless body to lay her into bed. "This is one of my last memories of my mother, and I think, My God, is this the end result of her care?"
With so many documented cases of elder abuse and neglect, and so many more suspected, you’d think oversight would be strenuous. It hasn’t been.
At the federal level, the Department of Health and Human Services spends money to train state inspectors, and Congress has legislated quality standards for nursing homes.
But the real hands–on oversight is designed to take place at the state level, with health agencies monitoring the quality of care and being able to impose fines or shut down homes. Every state is also required to have a "long–term care ombudsman program" that fields complaints from families or residents, as well as schedules visits to the facilities to gauge their quality.
However, it’s difficult for inspectors to spot signs of neglect during infrequent visits, and it’s far too easy for nursing homes to conceal their problems. New York’s Attorney General, Eliot Spitzer, announced this past January the arrest of 19 nursing home employees who were caught through hidden cameras neglecting patients. According to law enforcement reports, the caretakers moved call bells out of reach of patients, as well as watched movies, slept or even left the building when on duty. Spitzer contends they then falsified records to document that they had provided care. (To date, 14 have pleaded guilty.)
"Be There –– Often"
Last February in Michigan, Attorney General Mike Cox charged eight employees from the Big Rapids–based Metron Nursing Facility with 18 felonies in connection with the death of a 50–year–old resident (all have pleaded not guilty).
Sarah Comer, who had recently suffered respiratory and kidney failure, died from asphyxiation after the nursing home failed to refill her oxygen tanks. The morning she passed away, reports that she was dizzy went ignored by staff. Later, the medical examiner who looked into Comer’s death was not told that her oxygen tank was empty. Cox said the facility also falsified Comer’s medical records and covered up her asphyxiation.
Many experts believe that incidents like these are just the tip of the iceberg. The law requires nursing homes that receive federal money through Medicaid and Medicare to report incidents of abuse –– but self–reporting is hardly dependable. Randy Thomas, president of the National Committee for the Prevention of Elder Abuse, says, "If the nursing home is in charge of reporting and it’s their neglect, why report it? If you do, you try your best to make it all look not so bad."
Over several decades, legislators in Washington have tried to force the nursing home industry to provide better care, but without much success. There are new initiatives under way, some of which have a shot at bringing about real changes (see Getting Serious Abut Reform).
But no legislation will ever substitute for the best oversight of all: the vigilance of families. Thomas travels the country teaching law enforcement officers, judges, forensic nurses and ombudsmen how to spot signs of neglect in nursing homes. And he has a message for the concerned families of residents. "If they don’t have a lot of visitors and they have cognitive issues, then [staff] forget they are real people," he says. "They become more of a body that you have to change and feed, and it’s easier to neglect them. The best advice I can give families is to be there –– often."
Getting Serious About Reform
Legislation has done little to curb elder neglect in nursing homes, but that could change: A nursing home bill, sponsored by Rep. Henry Waxman of California, would require facilities nationwide to have enough nurses on duty to provide each resident with at least four hours of care per day. Florida has funded a similar law requiring nursing homes there to provide a minimum of 2.9 hours of direct care to each patient per day.
Arkansas may have passed the most effective reform to date: a 1999 law requiring that a coroner investigate every nursing home death. According to Pulaski County coroner Mark Malcolm, who authored the bill, in the first six months after it became law, his county alone reviewed 489 deaths and found 21 cases where the causes were unacceptable.
"Today, facilities can’t just say someone died of old age when the cause was sepsis from bedsore infections or starvation. Someone is going to notice," Malcolm says. "There are facilities closed as a result of the information we developed."