Aggressive Nursing Home Inspections Underscore Abuses

Using a new breed of aggressive investigators and off-hour surprise inspections, state health officials have launched a crackdown on nursing home abuses that after three months has dramatically increased the number of serious citations issued.

The vigorous enforcement effort by the Department of Health Services has produced nearly as many serious citations against nursing facilities in five months this year as in all of 1984, state records show. The state attorney general’s office has used health department information to file notices to revoke the licenses of 11 nursing homes, six more than the number filed through May of last year.

In addition, the state ordered the evacuation of patients from Northlake Convalescent Hospital in San Jose last month; it was the first time in three years that state health officials shut down a nursing home.

Abuse, Degradation

The new state inspection effort of California’s 1,200 nursing homes has uncovered case after case of patient abuse, inadequate medical care and degrading living conditions, including:

- Rape of female patients by employees and other patients.

- Neglect of handicapped patients, in some cases causing death by drowning or falling.

- Filth pervading the facilities, including cockroach infestation, urine splattered on floors and patients lying in their own feces.

Charlene Stewart said before her recent resignation as deputy director of health services that she was pleased with early results of the enforcement program, which has also used legislative reforms approved in March that increased penalties and fines for nursing home abuses.

“To those providers who are offering substandard care, we are saying they need to either improve their programs or they need to get out of the business,” Stewart said.

Many nursing home owners are doing just that, said Michael Ellentuck, vice president of the San Diego Health Assn. “A lot of independent operators are getting out,” Ellentuck said. “It’s gotten to the point where it’s not enjoyable to be in the industry anymore. There’s no real support. Everyone is against us.”

Ellentuck said the state is more interested in punishing nursing home administrators than in seeing that they comply with regulations.

Lack of Aggression Cited

Although nursing home owners criticize the enforcement effort, patients’ rights advocates and state legislators have complained that previous inspectors for the state health licensing division did not aggressively pursue abuses.

Assemblyman Larry Stirling (R-San Diego), who has been in the forefront among those pressing for nursing home reforms, has charged that previous inspectors were ineffective, preferring to advise and consult nursing home administrators instead of writing citations. He said citations have increased largely because the state recently hired the new investigators.

State health officials unexpectedly were presented with a way to infuse their enforcement program with new blood last year when Gov. George Deukmejian announced a “golden handshake” program to entice longtime state employees into early retirement. The program, intended primarily as an economy move, resulted in 20 of the 62 inspectors in the Berkeley, Redding, San Diego, San Francisco and Santa Ana district offices retiring early. In Santa Ana, nearly half the district’s 33-member staff quit.

“Whenever people are on a job too long, they get stale,” Health Services Director Kenneth W. Kizer acknowledged. “Bringing new blood in . . . that sort of thing is good, not only in licensing but in a number of other areas, too.”

Stirling has blamed the state’s licensing and certification division for allowing San Diego County’s Edgemoor Geriatric Hospital to fall into chaos. The state recently issued fines against the facility for inadequate nursing care in connection with the deaths of a 66-year-old paralyzed woman who drowned in a bathtub and a legless man who fell out of his bed and later suffered a heart attack.

“I think they got co-opted,” Stirling said of state inspectors who issued two major citations against Edgemoor in the last three years compared to four already this year. “When you become friends with the (Edgemoor) people, it’s hard to burn them. In my mind, only the presence of a new chain of command made the difference. They were shocked and appalled at what they found.”

The younger, more aggressive recruits have given the inspection division its new-found image of toughness.

“We went out and recruited people who had good backgrounds in the health profession and people who could take a tough enforcement stance,” Stewart said.

The result is a new type of inspector who is breaking up the “old boy network” in the nursing home industry, said Winter Dellenbach, a lawyer who works as a Santa Clara County patients’ rights advocate.

“As new people . . . see these facilities, they are absolutely shocked,” Dellenbach said. “They walk around kind of shellshocked for weeks until they get used to reality. The other people after 15-20 years get inured to it.”

Some evidence of an “old boy network” cropped up last month when one veteran nursing home licensing official resigned rather than face disciplinary action after he was accused of advising nursing home operators how to circumvent the tougher new enforcement laws.

With the new inspectors, the state enforcement program is accomplishing what it set out to do at the beginning of the year.

On Thursday, for example, the state halted patient admissions to a Sacramento nursing home and fined it $136,000, the largest fine ever assessed against a California licensed nursing facility. Officials said that lack of care at the 121-bed Countryside Convalescent Hospital could be linked to at least two patient deaths and that criminal charges are being considered for what may prove to be misuse of Medi-Cal funds.

On Tuesday, the state fined El Dorado Guidance Center $92,250 after a report said that women at the 99-bed facility in San Jose, which houses mentally disturbed patients, were raped by employees and other patients and that other inmates in a predominantly male ward reportedly paid $1 or cigarettes to have sex with a 21-year-old woman whom psychiatrists had described as “sexually vulnerable.”

Through May, state inspectors issued 107 Class A (serious) and 546 Class B (minor) citations. During the same period last year, 61 Class A and 321 Class B citations were filed.

The crackdown effort was given a boost in March, when Deukmejian signed sweeping nursing home legislation that was 10 years in the making.

The reforms increased Medi-Cal payments to nursing homes this fiscal year by $8 million and provided for annual increases of $87 million in future years to raise wages and staffing levels.

$25,000 Fine for Death

The legislation also stiffened penalties for negligent patient care, instituted fines for falsifying records and upgraded training for investigators. Nursing homes that were fined a maximum $5,000 for patient deaths in the past can now be assessed penalties as high as $25,000.

