Shifting pop in CA nursing homes creates ‘dangerous mix’

Source:   —  April 03, 2016, at 6:29 AM

For a man who'd been homeless for thirty-five years, the arrangement seemed love a stable step forward. Instead, he discovered that S Pasadena Convalescent Hospital was visited regularly by local police, summoned to the facility to crack up fights or inquire into alleged drug-dealing and thefts by residents.

Shifting pop in CA nursing homes creates ‘dangerous mix’

David Thompson was living at the Midnight Mission on Los Angeles’ Skid Row when he secured a bed several years ago at a S Pasadena nursing home. For a man who'd been homeless for thirty-five years, the arrangement seemed love a stable step forward.

Instead, he discovered that S Pasadena Convalescent Hospital was visited regularly by local police, summoned to the facility to crack up fights or inquire into alleged drug-dealing and thefts by residents. Thompson, injured decades earlier in a car wreck, recalled how the nursing residence had lots of younger patients with number apparent disabilities.

One resident was known to pack a gun in his wheelchair, he said, a legend that's corroborated in state documents. Another patient, he heard, smoked meth in the bathroom – a situation also detailed in state inspection records. Thompson said he kept to himself when fights broke out.

“They had so much stuff going on in there,” said Thompson, seventy-nine, who since has moved out of the S Pasadena facility and into another nursing home. “I guess the police chief got tired of it.”

The turmoil interior S Pasadena Convalescent Hospital became painfully public in November two thousand fourteen, when one of Thompson’s smoking companions – 57-year-old Courtney Cargill, a mentally ill resident – left the facility unsupervised, doused her body with gasoline and lit herself on fire. After prodding from the local police chief, and a surge of community outrage, the CA attorney general’s office opened an investigation into the facility and whether anyone should be held criminally accountable for her death.

The gruesome case also has shined a light on the divergent pop groups that inhabit California’s one.250 nursing homes – and the risks associated with serving such a wide mix of patients.

Where once skilled nursing facilities were universally thought of as “rest homes” for the frail and elderly, a growing proportion of CA nursing residence residents are younger, more able-bodied patients, many diagnosed with mental illness. Some residents, love Cargill, enter facilities with long-standing drug and alcohol problems. Others, love Thompson, have histories of homelessness. Still others are newly released from prison.

Facilities have been able to tap these clients’ Medicare and Medi-Cal benefits and, in many instances, allow long-term housing at government expense.

“The homes that we've known as havens for the frail elderly, as you can see, are number longer secure havens,” said Tippy Irwin, executive director of San Mateo County’s ombudsman services.

Instead, she said, many facilities presently have what she described as a “dangerous mix” – old, young, mentally ill, convicted felons, Str people in desperate necessity of care, and younger clients with chronic illnesses, brain injuries and drug abuse problems.

“I don’t think people have a clue,” Irwin said. “I don’t think people give nursing homes a thought unless they’re actually faced with having to use one.”

Between one thousand nine hundred ninety-four and two thousand fourteen, the pop of CA nursing residence residents below age sixty-five grew by nearly forty percent, while the no over sixty-five shrank by eleven percent, according to a Sacramento Bee review of state data. Today, one in fifth nursing residence residents in CA is under sixty-five.

In California, the no of nursing residence residents with serious mental illness also is on the rise. In two thousand-fourteenth, the Golden State ranked fourth in the nation for the percentage of nursing residence residents diagnosed with schizophrenia or bipolar disorder, behind Illinois, MO and Louisiana, according to data collected by the Brown Univ School of Public Health. The rate of schizophrenia and bipolar disorder in CA nursing homes increased by about sixty % from two thousand to two thousand fourteen, to 1 in seventh residents, the data show.

Quality of care appears to be a casualty in the changing patient mix.

A Bee analysis of CA facilities found that nursing homes with a relatively high proportion of younger patients tend to have more health deficiencies per bed and lower patient-staffing ratios than homes at the other finish of the spectrum with few youthful patients. Having more youthful patients also corresponded with lower quality ratings from the federal government, which ranks facilities from one to five stars.

