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Article:
"Casualties of Care"


Original source:
http://www.pe.com/reports/2008/casualtiesofcare/stories/
PE_News_Local_S_publichealth08.e97977.html

The Press–Enterprise

Many nursing home patients and family members say their complaints about caregivers are dismissed with little explanation or result in minimal punishment

07:34 PM PDT on Saturday, June 7, 2008
By LORA HINES
The Press–Enterprise

Christopher McNeill remembers the audible snap when nursing home employees lifted him into a van while his foot was entangled in a seat. Someone made a crack about his creaky bones, he recalls.

A paraplegic, McNeill didn’t feel any pain. But the next day, when he saw the swelling and bruising in his left leg, he knew something was wrong.

Still, the 45–year–old former construction worker waited a week to ask for help, because he was afraid of getting kicked out of the San Bernardino nursing home where he had lived for two years.

McNeill, after eight weeks without adequate treatment, sought help at a hospital and filed a complaint with the state agency that oversees nursing homes. The state cited and fined the nursing home six months later: $390 for bungling McNeill’s medical records — and nothing for ignoring his injury and, he says, persecuting him when he tried to get help.

McNeill is among thousands of nursing home patients and their relatives who have found little satisfaction when they complained.

From March 1, 2004, through Dec. 31, 2007, state investigators found that more than 56 percent of such complaints did not merit action. In addition, about 9 percent, some dating back as far as 2004, had yet to be resolved.

Many nursing home patients and their families said they feel frustrated and betrayed by a regulatory agency they thought was supposed to represent them.

On top of the high percentage of dismissed complaints, patients, advocacy groups and government agencies describe numerous shortcomings in a system that’s supposed to protect hundreds of thousands of medically fragile people in California.

The California Public Health Department’s nursing–home licensing arm, the office responsible for investigating complaints, has been under scrutiny by state and federal officials concerned about patient welfare. Among their criticisms:

The licensing agency often fails to investigate a complaint promptly. Under state law, investigators are supposed to respond within 10 days, or within two days if patient well–being is at risk.

Inspectors take too long to complete investigations. Some Inland investigations have taken more than a year.

Gov. Schwarzenegger vetoed legislation that would have forced the agency to finish investigations within 40 days.

Investigators don’t adequately explain their findings to the patients or family members who complained. Some families said all they got was a phone call or a letter stating the investigation results, without explanation.

Routine inspections are predictable, sometimes late and often too lenient.

Fines imposed on nursing homes provide little incentive for improvement because they can be negotiated down or appealed and may not have to be paid for years. From 2004 through 2007, fined nursing homes paid the full amount in only 16 percent of cases. Some fines were reduced as much as 80 percent.

Kathleen Billingsley, the state’s health care facility–licensing chief, has blamed many of the problems on staffing shortages and lack of training. The state Public Health Department hired about 150 new inspectors in 2006–07 to bolster the 400 positions that already existed.

Billingsley’s spokeswoman, Lea Brooks, said having more inspectors doesn’t necessarily mean more complaints will be substantiated. The bottom line is that inspectors in many cases don’t find evidence the nursing homes violated any regulations.

"A death can occur without violation of regulations and/or statutes, especially in long–term care facilities where care is being provided to medically fragile residents with multiple and complex conditions and illness," Brooks said in an e–mail.

Nursing home industry representatives have said they want state regulators to perform timely complaint investigations and nursing home inspections using consistent criteria.

"Do bad things happen in nursing homes? Yes. Bad things happen everywhere," said Betsy Hite of the California Association of Health Facilities, an organization representing nursing homes and other long–term care providers. "Our patients would not be with us if they were not medically compromised. Accidents do happen."

Nursing home reform advocates say the state Public Health Department faces no consequences if it does a poor job of policing nursing homes. Even the federal government, which pays most nursing homes bills, hasn’t put teeth in its requests for improvements.

