South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Contra Costa Times had an article about the class action lawsuit against Skilled Healthcare Group Inc that has been in trial for 7 months.  The case is to insure proper staffing in nursing homes which benefit the residents and the overworked employees of the nursing home.  The main issue in the trial is how to properly count the number of hours a person works.

Skilled Healthcare, along with its subsidiary Skilled Healthcare LLC, owns 22 nursing homes currently under scrutiny.  Whether the nursing homes maintained staffing levels required by the state is at the heart of the trial, which lasted more than 100 days. California law mandates that nursing homes provide a minimum of 3.2 hours of care per resident, per day.

One of the plaintiffs' attorneys, Michael Thamer, who specializes in corporate abuse, said that the case is not about documents, but a matter of patients getting their needs met. Thamer said that if one thing controls the activities of a major corporation, it is the budget.

”The message from the top is simple: Stay beneath the budget,” Thamer said in his closing argument before making way for Wroten. “This corporate greed is what has kept the defendant from adequately staffing their facilities.”

Skilled Healthcare, which filed for bankruptcy in 2001, has been growing steadily over the past five years. The company has since bought up nursing homes in Texas, Kansas, Illinois, Missouri, New Mexico, Nevada and California.

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Here is another article (from The Orange county Register) about how nursing homes used increased funding to pad their bottom line instead of increasing staffing.  Nursing homes were supposed to use the increased funding to hire more staff and increase the hours per patient.  One again, greed and profits take precedence over the care provided to nursing home residents.

Covenant Care's facilities are among hundreds of California skilled-care centers that received $880 million in additional compensation from the state since 2004 to increase staffing and wages at homes that serve Medi-Cal patients. An analysis by the non-profit newsroom California Watch found that 232 of those homes statewide slashed staff and let nursing ratios fall below the state minimum despite receiving the additional funds.

St. Edna and 12 other homes run by the Aliso Viejo-based Coventant chain were among those that stood out: They accepted $15 million in additional compensation from the state but still cut caregivers, California Watch found. Meanwhile, Covenant Care rewarded facility leaders with bonuses based, in part, on new profits.

The company's marketing promises the "highest quality of care" and a staff that treats consumers as "family." But St. Edna's overall service is rated "much below average" on the California Department of Public Health website – the lowest rating given. Staffing at the facility fell 5 percent between 2004 and 2008, settling below the state minimum of 3.2 hours per patient.

St. Edna received 119 citations and warnings over the past three years, compared with a state average of 54.

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There were several articles the past couple of weeks regarding Illinois' new  law improving the safety and staffing in nursing homes. Lawmakers unanimously approved legislation that would raise the standards of care and safety in Illinois' troubled nursing homes. See articles from the Chicago Tribune here and here.  The law reflects the 38 recommendations of Quinn's Nursing Home Safety Task Force, which was formed last fall in response to a Tribune investigation into attacks, rapes and murders in the subset of facilities that mix aggressive and vulnerable residents.

The law would require nursing homes to increase staffing levels, meet higher standards before admitting patients with serious mental illness, tighten existing criminal background checks, psychological screenings of incoming nursing home residents, and segregate the most dangerous residents in secure units where they should receive more monitoring and treatment. 

Among the bill's other key provisions is a mandate that nursing homes admitting people with serious mental illness obtain a new certification demonstrating that they can and will effectively monitor and treat those residents. The new standards for those homes would require the homes to have sufficient staff, including psychiatric professionals, on a 24-hour basis; training of staff on "managing aggression and crisis prevention"; and substance abuse programs.

The bill also would establish a database that would track violent incidents inside the homes. It would add safeguards to ensure the informed consent of residents administered psychotropic drugs. And it would expand the state's ability to deny operators permits to open new homes if they run facilities that have repeatedly violated safety standards.

Lobbyists for the nursing home industry agreed to increase nursing staff levels in the next four years to 3.8 hours of daily nursing care for each resident who needs skilled care, up from the current minimum of 2.5 hours. Quinn's task force had recommended 4.1 hours.

It took tense negotiations and an eleventh-hour deal to strike a historic bill that aims to undo a half-century of failed policies and end a legacy of violence in which nursing home residents were raped, assaulted and murdered.

I wish South Carolina lawmakers were open to the idea of protecting residents and reforming nursing home care.