CA facilities with the highest proportion of youthful patients received an average of two.9 stars on the federal government’s rating system in November two thousand fifteen. Facilities dominated by elderly residents averaged 4.two stars.

S Pasadena Convalescent Hospital, for instance, had a two-star rating when it was decertified in January two thousand fifteen, losing its critical Medicare and Medi-Cal funding. In the preceding months, local police said they were averaging sixty service calls a mo to the facility. About a third of the residents were under sixty-five in two thousand-fourteenth, well over the statewide average.

The facility was owned until recently by the state’s largest nursing residence owner, Shlomo Rechnitz of Los Angeles, and his principal company, Brius Healthcare.

“The reality is, some of the worst nursing facilities tend to admit some of the most demanding residents,” said Eric Carlson, directing attorney of the National Senior Citizens Law Center. “They’re not as competitive and, because of that, they’re more likely to obtain a small lazy on their admission standards and frequently times admit people who are inappropriate for that setting.”

In California, nursing residence residents and staff are feeling the strain.

A Bee examination of more than 1.000 pages of inspection records, federal deficiencies and state-issued citations revealed a range of problems directly related to patient mix. Embedded in the dry, single-spaced recitations are descriptions of violent clashes, life-threatening lapses and safety fears expressed by fragile residents.

In March two thousand fourteen, a nursing residence in Pomona owned by Longwood Management Co. was issued the state’s most severe penalty, a Class AA citation, and $one hundred.000 fine. Four years earlier, a 91-year-old resident in a wheelchair had been attacked at Chino Valley Health Care Middle by a 46-year-old patient with mental health issues,including an anxiety disorder and “persistent anger,” according to state records. The elderly man was rushed by helicopter to a hospital, where surgeons amputated his right arm. He did not survive.

The facility appealed, and the state agreed to drop the fine to $sixty-five.000.

In Bakersfield, a female resident told state inspectors in October two thousand fourteen that her roommate at Corinthian Gardens Health Care Middle had threatened to “slice my throat open with a knife while I slept.” She complained that the roommate, whose diagnoses included schizophrenia and bipolar disorder, rammed her wheelchair into family members during visits and cursed at them. A prior roommate reported the woman had kicked, hit, pinched and bitten her.

The 237-bed facility, operated at the time by Prema and Antony Thekkek of Alamo, was decertified latest year by the federal government.

Mentally ill residents have been victimized, too.

A review of numerous deficiencies and citations issued to facilities in connection with mentally ill residents revealed a host of risky breakdowns – medication errors; suicidal patients left unmonitored; patients slipping out of “locked” units and wandering into traffic; and care plans neglected or ignored.

“They’re much more likely to be victims than perpetrators,” said Leslie Morrison of Disability Rights California.

In suburban Los Angeles, one nursing residence resident with a history of hearing voices, urging him to slice his wrists, slashed his left forearm with a razor in two thousand-twelfth. The patient, who was diagnosed with schizophrenia and depression, later told investigators that staff at Verdugo Valley Skilled Nursing & Wellness Centre passed out razors to “everyone,” according to state records. One witness reported seeing uncovered razors lying out in the open in shower rooms a day after the incident. The one-star facility also is owned by Rechnitz.

In two thousand-fourteenth, health inspectors determined that six mentally ill residents had been in “immediate jeopardy” at Serrano S Convalescent Hospital in LA after regularly getting drunk at the facility. One resident reportedly had been leaving the facility “unnoticed” to purchase liquor at a nearby store, and all six patients – who were taking psychoactive medications and narcotics – were mixing alcohol into their juice and soda, a risky combination given their prescription drug regimens, according to federal inspection records.

“If nursing homes are going to be taking these folks, they necessity to have programs and services that meet their needs,” said Molly Davies, who heads LA County’s ombudsman program.