A California consumer group filed a lawsuit in 2005 to force state inspectors to investigate hundreds of backlogged cases and respond to new complaints within 10 days, as they are supposed to do.

Sen. Elaine Alquist, D–San Jose, was one of a few lawmakers who sought a state audit of the California Public Health Department’s licensing division in 2006. Seven years before that, she sponsored a bill that required the department to post nursing home complaints on its Web site, but that didn’t happen until this year.

"I plan to continue holding the Department of Public Health accountable for its responsibility to protect our family and friends in nursing homes," Alquist said in an e–mail. "I didn’t think that it would take the department nine years to implement my bill on Internet posting of nursing home complaints, but it did. If I have to author additional legislation or hold more oversight hearings, I will."

Complaints Not Verified

The state Public Health Department’s Riverside and San Bernardino district offices are among 15 statewide that together license and investigate an estimated 1,100 nursing homes. California has 755 inspectors, including 67 in the San Bernardino office and 77 in Riverside, to oversee all nursing homes, hospitals, medical clinics and other licensed health care facilities.

The two district offices, which together oversee 105 nursing homes, responded to 2,625 complaints between March 1, 2004, and Dec. 31, 2007, and concluded that 1,438 were unfounded.

"They’re all allegations," said Lorraine Sosa, director of the licensing agency’s Riverside district office. "We are not always able to substantiate complaints based on information from the complainant, or there is not enough information in the (patient’s) record. It’s not as though we have not thoroughly investigated things. The staff does everything it can to substantiate allegations. We are here to protect all residents and clients."

Elizabeth Plott Tyler, whose family owns five Inland nursing homes, said inspectors are tough and hold operators accountable.

"I don’t feel like we’re getting any breaks from the regulators," said Tyler, a lawyer who represents her family’s business and other nursing home owners.

Officials at the Centers for Medicare and Medicaid Services keep track of complaint numbers and how many are substantiated. In 2003–04, 30.9 percent of complaints nationwide were determined to be valid, while California substantiated 14.2 percent. Only Kentucky substantiated a smaller percentage.

Medicare–Medicaid spokeswoman Mary Kahn couldn’t immediately explain what those numbers say about the quality of nursing homes or the states’ oversight.

"I don’t understand why you would ask the question. The answer is so obvious. We are responsible for the quality of care in the nation’s nursing homes."

Since early April, Kahn’s office has not responded to repeated telephone and e–mail attempts by The Press–Enterprise to get more recent complaint investigation statistics and other information.

Byrd Miller’s August 2007 complaint about his wife’s care was among 219 reports filed last year in Riverside County that state inspectors classified as unsubstantiated. Late last year, he appealed to the state Public Health Department’s deputy director of licensing and certification in Sacramento, and on May 27, he learned that he had won his appeal.

But the outcome left him dissatisfied. The nursing home was ordered to submit a correction plan detailing how it would ensure patient safety, he said. The home was not fined, he said.

"There is no incentive there to do any better," he said. "It’s like me getting stopped for speeding and telling the officer that I won’t do it again. It’s a slap in the face."

Miller said he doesn’t understand why Riverside district inspectors couldn’t validate his complaint while those in Sacramento could.

Miller’s wife, Norma, fell Aug. 24 as she tried to leave her bathroom at Devonshire Care Center, a Hemet nursing home. She called for assistance, but no one responded, he said.

Devonshire administrator Madelyn Smith declined to comment.

A stroke had left Norma Miller unable to get around on her own, and two people were supposed to help when she needed to move, according to her medical record. One person assisted her on Aug. 24 but was not present when she fell, according to the record. She had fallen three days earlier, injuring her knee, but the chart doesn’t indicate whether anyone had been helping her that day.

Norma Miller’s medical record doesn’t state why she was alone when she fell Aug. 24, or how long she waited for someone to help her. She fell on her buttocks but refused an X–ray because she was in too much pain, her medical record states.

"I know she must have been in agony," Byrd Miller said.

