Crisis Point in Caring for the Elderly? : Nursing Homes Under Fire; Staff Woes Cited

Joe Diaz was beginning to sound a little foolish.

First, the state had cracked down on a nursing home in Vista, barring it from receiving Medi-Cal and Medicare payments. Diaz, representing the industry, had found himself explaining to the residents’ families why their aging relatives would have to move.

Then the regulators had taken on Alvarado Convalescent and Rehabilitation Hospital in La Mesa, forcing another 150 Medi-Cal and Medicare patients to relocate. A few months later, they did the same to a third nursing home, Cresta Loma Convalescent Home in Lemon Grove.

“When I addressed the relatives at Cresta Loma, half the families were families I had addressed at Alvarado,” Diaz recalled last week. “To tell you the truth, I don’t want to have to do that again. They became very angry. And I don’t blame them.”

Tough Stance Toward Homes

Times are tough in the nursing home business in San Diego County.

In the past 14 months, state and federal health officials have barred three facilities from receiving Medicare and Medi-Cal funding, accusing them of widespread violations of health and safety rules that in some cases, they say, may have cost residents their lives.

The regulators have also moved to take similar action at another seven homes, though those have appealed and currently remain in the program. And the regulators have imposed dozens of fines on those and other facilities, totaling hundreds of thousands of dollars.

“Compared to the other 56 counties, San Diego has the highest number of decertification attempts and the highest number of decertification actions completed,” Diaz, regional director of the California Assn. of Health Facilities, concluded last week.

Industry and state officials trace the friction in part to stricter regulation of nursing homes, stemming largely from 1985 legislation that tightened surveillance, raised penalties and sped up the process for decertifying inadequate facilities.

Officials Cite Staffing Problems

But nursing home officials say their difficulties also reflect problems plaguing their industry nationwide: A dramatic worsening in the conditions of patients entering nursing homes, and a chronic inability to hire and keep qualified staff.

Some claim the staffing problem is especially severe in San Diego County where pay is lower and more desirable minimum-wage jobs can be found. In addition, they say a proliferation of new nursing homes is stretching the limited supply of nurses and nursing aides.

“Staff is 90% of the problem,” insisted Helen Knight, president of the San Diego chapter of the Council of Long-Term Care Nurses of California. “ . . . When you don’t have the properly trained staff, you cannot do the work.”

As a result of the recent conflict, nursing home administrators in the county have begun meeting regularly with state Department of Health Services (DOHS) officials, in hopes, the administrators say, of learning how to avoid more decertification attempts in future.

Knight, director of nursing services at Valle Vista Convalescent Hospital in Escondido, has attempted to recruit nurses aides by speaking at local nursing school graduations. And Diaz’s organization has been lobbying the state to raise the reimbursement rate for the 70% of all nursing home patients who are on Medi-Cal.

“I suspect that in San Diego, coupled with the problem of woeful staff availability, you’ve got an environment ripe for conflict,” said Diaz. “It’s a real concern to all of us simply because we don’t see an immediate resolution in the near future.”

Long-Standing Problem?

Another industry official took a different view.

“What we have is a long-standing problem that is getting attention,” said Dave Helmsin, who works with Diaz’s group, but in Sacramento. “I would say that in California and nationwide, society has not put enough emphasis on the care available for the elderly.

” . . . I believe that as more people become aware of the relationship between quality, access and reimbursement . . . and of the gaps in the financing system for long-term care, we will see more commitment towards this end of the health-care stream.”

There are some 80 nursing homes in San Diego County totaling about 11,000 beds. They are regulated for the most part by the state health department’s division of licensing and certification under the state Health and Safety code and the Administrative code.

Nearly all the facilities have contracts with Medi-Cal and Medicare, the state and federal health insurance programs for the poor and elderly. Because those programs cover about 70% of all nursing home residents, they are the nursing homes’ principal source of income.

So the facilities must meet state licensing requirements as well as requirements for so-called certification for federal and state funding. If they fall short, they can face financial penalties, decertification and, in extreme cases, loss of their license.

Daily Complaints

Ernest Trujillo, the DOHS district administrator for San Diego, said his 19-member office receives two to three complaints a day. If a complaint suggests an immediate threat to a patient’s health and safety, an inspection will be done within 24 hours, he said.

The first of the recent rash of decertifications involved Golden Age Leisure Gardens in Vista, where Trujillo’s office began a series of surveys in June, 1986, and found what the inspectors said were widespread violations of state and federal requirements.

Among the instances they cited were the deaths of three patients from malnutrition, dehydration and choking on food. The inspectors concluded that those deaths, and numerous other shortcomings in maintenance and patient care, resulted from staff negligence.

State and federal officials decertified the 176-bed facility in September, 1986, forcing the Medi-Cal and Medicare patients to be moved to other homes. (The nursing home has since changed ownership and successfully reapplied for certification, Trujillo said.)

Next came Alvarado, a 301-bed facility that Diaz said was viewed as the “flagship” of the large nursing-home chain that owns it. In April, 1987, federal and state officials decertified the home after two extensive inspections.

During the surveys, inspectors reported finding inadequate nutrition, medication errors, insufficient staffing and poor record-keeping. They said nurses had failed to follow doctors’ orders and to take steps to prevent patients from injuring themselves.

One patient at the home had lost 34 pounds in less than 30 days, according to reports on file with the state. Other findings included instances of bed sores, scabies, soiled linen, lack of privacy and patients being injured in falls.