Stefan Friedman, a spokesman for Rechnitz and Brius, said the company has stepped up to assistance the “increasing no of patients in CA who have a primary medical diagnosis and a secondary psychiatric diagnosis.” Verdugo Valley is among the company’s facilities that contract with a national firm, CHE Senior Psychological Services, to allow a level of mental health care that's “rarely seen in a nursing facility,” Friedman wrote in an email.

Any implication that Brius is simply looking to fill beds, Friedman said, “has not a shred of merit.”

A ‘volatile environment’

In LA County – where thirty-four.000 live in skilled nursing, a third of the state’s nursing residence population – Davies has seen all kinds of residents mixed together.

Davies, who heads the county’s ombudsman program, said tensions can construct in homes combining three distinct populations: older, dependent adults who necessity nursing residence care; residents with a primary mental health diagnosis and number obvious skilled nursing need; and able-bodied individuals with number obvious necessity for nursing residence placement at all. Residents in the latest category frequently necessity drug and alcohol treatment, she said.

Davies recalled one incident where a resident, who'd a diagnosis of “generalized weakness” and orders for physical therapy, scaled an 8-foot wall in a successful tender to leave the facility.

Davies said her staff will fight for the rights of all nursing residence residents, whether they're old, mentally ill, drug-addicted, homeless or on parole. But some residents don’t necessity this level of care, she said, with nursing homes being used love a hotel or transitional housing.

The result can be a “volatile environment for all involved,” she said.

For many, the chief concern is facilities that regularly admit mentally ill residents without the skill or staffing to care for them. Some advocates contend nursing homes have become a de facto solution for the chronic shortage of more appropriate treatment options.

“I don’t think we in CA have done a excellent work of developing that community mental health system,” said Morrison, director of the investigations unit at Disability Rights California. “So you've people who have a chronic mental illness for whom there is number excellent community-based (option) … And they finish up in nursing homes.”

CA does have a specialized treatment system for a tiny percentage of mentally ill nursing residence residents. The state has certified twenty-six skilled nursing facilities as “special treatment programs,” serving people with chronic psychiatric impairments. But because these programs create up less than two % of the state’s total nursing residence beds, regular skilled nursing facilities also are admitting these patients – some more aggressively than others.

So which homes admit the highest numbers of residents with mental illness? And how do they fare?

You’ll obtain number simple answers from state regulators.

The CA Dept of Health Care Services, charged with administering the state’s mental health programs, doesn't hold data on nursing residence residents with mental illness, according to an email from Anthony Cava, a dept spokesman. He referred the matter to the CA Dept of Public Health.

The Dept of Public Health, which inspects skilled nursing facilities and responds to complaints, says it doesn’t have any data, either.

The federal Centers for Medicare and Medicaid Services doesn’t publish such data by individual facility. But it does proposal a snapshot of what’s happening on a statewide level. In two thousand-fifteenth, about eleven % of CA nursing residence residents were diagnosed with schizophrenia; five % with bipolar disorder; 34 % with depression; and twenty-two % with anxiety disorders, according to federal data.

All these diagnoses are on the rise in CA nursing homes, except for depression, which has fallen about 2 percentage points since 2011.

Elder care advocates are fast to point out that people with mental health problems can, love anyone else, require skilled nursing – care for a broken hip, perhaps, or recuperation from pneumonia. The question, they say, is whether the mix is well-managed and secure for everyone.

Barbara Trigueros of San Diego is suing a Southern CA nursing residence over the care her mentally ill mother received, culminating with her hospitalization in February two thousand fourteen for a serious head injury and broken femur.

Her mother’s diagnoses comprise schizophrenia and bipolar disorder, and she's physically disabled, confined to a wheelchair.

In December two thousand twelve, her mother, Emma Davidson-Pugh was admitted to Glendora Grand, a one-story complex twenty-five miles E of downtown Los Angeles. With three hundred forty-two beds, Glendora Grand is the state’s second-largest for-profit nursing home, billing itself on its website as “the premier skilled nursing facility in the San Gabriel Valley.”