Norma Miller was sent to a hospital three days after her fall because her health had deteriorated and she had stopped eating, her record states. Two weeks later, her husband took her home.

Norma Miller died Sept. 16 of congestive heart failure at the couple’s San Jacinto home. She was 69.

"Something has got to give," said Byrd Miller, who recalled the recent controversy involving the treatment of cows at a Chino slaughterhouse. "People are more worried about the animals, but not the old people lying in nursing homes."

Federal Scrutiny

It is well–documented that Medicare–Medicaid and lawmakers have been aware of problems with the investigations of nursing home complaints since at least 1999. That year, officials acknowledged at a federal hearing that they were launching efforts to examine the complaint process to come up with national standards that would better regulate it.

In about 2000, Medicare–Medicaid commissioned the Center for Health Systems Research & Analysis at the University of Wisconsin–Madison to conduct two research projects: improving nursing home complaint investigation processes and improving nursing home enforcement.

It’s not clear what became of the research. No one at Medicare–Medicaid responded to questions about the studies’ results or costs. The university researcher who headed the project did not return telephone calls.

Staff members for Sen. Herb Kohl, D–Wis., and the Senate Select Committee on Aging, which he heads, said Kohl was not aware of the nursing home complaint studies.

Committee members, including Kohl and Sen. Charles Grassley, R–Iowa, are sponsoring legislation they think would improve the nursing home complaint process, said Anne Montgomery, a committee spokeswoman. It would establish a nationwide complaint–resolution process for inspectors to follow, she said.

"One problem is people don’t know how to file a complaint or fear retribution," Montgomery said. "We have serious concerns."

Lawmakers, consumer advocates, researchers and ombudsmen who monitor nursing home operations say complaints are a last resort for patients and their families, who fear confrontation and retaliation from nursing home employees and administrators.

Some advocates and lawmakers said the investigations depend on inspectors with varying degrees of skill.

Toby Edelman, senior policy attorney for the Washington, D.C., consumer group Center for Medicare Advocacy Inc., thinks some inspectors are poorly trained and won’t substantiate an offense unless they witness it.

Pat McGinnis, executive director of California Advocates for Nursing Home Reform, said the state’s low rate of substantiating complaints could be a result of delayed or sketchy investigations. Some investigations are started months after a complaint, and some rely on medical records that are inaccurate or incomplete or on interviews with the people said to be at fault, she said.

"A low substantiation rate shows the state is diminishing what clients are saying and not taking complaints seriously," she said.

In 2004, Grassley told then Medicare–Medicaid Administrator Mark McClellan that nursing home inspectors had told his staff that complaints rarely were thoroughly investigated.

"Patients and/or family members are rarely interviewed; administrative and medical records are rarely reviewed; valuable information is routinely recorded incorrectly; and the word of the facility is often taken at face value over that of a resident and/or family member," Grassley stated in his letter to McClellan. "As a result of these inherent procedural failures, complaints are rarely substantiated and serious quality problems are therefore not corrected."

In January this year, Grassley contacted Kerry Weems, Medicare–Medicaid’s acting administrator, about a botched investigation of a complaint about a Waterloo, Iowa, nursing home. Iowa inspectors did not substantiate the complaint, which alleged that the nursing home’s staff had ignored the patient’s deteriorating health. Medicare–Medicaid officials later found that the Iowa inspectors had failed to investigate the complaint properly.

In an April 30 interview, Grassley said he believes the Waterloo case could be evidence of a more widespread problem with the investigation of nursing home complaints.

"It’s probably not an isolated incident," he said.

A decade of involvement in nursing home oversight has led Grassley to believe greater vigilance is needed to ensure state agencies properly investigate complaints and that federal inspectors hold them accountable, he said.

Nursing home inspections tend to be predictable, Grassley said, "and I think that’s a bad situation."

California was among a handful of states with significant problems in the late 1990s, when he began looking into the issue, Grassley said.

Legislators’ scrutiny has brought about some improvements, he said. "But we still have a ways to go."

