Monday, March 5, 2001: Staff Crunch Impairs Care

Wayne Karczewski quit his job as administrator of a chain-owned nursing home in Orlando to manage a smaller, family-run facility in Sanford because he was frustrated with a bureaucratic system that he thought put profit over the welfare of the residents. "Some of the big chains really aren't focused on the business they are in: taking care of people,'' said Karczewski, now administrator of Lakeview Nursing Center in Sanford. "But if you don't treat the human life appropriately, your bottom line is going to suffer even more when a sheriff shows up with a subpoena.''

Karczewski thinks staffing levels and quality of care suffer when administrators must pinch pennies. Indeed, nursing homes that are short of staff or score poorly during inspections are far more likely to wind up as the target of lawsuits, according to a review of court and state inspection records by the Orlando Sentinel and South Florida Sun-Sentinel.

Central and South Florida nursing homes slapped by regulators for a high number of quality violations were sued three times as often as homes that had few violations.

Four of the 10 Orlando-area nursing homes cited most often for quality violations during the past four review periods ranked among the five most-sued facilities.

Halifax Convalescent Center in Daytona Beach, for example, ranked eighth with 48 inspection violations and first with 11 lawsuits. IHS of Central Florida at Orlando ranked sixth with 49 violations and second with nine suits.

"Without bad care, you don't have a rash of lawsuits," said Robert Brown of Freidin & Brown, a Miami law firm that specializes in suing nursing homes.

Still, nursing-home operators say many lawsuits are unjustified and the recent flood of litigation, which often results in six- and seven-figure payouts, is threatening their survival. Compounding the problem, nursing homes say, the legal awards are forcing many insurers to abandon the state, while the ones left behind charge skyrocketing rates.


To counter the financial assault, the industry wants the Legislature, in its session opening Tuesday, to restrict how much nursing-home residents or their families can win in court and how much lawyers can collect.

But even some state regulators acknowledge that nursing homes are partly to blame for the lawsuit debacle. They say they have been unable to persuade persistently troubled homes to comply with minimum quality standards.

Subpar homes have learned they can stay open by sprucing up for state inspections, then often backslide once the license is renewed, state inspectors said.

"Some facilities just can't seem to get it right, but they stay open," said Patricia Feeney, supervisor of nursing-home inspections in six South Florida counties. "Continual violations, continual turnover of staff, continual budget problems, low quality."

Consider Integrated Health Services of West Palm Beach. During the course of its past four inspections, the home was cited for 58 violations.

Marie Massey blames that record of citations for the 1998 death of her sister, Doris LaJeunesse, who went to Integrated for a few weeks of physical therapy after a stroke.

A nurse misread the order for her insulin shot. Instead of giving six units, she gave 64 units, according to a suit filed by Massey. LaJeunesse, 82, went into diabetic shock and deteriorated until she died five weeks later.

"She was suffering. She had pains. She just kept getting worse. They killed her," Massey said.

The home's attorney, Raul Romaguerav, agreed that the insulin overdose was a dangerous error, but he said it didn't kill LaJeunesse. She recovered enough to go to another nursing home, he said, and she likely died from complications of her stroke.


The debate over nursing-home quality goes back to the 1970s, when a Miami grand jury documented widespread problems, from rats in beds to roaches in food, in the facilities.

In response, the Legislature in 1976 passed a residents' bill of rights that listed 33 rights a nursing home must uphold, such as a safe environment, nutritious food and dignified treatment. The state also upgraded its inspections and set standards for staffing ratios, cleanliness and many other areas.

Today, staffing is the key standard. The state requires that every resident receive a minimum 1.7 hours of direct care from the home every day.

Critics say that's too little. The federal government agrees.

In a report published last year, the Health Care Financing Administration said the minimum amount of time nursing assistants should spend with residents, to deliver optimal care, is 2.9 hours.

More than 92 percent of U.S. nursing homes fall below that standard.

In Central Florida, only five of 98 homes make the cut. Worse, a dozen homes fall below Florida's 1.7-hour minimum, the newspapers found.

Some nursing-home administrators see federal and state standards as a goal, not the bare minimum, said Charles Sinclair, an attorney who used to defend nursing homes.

"They just wanted to keep the state from citing them," Sinclair said. "I couldn't sleep at night. I would see clients of mine driving Bentleys, and the home didn't have money for diapers."

Understaffing "is the cause of most of the neglect and the lawsuits," said a former state inspector, Gloria Suarez of Coral Gables. "Staffing will get these people fed, hydrated and turned."

Aides have little time to escort residents to the bathroom or to change their diapers, so people remain soiled for hours, said Suarez, who is now a consultant for lawyers who sue nursing homes.