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Another tale of greed and callous disregard to nursing home residents in California Watch.  The article explains how nursing homes in California were given an additional $880 million in government funding to increase staffing, boost wages, and improve care, but the vast majority used the extra taxpayer money to pad their bottom lines and give bonuses to corporate managers.

Most either cut staff, paid lower wages or let caregiver levels slip below a state-mandated staffing minimum. Many nursing homes appeared to use the cash infusion to help bolster their bottom lines, according to a California Watch analysis of state nursing home data.   The failure to improve staffing led to increased violations and neglect.

“Money talks, we know that,” said Molly Davies, director of the nonprofit Wise & Healthy Aging, the Los Angeles elder care ombudsman program. “If you’re going to give extra money, there needs to be an understanding of what the state is going to get in return and what those clients are going to get in return. I don’t think that was made clear.”

In 2008, dozens of homes operated beneath the decade-old staffing standard – which is set at a minimum of  three hours and 12 minutes of caregiver attention a day for every nursing home patient. In the homes where staffing lagged, patients suffered.  The state, however, has not issued staffing-related fines to any of the homes that failed throughout 2008 to reach the minimum staffing level, records show.

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The Indianapolis Star has found that many of Indiana's nursing homes employ fewer critical staff members than are needed to care for their residents. The newspaper found that staffing levels are low at the state's large number of for-profit nursing homes. The Star also found that those for-profit nursing homes dominate the ranks of Indiana's most poorly performing homes.

The newspaper reviewed thousands of pages of nursing home documents and analyzed data compiled by regulators and provided by the industry.  Its investigation found a system that tolerates nursing homes that skimp on quality to maintain profits. It found that pay and benefits are low, especially in for-profit homes.

State lawmakers should initiate minimum staffing requirements. The amount of time certified nursing assistants spend with residents in Indiana is less than in any other state and the District of Columbia. The Star said that the number of hours these critical caregivers -- the ones who must get residents into wheelchairs, bathe them, change their bedding and feed them -- devote to each resident is just 15 a week. Their tasks are so grueling and pay and benefits so low, the turnover rate for nursing assistants in Indiana is a stunning 93 percent annually.  Lack of adequate staffing may have been a contributing factor in a South Bend nursing home where staff failed to keep a cut on woman's leg clean. The Star reported the leg became so infected it had to be amputated. The woman later died from the infection.

The South Bend Tribune had an editorial opinion about Indiana nursing homes.  The editorial bemoans the lack of quality care provided in a majority of nursing homes in Indiana. The editorial emphasizes regulatory oversight and enforcement to turn around the sad state of long-term care in Indiana.  Enforcement of existing state and federal regulations is an issue that can and should immediately be addressed. Efforts to ensure compliance with regulations have eroded. Financial penalties so often are reduced on appeal that breaking the rules makes more profit than following them.

28 percent of Indiana's nursing homes were assessed the lowest overall rating. It placed Indiana among the 10 worst states in the nation. St. Joseph County ranked even more poorly than the state as a whole. Now, overall conditions for 40,000 of the most fragile Hoosiers appear even more bleak. The system requires a complete overhaul.

A Government Accounting Office report released last August identified 52 Indiana nursing homes, or about 10 percent of all those in the state, among the 580 "most poorly performing" in the nation. Not a single long-term care facility was decertified in 2008, the final year covered in the dismal GAO report.

During a five-year period ending in 2008, state health inspectors said the percentage of Indiana homes cited for problems that placed residents in jeopardy or resulted in actual harm grew from 32 percent to 45 percent -- nearly twice the national average.

State regulation that fails to standardize good care defrauds the public. It is unconscionable that legislators continue to ignore the scandal.   The standards for protecting the health and safety of long-term care residents are, indefensibly, lower than those aimed at the well-being of the rest of us. When a patient claims abuse, for example, police aren't typically called and an investigation may not even begin for a week or more. REAL Services notes an area nursing home kitchen was granted 30 days to clean up mouse feces in food; it wasn't shut down like we'd expect a restaurant would be.

Medicaid, funded by state and federal dollars, picks up about two-thirds of the annual $1 billion cost of long-term care in Indiana. The needs of those whose personal welfare is at stake must be considered as seriously as the wishes of the state's powerful nursing home lobby. 

If there is to be improvement, the state must intervene forcefully. Indiana must address these life-and-death issues. The pressure on families, care providers and government can only increase as the baby boomers age. Failure to act would be shameful.
 