Medicare–Medicaid annually reviews state agencies that license and inspect nursing homes and other health care facilities that receive federal payments.

The agency’s 2005–06 review of the California Department of Public Health indicates that nursing home inspectors:

Did not always initiate investigations on time; in nonurgent cases, almost half were not initiated within 10 days.

Did not complete investigations in 20 days — the federal guideline — in about 44 percent of the cases evaluated. The state does not have a time limit for completing investigations.

The state Public Health Department’s written response to the Medicare–Medicaid review states that the problems resulted from scheduling errors, job vacancies and turnover, computer problems, untrained staff and overwhelming workloads. Remedies include computer system upgrades, more training, policy and procedure changes and quality reviews and audits, according to the response.

A July 2006 report by the office of the inspector general for the U.S. Department of Heath and Human Services also found that states did a poor job of investigating nursing home complaints. Moreover, Medicare–Medicaid didn’t do a good job of holding state inspectors accountable for complaint investigations, the report said.

Unsubstantiated

In 2007, Joanne Kidwell filed a complaint with Inland nursing home inspectors after her father fell face–first out of a wheelchair, injuring his arms. Investigators concluded that her complaint was unfounded.

Nursing homes are under pressure to use restraints sparingly. In the past, the industry has been accused of using restraints as a substitute for keeping an eye on residents. State inspectors monitor the use of restraints.

A week before the fall, Kidwell said, a nursing home employee told her that her father, George Lauer, then 96, no longer would be restrained when he was in a wheelchair. That was contrary to Kidwell’s wishes, which were stated in his nursing home record. Lauer has been confined to a wheelchair since he broke his hip a few years ago and doesn’t have the strength to keep himself upright, Kidwell said.

Lauer had made a living rebuilding vehicles until he retired about 30 years ago, his daughter said.

"He was clever with his hands," Kidwell recalled. "It’s hard to envision him like that when you look at him now."

Kidwell had photographed the garish hemorrhages beneath the skin on her father’s arms.

She said Lauer’s injuries were not documented in his medical record when she reviewed it in August, after the investigation. Inspectors told her they had used those records in determining that her complaint was unfounded, Kidwell said.

"It appears to me that the Department of Public Health did not even question the fact that his records did not mention any injury in spite of the photos that we submitted to them," Kidwell said. "Nursing homes in general have nothing to fear when the very department they work under is totally ineffective. It is quite clear that (the department) is protecting the nursing homes more than the patients in their care."

An inspector investigated Kidwell’s complaint in one day — May 10, 2007 — said state Public Health Department spokesman Ken August in an e–mail. Kidwell didn’t get the results until August 2007.

August said heavy workloads with higher priorities prevented surveyors from contacting Kidwell sooner with their findings.

Representatives of ManorCare in Hemet, where Kidwell’s father lives, have said patient confidentiality laws prevent them from discussing Lauer’s care. ManorCare spokeswoman Julie Beckert said the nursing home is in compliance with the state Public Health Department and pointed out that Kidwell’s complaint was determined to be unfounded.

Nursing home employees have been using Velcro lap belts to restrain Lauer in his wheelchair since the end of last year, Kidwell said.

Slow Investigations

In 2005, the California Advocates for Nursing Home Reform sued the state Public Health Department’s licensing division to force it to follow state law and to start complaint investigations within 10 days.

"They had a thousand backlogged complaints," said McGinnis, the organization’s executive director. "Some of them weren’t even investigated until a year after they were reported. What are the chances they were going to substantiate them?"

A year later, a San Francisco Superior Court judge ordered the state Public Health Department’s licensing division to start investigating 1,300 then–backlogged complaints and to begin investigating 80 percent of new complaints within 10 days.

State inspectors have complied.

"Apparently, a lawsuit is exactly what it takes to get something done," McGinnis said.

She said no government agency, including Medicare–Medicaid, holds California’s nursing home licensing agency responsible to the public. Medicare–Medicaid, in its own 2005–06 annual review of the state Public Health Department, describes problems with the way complaints are handled, she added.

