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Many view assisted living as just housing,
not health care. That’s dangerous

By: Ed Dudensing and Anthony Chicotel
(Special to the Sacramento Bee)
August 21, 2019

A new therapeutic and healing garden was opened at the Eskaton Care Center Greenhaven for residents to use.
(By Hector Amezcua)

California’s rapidly aging population, and the challenges posed by this so-called “gray wave,” have sparked much discussion among health care experts and policymakers. Gov. Gavin Newsom’s Master Plan for Aging, scheduled to be unveiled next year, affirms the need for decisive and strategic action. Reforming the assisted living industry must be a part of this strategy.

The graying of California has been a boon for assisted living programs, as families look for alternatives to traditional nursing homes for loved ones who are living longer. Assisted living centers appear attractive because they more closely resemble homes than hospitals, with comfortable living spaces, social programs and other amenities.

But as the popularity of assisted living continues to grow – and with it the economic clout of corporate owners – oversight and sound health care standards and practices have lagged, imperiling vulnerable people. We can attest to this firsthand: Recently, one of us represented the family of a 77-year-old resident of the long-term care mega-provider Eskaton, who choked to death after she was given powerful sedatives to chemically restrain her.

The tragedy, which resulted in a record $42.5 million verdict against Eskaton by a Sacramento jury, raised questions that go to the heart of assisted living policy in California: Why was a powerful psychotropic drug, in this case Ativan, improperly administered? Why were staffing levels and training inadequate to ensure safe and effective care? Why was oversight lacking, both inside the facility and on the part of regulators?

The answer lies in our dangerous tendency to view assisted living as housing, rather than health care. The level of care required by some assisted living residents can be indistinguishable from the level of care required by some patients in skilled nursing facilities.

Yet staffing and training requirements are far lower for assisted living programs, which, for example, don’t require a physician or nurse on-site, and do not have any minimum staff-to-resident ratios. Rising demand has only intensified the workload for assisted living staff. And the drive for profits creates an incentive to keep staffing levels lean and training minimal.

Powerful psychotropic drugs of such as Ativan may in some cases have therapeutic benefits, but they also are potentially dangerous and must be used judiciously under a physician’s order and supervision. Even though assisted living programs are required to have a medical doctor sign off on a particular medication’s use, undertrained and overworked staff often are left to make real-time decisions, especially when a resident is expressing discomfort through unruly behavior or not following instructions. This has become an issue particularly in popular memory care units, where Alzheimer and other dementia patients reside.

Since the Residential Care Facilities for the Elderly Act was passed in 1985, there have been numerous efforts to bolster oversight. Unfortunately, most reforms have focused on industry issues such as licensing and liability, and less on quality of care. While there have been additions to the state Health and Safety Code to include tiered “levels of care,” implementation has not followed.

Assisted living has many advantages. But if we are to be successful in caring for our growing ranks of elderly citizens, California needs to reset how it regulates the industry, increasing training, staffing levels and physician and nursing involvement.

This may impact the bottom line, but business priorities can’t supersede delivering responsible long-term care. This is a challenge we all – the governor, Legislature, industry and individual citizens – must confront head-on.

Anthony Chicotel is a staff attorney for California Advocates for Nursing Home Reform.
Ed Dudensing is a former deputy district attorney for Sacramento County who represents victims of nursing home and assisted living facility neglect and abuse.

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