June 22, 2008
Where Are We Sending Our Elders? Quality Varies Widely at Marin Nursing Homes
By Richard Halstead, The Marin Independent Journal, Novato, Calif.
Jun. 22--When Twila Petker died on March 29, 2004, medical examiners couldn't miss the ugly ulcer on her back.
The Marin County coroner determined that the massive infection that killed 74-year-old Twila Petker was caused by the ulcer. The wrongful death lawsuit that Petker and his sister later would file against Pleasant Care Corp. -- the La Canada Flintridge-based owner of the Novato nursing home caring for his mother -- alleged that she lost 75 pounds during the last six months of her stay there.
"It was just pure neglect," said her son.
The incident was among the most extreme examples of problems reported for Marin's 14 nursing homes, according to a review of data from the federal Centers for Medicare and Medicaid Services, California HealthCare Foundation and California Advocates for Nursing Home Reform.
Marin's nursing homes are performing at about the state average, according to the data, and there are signs of improvement: The total number of deficiencies cited by inspectors has declined steadily, from 300 cases reported in 2004 to 142 last year.
"I'm not aware there are any particular issues here that are really bad," said Nick Trunzo, director of Marin County's Division of Aging.
Several Marin nursing homes, however, performed far
below average in at least two key rankings: the number of citations issued to them by the state Department of Health Services and the number of deficiencies found during state inspections. And the yearly average number of deficiencies at Marin nursing homes from 2003 to 2007 was 81, higher than the state average of 72.5.
Carolyn Rosenblatt, a registered nurse and lawyer who helps Marin families figure out how to care for their aging elders, said all of Marin's nursing homes have some
"In all the facilities in Marin, mistakes are made," Rosenblatt said. "A nursing home is not a place I would send an elder to without checking on them all of the time."
In California, nursing homes are considered health-care facilities and are allowed to dispense services that cannot be provided in assisted-living or board-and-care homes.
Marin's landscape Marin County's 14 nursing homes have 1,032 licensed beds. Three of the homes have more than 100 beds each. Nine of the homes are operated by for-profit corporations; the other five are operated by nonprofits, two of which are churches. They range in price from $5,700 to $9,420 per month.
There have been major changes in the Marin nursing-home landscape over the past 18 months. Four of the county's homes were acquired in 2007 by two nursing home chains: Los Angeles-based Country Villa Service Corp. and Kindred Healthcare, based in Louisville, Ky.
Country Villa Health Services, which operates 51 nursing homes in California, acquired the Hillside Care Center in San Rafael in February 2007 and the Pleasant Care Convalescent facility in Novato in July 2007.
Also in February 2007, Kindred Healthcare, which operates 240 nursing homes in 28 states, took control of the Greenbrae Care Center in Greenbrae and the Smith Ranch Care Center in San Rafael. Kindred has owned the Fifth Avenue Health Care Center in San Rafael since 2001.
Between them, Country Villa and Kindred now own 47 percent of the
county's licensed nursing home beds.
Two of the homes that changed hands last year -- Pleasant Care and Hillside Care -- had been among the county's poorest performers.
"With Pleasant Care and Hillside, we were well aware that extra attention needed to be put there," Trunzo said. "I think the situation has improved because of the new ownership."
Betsy Hite, a spokeswoman for the California Association of Health Facilities, an industry group representing nursing homes throughout the state, said care in the state's nursing homes is improving because of an increase in Medi-Cal reimbursement rates required by a state law in 2004.
"We are beginning to see a trend of bad nursing homes either going away or being absorbed by better companies," Hite said.
A study by the University of California at San Francisco last month belies that notion, however. The study found that quality of care at California nursing homes declined after the rate hike.
Kathryn Stebner, a San Francisco lawyer who specializes in elder abuse, said the trend toward more nursing homes being acquired by large chains is occurring statewide -- and bodes ill.
"When you have a chain, the people who are making the decisions are the people in the corporate office, so you have a disconnect between the needs and the care that is given," Stebner said. "Generally speaking, I find the quality of care is poorer at the larger chains."
Pleasant Care -- which once operated 38 nursing homes in California, including Pleasant Care Convalescent at 1565 Hill Road in Novato -- filed for bankruptcy in March 2007. In 2006, the company agreed to pay $1.3 million to settle a suit brought by the state attorney general. The suit was based on more than 160 regulatory violations cited over the previous five years.
When Pleasant Care auctioned off most of its facilities in 2007, it left behind a trail of lawsuits filed by family members of former residents, many of whom died while under Pleasant Care's supervision. In Marin County Superior Court alone, at least five wrongful death suits were filed against Pleasant Care over the years.
Dr. Raymond Seet, former assistant medical director at Pleasant Care's Novato facility, is suing Pleasant Care because he was named as a defendant in several of the cases. In his suit, Seet alleges that Pleasant Care "was aware of failures to comply with protocols and regulations established by the state of California, including but not limited to protocols, regulations and standards respecting care, maintenance and calibration of scales and other devices."
Seet oversees the care of some patients at Country Villa Novato but is not employed by the facility's new owner. Seet did not respond to requests for an interview. No representative of Pleasant Care, which is now defunct, could be reached for comment. Paul Delano Wolf, an Oakland lawyer who has represented Pleasant Care in the past, said no one is speaking for the company.