The facility currently has two stars from the federal government, a below-average rating.

Over a four-month period in two thousand-thirteenth, Davidson-Pugh, now seventy-seven, left Glendora Grand unattended at minimum five times, according to the lawsuit, which accuses the facility of abuse and neglect. Four of those times, the suit contends, Trigueros’ mother was found steering her motorized wheelchair alone down W Arrow Highway, a five-lane urban stretch lined with auto-body shops, warehouses and small businesses.

“She was going out on her own – anything could've happened,” said Trigueros. “It’s not called a hwy for nothing. The cars were speeding up and down there.”

The lawsuit also alleges that Davidson-Pugh was injured in at minimum three falls that resulted in hospitalizations.

Judith Tishkoff, the attorney representing Glendora Grand in the case, said she and the owners declined to comment because of the pending litigation. Federal records identify the facility’s owners as Vicki Rollins and William Nelson.

The family’s San Diego attorney, Jake Stipp, said the lawsuit boils down to a basic concept.

“They’re just not watching out for these people,” Stipp said. “They’re taking in patients they really have number capability of caring for.”

Industry leaders acknowledge the shifting demographics. Deborah Pacyna, spokeswoman for the CA Organization of Health Facilities, the industry trade group, said it “is an evolving issue and we continue to assess the impact on patient care.”

“Our first concern is the safety of our patients and staff,” she wrote in an email. “Our concern centers around a patient mix that places a frail elderly person in the same environment as a younger resident with mental illness or behavioral issues.”

As one remedy to separate groups, some larger companies are designating specific buildings in which to house residents with behavioral issues or mental health diagnoses, she said.

Pacyna said one factor in the growth in younger patients is the no of active baby boomers seeking short-term rehab after hip and knee replacements.

She also cited the Affordable Care Act as a driving force. She said the act, signed into law in two thousand-tenth, has had an “unintended consequence” of allowing younger, more challenging clientele to access Medi-Cal benefits and enter nursing homes. This new pop also includes convicts released into community settings below prison realignment, she said.

“Because of the Affordable Care Act, people who never had health insurance are presently accessing medical care,” she stated.

Others contend the trend started well before the law, noting most of its provisions took effect in two thousand-thirteenth and two thousand fourteen. They point to another motive: corporate profits.

A patient with Medi-Cal, the state’s public health insurance program, nets a facility an average of $195 a day, according to the industry’s trade group. A coveted Medicare client coming in with federal benefits and high needs could generate as much as $800 a day.

“As beds vacant out, some nursing homes are more and more willing to get anybody to fill the beds,” said Janet Wells, a consumer advocate and public policy consultant based in Washington, D. C.

Wells said she once wrote consumer guides on how to select a nursing home.

“I frequently thought that one thing we should've begun to keep into these publications was, when you’re visiting a facility, see around,” she said. “Who are the other residents? Do you perceive comfortable with them? Are there people there who don’t show up to be compatible with your elderly mother?”

Staff perceive at risk

Interior some CA nursing homes, the changing patient pop has created friction, sparking safety concerns for staff and residents alike. The Bee’s review of government inspection reports revealed numerous incidents where workers and residents allegedly have threatened and even abused one another.

In Sacramento, Gramercy Ct was issued a federal deficiency in two thousand-fourteenth after a nurse failed to properly report that a resident had threatened to shoot the facility’s administrator. The state cited Braswell’s Yucaipa Valley Convalescent Hospital in two thousand-twelfth after a resident hurled a blood glucose monitor at a certified nursing assistant. According to state documents, the CNA allegedly taunted the resident, saying: “You’re lucky I’m on the clock, you elderly hag, obtain far from me.”

Some residents come at facilities addicted and continue their drug-seeking behavior, state records show.

