"Nursing home plight revealed"
The Fresno Bee
Fresno patient stuck in hospital after care center refused to readmit her.
By Barbara Anderson / The Fresno Bee
For more than three months, Traci Escobar has been stranded at Saint Agnes Medical Center in Fresno after her nursing home wouldn’t let her come back.
The 43–year–old woman — who has a brain injury and is severely disabled — left the Hy–Pana House Care Center in east–central Fresno on Jan. 7 to go to the hospital for dehydration and diarrhea. But when doctors said she could go home four days later, Hy–Pana refused to take her.
The state says the nursing home broke the law and has to readmit Escobar.
Hy–Pana’s medical director says Escobar is welcome — but not her fiancé, who is also her conservator. And the fiancé, Michael Wilcox, says Hy–Pana is retaliating against him after he complained about Escobar’s care.
"Now, she’s homeless," Wilcox said.
Advocates for nursing home residents call it a case of "patient–dumping" — the illegal practice of closing the door on a resident without proper notice.
Sometimes it happens when a nursing home clashes with a patient’s family, but patient advocates say that doesn’t justify refusing to readmit a patient after a hospital stay.
While exact numbers are hard to track, patient advocates say dozens of residents like Escobar are discharged against their will every year in California, and they fear the number is growing. The practice is traumatic for residents and their loved ones — and costly for taxpayers, who must foot the bill for the hospital stay, which is much more expensive than care in a nursing home.
Nursing home representatives counter that challenges of involuntary transfers and discharges are rare in California, and that they should be kept in perspective with the thousands of discharges that are undisputed each year.
"I know the advocates want to make it sound like it happens a ton, but it really doesn’t," said Nancy Reagan, director of legislative affairs at the California Association of Health Facilities.
But Escobar’s situation "sounds like a classic case of dumping by the nursing home," said Michael Connors, an advocate at the California Advocates for Nursing Home Reform, a nonprofit organization that fights for the rights of long–term care residents.
"It’s appalling that the facility would use her illness and hospitalization as an opportunity and excuse to evict her."
Nowhere to go
"I want to leave here," Escobar said late last month from a wheelchair in her hospital room at Saint Agnes.
Saint Agnes doctors said Escobar was well enough to return to Hy–Pana on Jan. 11, four days after she had been admitted.
Hospital workers have been trying to find a place for Escobar, who has difficulty with speech and walking.
"We’re trying to do everything we can as a hospital to get the best care and ... the appropriate place of care for her," said Saint Agnes spokeswoman Jaime Huss.
But Wilcox said nobody has been able to find a place yet.
He said Escobar has received good care at Saint Agnes but needs intensive physical therapy that the hospital is not equipped to provide.
"I want her out of here in the worst way," he said.
Escobar suffered a brain injury in 2005 from an infection, Wilcox said.
"But she has every chance in the world of getting back up to 80%" with therapy, he said.
Each day, Wilcox spends hours by Escobar’s hospital bed. He wheels her out to a patio to get fresh air. They’ve known each other for 15 years and managed a campground together before she became ill, Wilcox said.
The couple moved to the Valley from Crescent City in September when Wilcox got a property management job, he said. He found Hy–Pana on the Internet and had Escobar admitted on Sept. 18 to receive physical therapy.
He spent days at the nursing home helping care for Escobar, he said. He worked evenings.
But Hy–Pana staff found Wilcox disruptive, said Dr. Stephen Grossman, the nursing home’s medical director.
Wilcox was hostile, aggressive and threatening when he was unhappy with care Escobar was receiving, Grossman said.
"The disruptive boyfriend got to the point where we had to lock the doors 24/7," Grossman said. "We had to hire a security guard to protect the residents as well as the staff."
Hy–Pana Executive Director Larry Meyer also said guards were hired.
But Wilcox said that’s not true.
"They didn’t hire a security guard until after the fact, until after I was gone," he said. "Most of the staff knew me, and most of the residents knew me. I had 100–year–old ladies grabbing my hand and asking for help."
Wilcox said he made complaints to the state about the care and about Grossman — whom he fired as Escobar’s doctor. That’s what Hy–Pana reacted to, he said.
"It’s not Traci they’re getting rid of," he said. "It’s me."
A hidden problem?
It’s difficult to gauge exactly how many nursing home residents are denied readmission and remain needlessly in acute–care hospitals for days, weeks or months.
The nursing home industry says it’s not a big problem.
Among California’s 1,100 nursing homes, there are about 275,000 discharges a year, said Reagan of the California Association of Health Facilities.
The state Department of Public Health logged 33 appeals filed by patients complaining they were refused readmittance.
But patient advocates said that’s not a good measure of the problem.
Discharge and eviction complaints increased nationwide 40.2% between 1996 and 2000, although they remain behind complaints about such things as accidents and lack of assistance, according to a 2003 report by the U.S. Office of Inspector General.
"People aren’t really aware of the fact that they have the right to appeal," said Barbara Jones, a senior attorney with the AARP Foundation in Washington, D.C., who specializes in health and economic issues that affect older Americans.
Ivan Flores, the program coordinator for the Fresno–Madera Ombudsman Program, agrees.
Flores helps resolve complaints and educate residents and their families about their rights.
He helped try to resolve Escobar’s case, which took longer than usual, he said.
Flores said he helps about half a dozen residents each year whose nursing homes did not hold their beds for seven days during a hospital stay, as required by law. He thinks that’s just a fraction of those who need help.
Fear of retaliation also can keep family members from complaining, the patient advocates said.