The law also gave Municipal Courts jurisdiction over nursing home violations, a maneuver that is expected to expedite legal cases, many of which have dragged on for years after patient deaths.

Deukmejian approved the reforms seven months after he vetoed similar legislation, saying he objected to such minor provisions as the creation of two advisory committees.

Jan Kohler, chief of the state Office of Patient Rights, said it is too early for the nursing home crackdown to be felt statewide. She said, however, that it is having a major effect in areas such as Santa Clara County, where numerous abuses have been uncovered.

“Facilities that we knew for years have been out of compliance have finally been put on the list of homes that could lose their license,” Kohler said. “I think that is probably most rewarding.”

The Los Angeles County Department of Health Services has conducted nursing home inspections under a contract with the state since 1966.

Similar County Program

“We’ve got the same kinds of problems here as anywhere else in the state,” said Marvin Brandon, program manager of the county health facilities division. “What (the state) is doing is similar to what we have done since at least 1975.”

The state health department’s licensing and certification division streamlined its operations in December by creating four regions and appointing administrators to direct and closely monitor enforcement at the district level. Previously, the state’s 10 districts reported directly to Sacramento.

Under the new alignment, regional administrators use expert medical consultants to assist inspectors in recognizing violations at nursing homes. For the last 15 years, these physicians, psychiatrists, dietitians, pharmacists and records specialists were employed by the state largely to consult and support nursing home administrators.

“Consultants used to go out and try to help the facilities,” said Joan Dowling, administrator of the Santa Ana region. “That’s no longer the philosophy. They’re used for enforcement on problem facilities because these facilities can hire their own consultants.”

Many of the reforms have not been well received by nursing home administrators, who said the increase in citations means that more time and money will be diverted from patient care to handle paper work and legal fees.

Joe Diaz, Southern California regional director for the California Assn. of Health Facilities, said that before the crackdown started, a typical 99-bed nursing home was required to follow 650 regulations and make more than 1 million medical entries each year.

‘Chill’ Throughout Industry

“Most of the citations deal with paper-type violations (and) a variety of things that do not relate to direct patient care,” Diaz said. “That’s why it is sending a chill throughout the industry.”

Paper work and legal battles are part of the business, said Kohler, the patient rights chief.

“You can’t have enough surveyors, you can’t have enough investigators in there,” Kohler said. “If you don’t comply, you get cited. If you get cited, it means hiring lawyers and paper work. Perhaps if you had an adequately trained staff, you wouldn’t have to worry about paper work.”

The most dramatic phase of the crackdown was introduced two months ago when Kizer, in his first major move since becoming director in March, caught nursing homes off guard by making a series of late-night and weekend inspections.

State licensing officials have been criticized by patients’ rights advocates for scheduling annual survey inspections at roughly the same time each year, on weekdays between 9 and 5.

Under Kizer’s plan, state investigators conducted surprise visits to 10 facilities in Orange, Riverside, Kern, Fresno and Santa Clara counties on a test basis.

Unsanitary Conditions

Kizer said that Northlake Convalescent Hospital in San Jose had the most serious problems. Investigators reported finding patients left in their own urine and feces. They also cited the 83-bed facility for inadequate staffing and unsanitary conditions, including puddles of urine on the floor.

The most serious charge against Northlake involved the death in April of an 83-year-old woman who was not treated by the medical staff despite having all the symptoms of extreme dehydration, including urine that was “cloudy, sticky as syrup.”

The state closed Northlake last month, and telephone calls to the facility were not answered. The last time patients were evacuated from a California health facility was in 1982, when Los Angeles County health officials shut down Broadway Community Hospital.

Northlake faces $55,000 in fines.

Another target of the surprise inspections, Bristol Care Center in Santa Ana, faces fines totaling $80,000 after investigators reported finding unsanitary conditions including numerous cockroaches, hot water levels at unsafe temperatures and a patient with serious bedsores that were not treated. State officials said they are considering revoking Bristol’s license.

Kizer said investigators will continue to schedule surprise visits to the worst of the state’s nursing homes.

‘A Better Perspective’

“I personally think that the . . . fact we are making unannounced visits at off-hours gives us a better perspective of what is going on at a facility at any given time,” Kizer said. “With the unpredictability, a facility can’t prepare for those inspections.

“This one element has had a very positive effect. It underscores the fact that we mean business.”

Diaz, the nursing home spokesman, questioned the benefits of the surprise visits.

“Most good administrators would not argue with the intent of having surprise inspections,” Diaz said. “What really concerns us is that in order for those teams to be viable and useful, a key staff person should be there to respond to their concerns.”

Robert L. Pruett, executive director of South Coast Care Corp., a Huntington Beach firm that operates six licensed care facilities in Southern California, said the new reforms were unnecessary.

“They did not need reform legislation to accomplish what they’re accomplishing,” Pruett said. “They had all of the tools they needed to issue citations.”

Pruett complained that as part of the crackdown, state inspectors are issuing petty citations for violations ranging from burned-out light bulbs to dirty fingernails.

Citations Called ‘Absurd’

“A light bulb is going to go out. To write it up is absurd,” said Pruett, whose nursing homes include Bristol Care.

“If you take a facility with 100 patients, it means you’ve got 2,000 toenails and fingernails. To say they found two patients with dirty nails . . . is that really a pattern?”

Dirty fingernails are not a trivial matter, said Esther Rains, the state ombudsman for long-term care.

“It takes a long time for a bedridden patient to get dirty fingernails,” Rains said. “It’s just an indication that for a prolonged period of time, somebody has not had their hands and nails cleaned. I don’t think it is a little thing. It has to do with people’s feelings of self worth.”