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The Evansville Courier & Press had an article written by Hanns Pieper is professor of sociology and gerontology at the University of Evansville regarding staffing.  He refers to Medicare.gov which contains nationwide nursing home comparison data.

"Staffing time measures are especially important because it's the staff that actually delivers the care. The data are based on the nursing home's staffing hours during the two weeks before the inspection and represent the average amount of time available per resident. All other things being equal, the more time per resident the better."

CNA data is the most important since they provide 90-95% of the direct care to residents.  CNAs have the most frequent contact with the residents, so the time they have available is key.  The time available measure is an indicator of staffing adequacy and there often is a significant difference among the different star ratings.

He looked at a list of Indiana nursing homes, and randomly selected a nursing home with a 4-star rating and one with a 1-star rating for staffing.  The 4-star nursing home provided almost an extra hour per day per resident.

There are other important indicators of staffing adequacy that are not presented in the charts such as staff turnover, and call bell response time.   Data that shows how many CNAs who were working on Jan. 1 and still were employed on Dec. 31 should be available.   A CNA's leaving often has a significant emotional impact on residents. The quality of care is affected. A high turnover rate also may be an indicator of other inadequate conditions in the nursing home.

The time it takes for a staff member to respond to call lights/bells requesting assitance made by a resident is also not presented in the data.  When facilities don't have an intercom to determine if the situation is an emergency or routine event, a long response time can lead to devastating results. Inrercom systems and electronic recording of alarms and call bells should be standard in most nursing homes.
 

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ChicoER.com had an article about consumer advocate watchgroups concerned about  Assembly Bill 1629, which changed how nursing homes are paid and provided them with higher payments. The workgroup held a number of meetings. Its efforts were overseen by the state Department of Health Care Services, which was supposed to issue a report to the California Legislature last March.  The workgroup included members representing nursing home owners, the SEIU, the watchdog group California Advocates for Nursing Home Reform (CANHR), senior citizens groups and others.

Requiring more nurses to be on duty in nursing homes is key to improving care.  Nursing homes are required to provide at least 3.2 hours of nurse staffing per patient per day. Some want the minimum raised to 3.5 hours.

Each member of the workgroup produced a list of recommendations for improving care at nursing homes. SEIU and CANHR both recommended raising the minimum nurse staffing level from 3.2 to 3.5 hours.

The union wrote that plans should be made, also, for how to reach the staffing level of 4.1 hours that some experts have recommended.

CANHR recommended that nursing home rate increases should depend on homes' meeting the 3.2-hour minimum.   "We don't think they should be granting any rate increases to homes that don't meet 3.2," said Mike Connors, a CANHR advocate who served on the workgroup.

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L.A. Times had an article about the obvious importance of staffing in providing quality care in nursing homes.  The cornerstone to quality care in a nursing home is staffing.  Those with larger staffs tend to have less turnover, more stability and are more likely to meet the needs of all the residents.

"There is some very persuasive data showing staff simply can't perform all of the responsibilities they have unless there is an adequate ratio of staff to residents," says Janet Wells, policy director for the National Citizen's Coalition for Nursing Home Reform, a reform-activist-advocacy organization.  Homes should be staffed to provide at least 3 1/2 to four hours of care per resident in a 24-hour period, says Larry Minnix, chief executive of the American Assn. of Homes and Services for the Aging, a nonprofit organization that represents not-for-profit elder-care facilities. Some may need to offer four to five hours daily depending on the conditions of the residents.

To assess staffing levels, Pat McGinnis, executive director of California Advocates for Nursing Home Reform, recommends visiting at a time when a facility is most likely to have maximum staff on duty (like at lunch, the biggest meal of the day).  Telltale signs of understaffing include diners with food trays who are not eating because they are not receiving necessary assistance, residents sitting idly in common areas or their rooms with nothing to hold their attention, call buttons going unanswered, and development of pressure ulvers.

Visiting during mealtime is also a good way to gauge food quality. Weight loss can be dangerous to the elderly, so food should look and smell appetizing.  Some of the more progressive homes have buffet lines rather than the "school lunchroom program," in which residents shuffle through with trays, Minnix says. "Food is the most looked-forward-to institution for many people, especially those confined to a home," he says. "You should ask about snacks and what kind of weight loss-weight gain program they have."

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