When a family member raises a concern about care, the reaction by nursing homes often is to look for ways to keep the resident "from being readmitted or keep the family from visiting," said Janet Wells, director of public policy for the National Consumer Voice for Quality Long–Term Care, formerly the National Citizens Coalition for Nursing Home Reform.
Nursing homes have legal alternatives to denying readmittance when faced with disruptive family members, state officials said.
While nursing homes cannot restrict family members from visiting their loved ones without a valid legal basis, they can ask a judge for a restraining order, officials said. And the nursing home also can work with the family member through a mediator to try and resolve issues.
Even as patient advocates report receiving more complaints, the number of appeals to the state does not appear to be keeping pace.
All too frequently, residents "just get sent elsewhere" when the nursing home refuses to readmit them, said Eric Carlson, director of the long–term care project for the National Senior Citizens Law Center. "And that’s wrong."
Fighting to go home
Wilcox said he learned that Escobar was not being readmitted to the nursing home when he received a call from a Hy–Pana nurse telling him to pick up Escobar’s belongings.
Patient advocates appealed on her behalf.
On Jan. 30, a state hearing officer ruled that Hy–Pana violated Escobar’s right to a seven–day bed hold.
The officer also found that Hy–Pana did not give Escobar a 30–day notification of its intent to discharge her, as required by law.
The hearing officer also found that Hy–Pana already had plans to discharge Escobar when she became ill Jan. 7. Grossman testified that Escobar would not benefit from further therapy, and that Wilcox had unrealistic expectations.
The nursing home was going to turn her over to Wilcox, whose only option would be to move her into his motor home.
Wilcox argued that was not a suitable place.
Hy–Pana didn’t have a discharge plan — as required by law — to make sure Escobar would get appropriate care in the motor home, the officer found. And Escobar still needs services at Hy–Pana, the officer found.
The hearing officer ordered Hy–Pana to immediately readmit Escobar to the first available bed in the nursing home.
On April 7 — more than two months after the decision — the state cited Hy–Pana. The home has 14 days to file an acceptable plan of correction that shows how it has remedied the problem and ensures it won’t happen again.
Meyer, the Hy–Pana executive director, said a correction plan has been submitted to the state. He did not respond to questions specifically about the appeal hearing, saying that to do so would involve sharing confidential information about Escobar. But he said the nursing home followed recommendations by Escobar’s doctor in its decision to discharge her.
And in a written statement, Meyer said: "Hy–Pana places the safety and well–being of its residents and caregivers as its highest priority. That’s what we did in this case. We are proud of the care that we provide in the community and stand by our commitment to high quality care."
The wrong place
Everyone agrees Escobar shouldn’t be in a hospital.
"It’s not safe for people to just live in hospitals for months on end," said Connors of the California Advocates for Nursing Home Reform. "It shouldn’t happen."
Keeping Escobar in the hospital is also costly to taxpayers — and expensive for the hospital.
Escobar has Medi–Cal and Medicare insurance coverage. Medi–Cal is for the low–income, and Medicare is for the aged, blind and disabled.
Medi–Cal pays about twice as much for a nursing home resident to be kept in the hospital — more than $300 a day — as in a nursing home.
But that’s still less than the hospital would be paid for a patient who needs acute medical care.
Saint Agnes would not say how much it has spent on Escobar in the weeks since doctors said she was well enough to return to the nursing home, but Medi–Cal rates show it could be losing almost $1,000 a day to baby–sit her.
Besides getting paid less for nonacute nursing home residents, hospitals need the beds they occupy. Hospitals in Fresno operate at capacity or near–capacity on many days, and patients can wait hours in emergency departments for beds to become available.
Question of enforcement
Nursing home eviction appeals take time.
That plays in the nursing home’s favor, patient advocates said.
Connors, of the California Advocates for Nursing Home Reform, said he met earlier this year with state health officials to talk about better enforcement of residents’ rights to readmission to nursing homes.
"Nursing homes are more aware that the state is not enforcing the law," he said.
The Department of Public Health should issue daily fines in such cases, he said. And they should refer cases that drag on to the attorney general for prosecution.
"The state has all sorts of sanctions it can apply," he said.
State health officials said they take enforcement seriously.
Kathleen Billingsley, deputy director for the Center for Healthcare Quality, said in a written statement: "The Department of Public Health vigorously enforces the law in protecting the health and safety of California’s vulnerable residents in health–care facilities. Public health is our top priority."
Billingsley said in an interview that the agency’s goal is to process nursing home appeals as quickly as possible.
Her office is doing an assessment to see how long, on average, it takes cases to be processed, she said.
Billingsley said she could not talk about Escobar’s case due to confidentiality laws, but she noted that she was monitoring the case.
"I am working with staff to make sure this is moving forward quickly," she said.
An uncertain future
Escobar could end up anywhere, Wilcox said. It’s beginning to look like no place wants his fiancée, he said.
Discharge planners contacted nursing homes as far away as as Humboldt County about taking her, he said. Nursing homes don’t have to accept patients.
Wilcox said two area nursing homes interviewed him and Traci and accepted her. But when it came time to admit her, the homes called and said "no doctor would take her," he said.
Grossman said Wilcox has had offers to place Escobar elsewhere but has declined, an allegation Wilcox denies.
Wilcox said that the time Escobar has spent in bed at the hospital has weakened her — and the physical therapy she has missed will have to be made up, he said.
He’s not sure now whether he wants to put her back in a nursing home — but he doesn’t know whether she can receive intensive physical therapy anywhere else.
"This is about Traci getting help and us getting home," he said.