"Did they know the state wasn’t investigating complaints the way they were supposed to? Of course they did," McGinnis said. "They chose not to do anything about it."

A 2007 report by California’s state auditor also found that Public Health Department inspectors failed to quickly respond to complaints or to strongly state the extent of problems. Inspectors also did a poor job of communicating with people who had filed complaints. Similar concerns had been raised in a 2006 report by the state Legislative Analyst’s Office, which provides fiscal and policy advice to the Legislature.

According to the 2007 state audit, roughly 17,000 complaints were filed over 21 months ending April 14, 2006. Just 51 percent of the investigations were started within 10 days, and fewer than four in 10 were finished in an acceptable amount of time, the audit found.

In October, Gov. Schwarzenegger vetoed a bill that would have required nursing home inspectors to complete their investigations within 40 days and to better explain their conclusions. He said it would be premature because the state Public Health Department had significantly improved its handling of complaint investigations.

The state Public Health Department last reported Feb. 28 that it is in 99 percent compliance with the court’s order to perform investigations within 10 days.

A Death, A Complaint

Joseph Baroncini and his sister, Alda Norris, have been waiting almost five months for information on two complaints they made about two different Hemet nursing homes where their mother had stayed before her death on Sept. 16, 2007.

They see red flags when they look at their mother’s medical records.

On Aug. 28, Olga Baroncini, 81, of Hemet, was sent to Ramona Manor Convalescent Hospital in Hemet to recover from what doctors suspected was clostridium difficile, a bacterial infection. She was expected to be there five to seven days.

At Ramona, her condition deteriorated. After eight days, her son called 911, and she was taken to Hemet Valley Medical Center. Doctors diagnosed her with ulcerative colitis, acute renal failure, malnutrition, chronic blood–loss anemia, dehydration, urinary infection, deep venous thrombosis and a pulmonary embolism, but not the bacterial infection originally suspected, according to her medical records.

Her declining health was not documented in her medical record at Ramona Manor until Sept. 5, the day she went to the hospital.

On Sept. 13, Olga Baroncini was sent to Hemet Valley Healthcare nursing home to recover. She died three days later after suffering a suspicious blow to her head.

Her medical record did not include a head injury she suffered Sept. 14 during physical therapy until her son reported it. He said his mother told him that she hit her head on the back of a chair as she was being helped by a physical therapist, the record states.

"I would have never known if she hadn’t told me," Joseph Baroncini said.

He said his mother seemed OK the last time he talked with her, the night before she died. "She said, ’I love you, Butch. Thanks for coming. Give Sparky a hug.’ "

On Sept. 15, Olga Baroncini lost consciousness and ended up at Loma Linda University Medical Center. A brain scan revealed bleeding. She died the next day.

Norris and her brother blame the nursing homes.

"She had never been sick," Joseph Baroncini said. "What they did was as bad as murder."

They filed written complaints with the state Public Health Department at the beginning of the year and explicitly stated that they want to be present when inspectors conduct their nursing home investigations, documents show. State inspectors said they were unable to reach the family and completed their on–site visits without Norris and Baroncini, said August, the Public Health Department spokesman.

"It comes down to nobody cares," Baroncini said. "Human life is supposed to be more important than that."

Norris and Baroncini said they are prepared to keep fighting, through lawsuits and legislators, if their complaints are determined to be unfounded.

"You have to stay on top of people," Norris said. "You have to let them know you hold people accountable. You have to fight for the people you love."

Ramona Manor administrators said they didn’t know Norris and Baroncini had complained to inspectors, said industry spokeswoman Hite, who responded on the facility’s behalf.

Steve Collier, administrator at Hemet Valley Healthcare’s nursing home, couldn’t be reached after an exchange of messages between him and The Press–Enterprise.

August said the investigations of the two Hemet nursing homes haven’t been completed.