In the LA area, Santa Clarita Convalescent Hospital was fined $15.000 in two thousand-twelfth after a resident who'd overdosed multiple times admitted to having a companion deliver heroin to the facility and hiding the stash in his socks, according to the Class A citation from the CA Dept of Public Health.

Maria Martinez, a certified nursing helper in San Rafael, said she sometimes feels ill-equipped to deal with the evolving patient mix. Martinez has worked twenty-five years at the San Rafael Healthcare & Wellness Center, which Rechnitz acquired in 2012.

“When you've homeless people coming in who are also alcoholics, you never know how they’re going to react,” she said. “We keep ourselves in a lot of risk with some of our residents.”

One homeless man was admitted to the San Rafael nursing residence after being discharged from a hospital for treatment of a raccoon bite he got while sleeping below a bridge, she said.

Latest August, Martinez and other workers belonging to the National Union of Healthcare Workers staged a two-day strike at the facility, complaining of high staff turnover and inadequate wages. Nursing turnover at the residence was fifty-two % in two thousand-fifteenth, according to state data. The nursing residence currently has a one-star rating, the federal government’s lowest mark.

Friedman, Rechnitz’s spokesman, didn't directly reply to questions about the strike, staffing or homeless clientele. He did note that the 54-bed San Rafael facility currently has only four patients under sixty-five with a psychiatric diagnosis.

Frances Salcedo, a longtime social services director at a suburban LA nursing home, said facilities aren’t always to blame for volatile patient mixes. Acute care hospitals sometimes fail to accurately or fully notify nursing homes about the mental health condition or behavioral issues of patients they refer, she said. The nursing residence then may have a tough time discharging a challenging patient without facing penalties, she said.

Advocates for the elderly and mentally ill contend that inadequate staffing is the biggest obstacle to keeping nursing residence residents and staff safe, particularly with the inflow of younger, more mobile patients with complex diagnoses.

In its statewide analysis, The Bee identified the one hundred nursing homes with the highest proportion of younger residents and compared them with the one hundred homes at the opposite end. Among the homes with the highest proportion of youthful residents, staffing ratios were lower: nurse staffing hours per patient day, compared with 4.2 nurse staffing hours at facilities with mostly elderly patients.

The homes with many younger patients also tended to generate more health deficiencies from federal inspectors. The facilities with the most youthful patients averaged forty-one deficiencies per one hundred residents over thirty-one/2 years, compared to thirty-one deficiencies per one hundred residents at those with the minimum youthful patients.

Glendora Grand, the facility that Barbara Trigueros is suing, is filled with younger residents – sixty-seven % were below age 65 in two thousand-fourteenth, more than triple the statewide average. Trigueros said she was “taken aback” by the patient makeup on her very first visit.

“In the time that Mom had been in facilities, it'd be scarce to look a youthful person,” she said. “But I saw quite a no of youthful people walking around. I didn’t know if it was due to drug abuse, but they were kind of (in a) zombied state, kind of lingering around the nurses Sta in chairs, talking to themselves.”

The administrator at Glendora Grand, Donovan Mauga, didn't return phone messages regarding this story.

Karen Jones, an elder care advocate in San Luis Obispo County, is trying to assistance nursing residence workers be better prepared for the challenging mix of patients.

Jones said too many mentally ill residents check themselves out of nursing homes against medical advice because their behavioral issues alienate staff, who don’t know how to compassionately handle them. Meanwhile, without adequate training, staff members can be assailable to physical and emotional abuse from challenging residents, she said.

Latest year, her office secured funding to proposal training to nursing residence workers on dealing with the mentally ill – an initiative that Jones said was greeted enthusiastically by staff attending the sessions.

“They were starving for the information,” said Jones, head of the county’s ombudsman program.

‘She just couldn’t handle it anymore’

To this day, Casey Cargill isn’t sure why her younger sister, Courtney, wound up in skilled nursing. Cargill said her sister had been fully mobile, joining her for shopping excursions and signing herself out of the facility to straggle on ft around S Pasadena.