State citations A key indicator of nursing home quality is the number of citations issued by the state Department of Health Services, Rosenblatt said.
The citations come in three classes: AA, when a resident dies because of facility negligence; A, when violations present imminent danger or the probability of death or serious harm; and B, when violations have a direct relationship to health or safety.
Before it was sold to Country Villa, Pleasant Care Convalescent in Novato far outstripped the county's other nursing homes in the number of citations it received. According to the California HealthCare Foundation Web site, between Jan. 1, 2003, and Oct. 26, 2007 -- the most recent period for which data are available -- Pleasant Care received 52 citations. Three of them were AA class and four were A class.
The state average for citations is a little less than one per facility per year, according to California Advocates for Nursing Home Reform, a watchdog group.
Country Villa now operates the Pleasant Care Convalescent facility under the name Country Villa Novato. Joe Aguire, Country Villa Novato's administrator, said the new owner has invested more than $1 million in the building, buying new equipment and new beds. He said some Pleasant Care staff members who "didn't meet our standards" were let go.
"One of the issues in the past was that staff didn't get enough training," Aguire said. "Country Villa poured a lot of money into training staff."
Between Jan. 1, 2003, and Oct. 26, 2007, Hillside Care Center in San Rafael was runner-up in citations in Marin, with nine A class citations and 14 B class. Country Villa now operates the Hillside facility under the name Country Villa San Rafael. Five of the citations came after Country Villa took over.
Pine Ridge Care Center in San Rafael was slapped with 12 citations over this five-year period. Seven were A class and five were B class.
Reasons for citations run the gamut. According to state records:
-In January 2007, Northgate Care Center in San Rafael was fined $20,000 after a resident suffered pressure sores that required cutting away decayed flesh.
-Hillside was fined $18,000 after a male resident developed four pressure sores on his feet in July 2007. Culturing of the wounds never occurred because staff couldn't find a specimen container. The resident developed a fever and was hospitalized. Initially, doctors thought they would need to amputate his left foot.
-In April 2007, Pine Ridge was fined $20,000 after it failed to get the consent of a resident's designated representative before using Librium to treat his alcohol withdrawal symptoms. The Librium sedated the resident and contributed to his hospitalization with aspiration pneumonia. Pine Ridge also was fined $800 for sexual misconduct in September 2006 after a staff member was accused56-year-old male resident three times on his buttocks as he returned from the bathroom.
-Aldersly Skilled Nursing in San Rafael was fined $18,000 when a resident fell in September 2007 after a nursing assistant left her alone in the bathroom, in direct violation of her care plan. The resident fractured her hip and died six days later.
Certification visits Citations sometimes are the result of a California Department of Health Services' certification visit.
Inspections are conducted at least once every 15 months to ensure that homes are complying with rules established by the federal Centers for Medicare and Medicaid Services. Violations that may not be serious enough to merit a citation are documented as deficiencies during these inspections.
Five Marin nursing homes had 100 or more deficiencies between Jan. 1, 2003, and Oct. 26, 2007. The state average was 72. Pleasant Care led the way with 192. During the same period, Hillside Care had 141 deficiencies. Northgate had 121 deficiencies during the period Redwoods 109 and Greenbrae Care Center 102.
Citations may also result from consumer complaints.
Three Marin nursing homes logged more than eight complaints, the state average, for the period Jan. 1, 2003, to Oct. 26, 2007, according to the California Healthcare Foundation Web site. Pleasant Care had 43, Hillside had 27 and Pine Ridge had 24.
But these statistics don't tell the whole story, nursing home critics say.
Steve Garcia, a Long Beach-based lawyer who had several wrongful death suits pending against Pleasant Care when it went bankrupt, said the state's inspections are ineffective because inspectors wait until the latest possible date to make their required visit.
"It's like telling the kids they're going to have a pop quiz this year, and there is only one day left in the year," Garcia said. "So you bone up and all of a sudden you're smart for a day."
But industry spokeswoman Hite disagreed.
"No. That's not true," Hite said. "They don't know."
Rosenblatt said nursing home lawyers often challenge high-level citations and get them reduced.
"It doesn't publicly show how bad it was," Rosenblatt said.
Hite said nursing homes have every right to challenge disciplinary actions if they believe demerits are unjust. "A little thing can turn into a big thing and increase their vulnerability to litigation," Hite said.
Web sites also rate the nursing homes on various quality measures such as the incidence of pressure sores, urinary tract infections, precipitous weight loss, and use of restraints.
According to the Medicare Web site, both Rafael Convalescent and Northgate ranked 10 percent higher than the state average in the use of restraints. Pine Ridge had more than twice the state and national rate of pressure sores.
In many cases, however, nursing homes don't supply the data necessary to rate them on these quality measures. All of the information used to compute the ratings is self-reported.
"You're operating under the assumption they're telling you the truth," Garcia said, "and that is a big jump."
Contact Richard Halstead via e-mail at [email protected]
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Copyright (c) 2008, The Marin Independent Journal, Novato, Calif.
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