Fines Ineffective

A 2007 report by the General Accountability Office, a congressional agency that audits federal programs, concluded that fines are routinely reduced or avoided altogether. Nationally, nursing home inspectors preferred to avoid fines and instead worked with the homes on correction plans and follow–up inspections.

California’s nursing home inspectors issue three kinds of citations — B, A and AA, the most serious — based on the level of harm caused to a resident. Fines range from $300 to $100,000 for offenses from staffing shortages and theft to permanent injury and death.

A Press–Enterprise review of California records for 2004 through 2007 showed that allegations of sexual assault, injury, humiliation and physical violence involving Inland nursing home residents often resulted in fines of a few hundred dollars, many of which were never paid. Even when stiffer fines were imposed for serious injuries or deaths, an April review of state records showed that nursing homes had not paid in slightly more than two–thirds of the cases.

Under state and federal law, nursing homes and special–care facilities can pay a fraction of the fine, provided they agree not to appeal the penalty.

More than 50 Inland nursing homes were cited and fined between March 1, 2004, and March 30, 2007, records show. Of the $1.2 million in fines assessed, the nursing homes had paid about $284,000 by the end of March 2007, according to the records.

Statewide, nursing homes and special–care facilities fined from January 2003 to March 2007 for patient deaths and other violations had paid less than half of nearly $12.6 million owed during that period, according to state records.

Citations can be — and often are — appealed, a process that can take years. Fines don’t have to be paid until a resolution is reached.

Nursing homes can spend $25,000 to $50,000 contesting fines and citations, said Tyler, the nursing home owner.

Fines affect a facility’s insurance premium and impact people’s perceptions of how well a nursing home operates, she said.

"An appeal doesn’t mean there aren’t ramifications for what’s on the record," Tyler said.

The General Accountability Office repeatedly has reported that nursing home penalties, including fines, are ineffective because violations are minimized and fines are cut or never collected.

The agency suggested that fines might be more effective if they were collected before appeals are resolved.

Inspections Delayed

Federal and state records reveal that even routine inspections can be late and lax. Federal law requires nursing homes that accept Medicare and Medi–Cal patients to be inspected every 15 months. Inspectors assess facilities for health and safety violations during annual inspections.

In early April, at least 16 nursing homes in San Bernardino and Riverside counties were overdue for required annual inspections, according to Medicare–Medicaid’s consumer Web site, Nursing Home Compare, at www.medicare.gov. However, state Public Health Department records indicate that only 10 of those facilities, all in San Bernardino County, got late inspections.

Medicare–Medicaid’s 2005–06 annual review of the California Public Health Department’s handling of nursing home inspections also found delays. The review showed that state inspectors failed to perform routine inspections on time in at least eight cases.

Suanne Buggy, Public Health Department spokeswoman, said the department’s review results were not extraordinary.

In their written response to Medicare–Medicaid, state Public Health Department officials blamed a scheduling error for missing one annual nursing home inspection. The other seven delayed inspections cited in Medicare–Medicaid’s evaluation had been completed on time, officials said.

The state’s 2007 audit found that state Public Health Department inspectors had failed to detect problems during nursing home surveys, failed to follow up on problems, ignored state standards and performed predictable inspections. The report found that deficiencies were downplayed in nine of the 35 nursing home surveys it examined.

Billingsley, the licensing and certification director, has disputed the findings.

Federal records showed that the nursing home where David Cruz’s son lives hasn’t been inspected since June 8, 2006, nearly two years.

But state Public Health Department officials said Plott Nursing Home in Ontario last was inspected Sept. 21, 2007, about two weeks late. State officials said most inspections at Inland nursing homes were completed on time. But recent inspection information, including health and safety deficiencies, couldn’t be viewed on Medicare–Medicaid’s Nursing Home Compare Web site.

Cruz said he’s not sure more timely inspections would make a difference.

In the 10 years that his son has been in a nursing home, Cruz has seen inspectors in action.

"They walk in with blinders on. They’re not asking the right questions. They’re not looking at the building."