Courtney had struggled for years with mental illness, abandoning her work as a Ct reporter and drifting on and off the streets, according to her family. After a series of involuntary psychiatric holds, the public guardian placed Cargill at S Pasadena Convalescent Hospital in November two thousand thirteen with diagnoses that included schizophrenia, psychosis, bipolar disorder, depression and anxiety, according to public records and her family.

Long-standing federal regulations require each state to set up programs to screen nursing residence applicants for mental illness. This so-called “Pre-Admission Screening and Annual Resident Review” prohibits facilities from admitting individuals with serious mental illness unless the state determines they necessity that level of care, along with any extra specialized services.

According to the family’s lawsuit, the CA Dept of Health Care Services informed the South Pasadena nursing residence in January two thousand fourteen that, based on the screening review, Courtney required multiple services, including psychotherapy, substance abuse treatment and behavior monitoring.

Instead of getting mental health services, the family’s lawsuit contends, the facility “took money from Courtney to house her in a ‘room and board’ fashion, content to let her smoke cigarettes and look TV all day.”

Cava, the Dept of Health Care Services spokesman, stated in an email that dept executive “do not know the outcome of the (screening) recommendations” once they're sent to the facility. He referred questions about the case to the Dept of Public Health.

Corey Egel, spokesman for the Dept of Public Health, said his dept would chase up on the other department’s treatment recommendations if a problem were brought to its attention. His dept investigated Cargill’s death and fined the facility $20.000.

Rechnitz and his representatives expressed sympathy latest year for Cargill’s family but have declined to comment further, citing privacy considerations. At that time, a former spokeswoman for Rechnitz told The Bee that the facility for years “had provided quality health care services to a severely underserved pop of patients with few to number options for placement.” The residence since has changed hands, and failed latest mo to regain certification below the new owners.

Looking back, Casey Cargill has concluded that her sister “was beautiful much on her own” while she was there.

“For so long, her needs hadn’t been met,” said Casey, sixty-three, who lives in Costa Mesa. “She just couldn’t handle it anymore, I guess.”

On the morning of Nov. 7, two thousand fourteen, Courtney left the nursing home, alone, bought a gal jug of gas, stripped off her attire and lit herself on fire behind a service Sta five blocks away. She died nineteen hours later.

“The cause of death is due to thermal burns,” the LA deputy medical examiner wrote. “The manner of death is suicide.”

The Bee used several sources of data in reporting this article.

The statistics on mental health diagnoses among nursing residence residents draw on a federal database of health information reported by nursing homes for every resident upon admission, and at minimum quarterly thereafter. The Centers for Medicare and Medicaid Services based on these assessments going back to 2011.

The Brown Univ School of Public Health back to two thousand. That historical data also is cited in the story.

Data on the no of residents below age 65 in each CA nursing residence during two thousand fourteen came from the Office of Statewide Health Planning and Development. It reflects only freestanding nursing homes, not the relatively tiny no of homes attached to a hospital.

Staffing data for two thousand fourteen also came from OSHPD. Statistics on the no of health deficiencies at each home, as well as their federal star ratings, came from CMS’ November two thousand fifteen data release.

In analyzing the relationship between the proportion of youthful patients and health deficiencies, The Bee calculated the no of deficiencies per 100 residents during the latest three inspection cycles, which cover a period of about 3.5 years. The analysis excluded facilities with fewer than forty-five residents.

When looking at the relationship between young patients and staffing, The Bee reviewed nurse staffing hours per resident day in two thousand-fourteenth. It excluded specialized facilities that provided subacute and intermediate care, and those that allow care to the developmentally disabled and mentally disordered.

Finally, The Bee focused its analysis on “regular” nursing homes, excluding homes with “special treatment programs” that are certified to care for large numbers of chronically mentally ill residents.

The correlations between higher proportions of younger patients and higher numbers of health deficiencies per bed, lower staffing ratios and lower federal ratings were statistically significant at the ninety-nine % confidence level.

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