More important, she said, aides sometimes don't have time to feed residents who can't feed themselves. Nutrition is crucial. Many seniors decline rapidly and are prone to develop bedsores if they don't eat and drink properly.

Adding to the problem, tough working conditions and low wages make it difficult to attract good employees.

"The nursing-home industry is still in the dark ages in terms of the way it treats its employees,'' said Karl Pillemer, director of gerontology research at Cornell University.

"Nursing assistants provide about 90 percent of the care that goes on in a facility,'' he said. "Their jobs are extremely complex and stressful. Yet we give them very little in-service training, recognition and supervision and expect them to perform well and like their jobs.''


Wages rarely exceed $7 an hour for someone just starting out. That forces some nursing assistants to work second jobs to pay the bills.

"Money is not everything in this job, but if the wages are so absurdly low that people in places like Florida are going to work for Disney rather than become nurses, then something has got to change,'' Pillemer said.

Exacerbating the staffing problem: For-profit, national chains force many of their administrators to spend too much time worrying about budgets, critics say. As a result, many nursing homes are unwilling to spend money to increase staff, they say.

"It's a continual problem that administrators are forced to concentrate on the bottom line and not on staffing problems,'' Pillemer said.

Administrators blame the rise in lawsuits and higher insurance rates for draining scarce dollars they could otherwise spend on staff and improving conditions.

Steve Mulder, co-owner and administrator at Whitehall Boca Raton, said he had to cut his staff this year from 5.2 hours a day per resident to 4.2 hours because his insurance bill is five times higher than it was two years ago.


Florida's main hammer for ensuring quality is the annual, unannounced licensing inspection, when five to seven state officials spend three days reviewing a home.

But many administrators know beforehand when the review is coming, either by leaks from the agency or because the license is about to expire, administrators said.

Suddenly, stingy corporations spare no expense to spruce up their facilities, said Karczewski, the nursing-home administrator.

"All of a sudden, the checkbooks open up,'' he said. "You're fully staffed -- anybody who can work, they bring in."

Officials at the Florida Agency for Health Care Administration, which oversees nursing homes, are striving for more surprise in their supposedly surprise visits.

The federal government now allows states to do the annual inspections every nine to 15 months, so they are less predictable. Also, 10 percent of Florida inspections are done at night or on weekends. Inspections in response to complaints also are unannounced.

Still, the state agency has 223 inspectors to cover Florida's 679 homes plus about 20,000 other facilities.

Any violation carries a fine of $500 to $10,000 under state rules and up to $25,000 under federal rules, plus other punishments.

Writing violations is the easy part, said Feeney, the inspections supervisor. The hard part is getting the homes to change on a lasting basis.

Homes have 30 days to make a plan to correct a violation. If they do, the state does not fine them, no matter how severe the problems.

But, too often, homes fix the problems and then let things go again, officials said.


The state has disciplined homes by forbidding them to accept new residents. But it has used its biggest stick -- revoking a home's license -- only eight times since 1995.

In October, the state tried a new tack: The Medicaid program cut off payments to six homes with persistent violations. Because most residents are on Medicaid, the move was a sharp blow to the homes, none of which was in Central Florida.

"It was a message to be sent to the chronic facilities," Feeney said.

The Vencor chain, which is operating under bankruptcy-court protection, agreed to an extra state review and staff training to remove three of its homes from the list.

The state cannot just shut down a home, because elderly residents may be traumatized by a forced move, said Polly Weaver, a chief of field operations for the state agency. The goal, she said, is not to punish but to bring poorly performing homes up to standard.

All the inspections and disciplinary actions the state can muster cannot replace attentive, assertive family members watching their loved one and demanding good care, Feeney said.

Without doubt, she said, patients and families who complain get better care than those who cannot speak or have absent families.


Marie Massey could not have been more attentive, but it did not save her big sister from the insulin overdose.

Every day, she went to the nursing home to sit with her sister. One day, she went to lunch when her sister got her shot. When she returned, she said, LaJeunesse was ghost white, sweating and nearly incoherent.

"I could tell right away she was dying. I've seen this before," said Massey, a retired nurse's aide.

The home's nurse initially refused to give LaJeunesse a special syrup for diabetic shock and could not operate the finger-stick device that reads blood-sugar levels, Massey said. The nurse also declined to call for help, until Massey's granddaughter arrived and dialed 911 herself.

In the five weeks before LaJeunesse died, Massey said, her sister never got out of bed again.

"It was nice having her around. I really miss her," Massey said. "My parents both lived to be 93, so I think she would have been around for a long time. But she's gone."