Inspectors publicly ask patients and employees broad questions, such as, "How are things going?" Cruz said. Many people are afraid to be honest because they fear retaliation, he added.

Cruz’s 28–year–old son, David Cruz Jr., has required nursing home care since October 1998, when a crash left him with severe brain damage. Cruz goes to the home at least twice a day to oversee his son’s medication, and he spends two nights a week there. Cruz said he once stopped the staff from giving his son wrong medication. He believes his vigilance and complaints to management have kept his son alive.

Tyler said Cruz has no reason to fear that his son will be harmed when he is not there.

Cruz said he used to take his complaints to management, but he was dissatisfied with the response. Now he complains to the state Public Health Department and writes to legislators.

"They wanted to throw him out because I was complaining so much," Cruz said. "I told the administrator, ’What makes you think the grass is any greener anywhere else? This is happening everywhere.’ "

Tyler said Cruz sometimes identifies legitimate problems that require change.

"I encourage him to push us to be better," said Tyler, whose family has owned the facility since 1946. "I feel so horribly for this guy. We go through periods of time where we work well together."

She said her family would not have remained in business for three generations if it did not care about people.

"The life’s blood of a facility is new patients," Tyler said. "This is a business, and as a business, you want as many of your beds to be full. We are not in this profession because we want to harm people."

Afraid to Complain

After a six–month investigation, the nursing home where two caregivers accidentally broke Christopher McNeill’s leg paid a fraction of the fine levied.

Investigators fined the nursing home $600 — later reduced to $390 — because administrators didn’t review and update McNeill’s care plan. McNeill says the home should have been punished for not reporting his injury to state regulators and failing to provide adequate medical care.

August, the Public Health Department spokesman, declined to comment on McNeill’s case. Generally, he said, complaint investigations include observations, interviews and document reviews.

"There must be sufficient evidence based upon observations, interviews and/or documentation to substantiate that a violation occurred," August said.

Del Barrientos, administrator at Medical Center Convalescent Hospital, McNeill’s former nursing home, declined to discuss the care the man received.

"I don’t think I can do that right now," he said. "There is a court case involved, and lawyers."

Roberta Wertenberg, San Bernardino County’s long–term care ombudsman, said nursing home patients and their families have complicated relationships with the people who provide the care on which they rely. They often do not complain to inspectors because they don’t want to be identified as troublemakers, and they blame themselves for expecting too much from employees, she said.

"We have heard people say, ’I don’t want the person to get fired,’ " Wertenberg said.

McNeill said he told nursing administrators a week after the injury that he had been hurt when workers loaded him into a van.

"I didn’t want any trouble," McNeill said.

A week later, the nursing home staff X–rayed his ankle, although he told them the injury was higher on his leg, he said. The X–ray showed no break so McNeill was given a drug to reduce the fluid build–up in his leg, he said.

McNeill said he believes staff members were aware that his leg was seriously injured, but they ignored it because they feared they would lose their jobs.

Eight weeks after his leg first swelled and turned black and blue, a staff member was helping him into bed when she noticed his leg swinging side to side at the knee, McNeill said. He remembers her telling him, "You really need to go to the hospital."

The next day, he wheeled himself to a bus stop and took a one–hour ride to Arrowhead Regional Medical Center in Colton. X–rays revealed that his leg had been broken into two places — above and below his knee. But it was too late to repair the damage with surgery. Doctors stabilized McNeill’s leg with a brace. It won’t heal.

A day later, McNeill complained to state regulators. McNeill said the attitudes of the nursing home’s staff, many of whom he considered family, left him devastated. They were more concerned about whether he would sue them than his well–being, he said.

Barrientos declined to respond to the allegation.

McNeill moved out of the nursing home and sued the facility last year.

"Sometimes when I’m on the bus, I just sit there and cry," McNeill said. "It’s so upsetting to me. I knew they really did me wrong."

Staff writer Ben Goad contributed to this report.