Most Recent Case

The most recent decertification involved Cresta Loma Convalescent Home in Lemon Grove, barred from state and federal funding two months ago. The charges against the facility included problems with hygiene, nutrition and privacy, and two instances of patient abuse.

Records on file with the state report that the inspectors found numerous cases of residents lying in urine or feces. They also found cockroaches and ants in the facility and a permanent stench of excrement.

“Nursing staff were observed to be lacking in knowledge relative to the problems and needs of the aged, ill and disabled and patient care delivery system,” the inspectors reported. They found the facility had failed to offer much of the nurse training required by law.

Diaz contends that staffing shortages played a role in all three cases.

The Vista facility had admitted a large number of “acute” patients with relatively serious medical conditions, he said. Because the staff was not sufficiently trained to handle those “heavy care” patients, accidents began to occur, Diaz said.

State inspectors charged the facility with violations of the code governing nursing homes. The citations heightened pressure on the staff, Diaz said. There were more errors and citations, prompting what Diaz calls “the revolving door of quality deterioration.”

The same thing happened at Cresta Loma, Diaz said.

“Once the facility becomes the focus of a major survey or decertification action, it’s very hard,” he said. “It’s only human nature to begin to say, ‘I need to work, I’d better look elsewhere.’ Before you know it, you have your director of nursing leaving.”

Indeed, the state file for Golden Age Leisure Gardens includes a series of letters from the nursing home to the state announcing a new administrator or director of nursing, or both, on four occasions in nine months in late 1985 and 1986.

High Turnover

And Roger Caddell, administrator of Paradise Hills Convalescent Center in San Diego, said annual turnover among nurses’ aides at some facilities in San Diego County is currently as high as 120 to 130%.

Even in the best of times, hiring for nursing homes is not easy.

Nurses and aides must be trained, yet many begin work earning little more than minimum wage, officials say. Comparable work in hospitals or home health care or with free-lance nursing “registries” often offers more money and less stress.

In California, wages are held down in part by the Medi-Cal system. Nursing home officials say the average Medi-Cal reimbursement rate is about $48 a day, which they insist does not cover the costs many homes incur in caring for individual patients.

“They’re asking us to do a lot with not a lot of money,” said Kathryn Ruff, of the health facilities association. “ . . . The question is, can you hire the type of employee you want with the amount you have to pay.”

Now demographic and social changes are making the staffing problem worse.

The number of elderly people needing long-term care is on the rise while the proportion of younger people in the population to care for them is declining. Furthermore, few people have extensive experience in working with older patients.

At the same time, hospitals are discharging patients earlier than in the past because of new incentives built in to hospital reimbursement systems. So, nursing home officials say, they are receiving patients who are significantly sicker than in the past.

“Brand new surgeries, three and four days post-op,” Knight said, as he described some of the new cases. “ . . . We’re getting a lot more heavy care. It means a higher ratio of staffing. We’re doing the same thing as in acute hospitals, but with less staff and less money.”

Reform Legislation

Meanwhile, nursing home regulation has grown stiffer as a result of legislation and public pressure on both the state and national level. In California, sweeping nursing home reform legislation in 1985 introduced a new era of stiffer fines and closer scrutiny.

The maximum fine was raised from $5,000 to $25,000. Investigators received new training and new resources. Within months of the new law, there were dramatic increases in citations, fines and decertifications.

Some San Diego County nursing home officials said they have no objections to the state’s more aggressive posture.

“In my opinion, I don’t feel that the regulation has been bad at all,” said Dr. Robert Malkus, medical director of Lemon Grove Convalescent Hospital. “I think they have to do a job, and the more they regulate, the better it is for the safety and care of the patient.”

But others accused the state of excessive regulatory zeal and complained that the standards are open to subjective interpretation. They questioned whether the standards truly reflect the quality of patient care and regretted the loss of the old “cooperative” approach.

“It used to be we were out for the quality of care for the patient and we would do what we could, together,” said Caddell, administrator of Paradise Hills. “But a few years back, they went from surveyor to enforcer.

“A lot of (deficiencies) are questionable and could be resolved in a cooperative effort instead of a punitive effort,” he added. “In our level of care, we’re always getting blasted for how bad we are.”

Results Mixed

Observers suggest the results of the increased regulation have been mixed.

Hal Tindall, executive officer of the state board of examiners of nursing home administrators, a branch of the Department of Consumer Affairs, said the flurry of regulatory activity has drawn public attention to problems that were hidden in the past.

But he said the crackdown has also had a demoralizing effect.

“The minus side is that some administrators are getting very frustrated,” said Tindall. “ . . . A lot of good people are leaving nursing home administration because they don’t have to put up with this stuff if they go into hospital administration.”

“Personally, I think it’s going to lead to a lowering of the quality of care if we don’t go back to a more cooperative attitude between providers and enforcers,” said Caddell. “Because you’re driving good people out.

“(The regulators) don’t mean to, they don’t tell you they’re going to chop your head off,” he added. “But you full well know that when they walk in the door, your whole life sits in their hands. It’s a tremendous pressure.”

Helmsin of the health facilities association was more optimistic. He predicted that the current scrutiny would gradually raise public awareness of the difficulties facing the nursing home industry and the need for increased resources.

“And the interest will continue to grow as more and more people become aware of the imbalance between what they perceive should be occurring in the nursing homes and what nursing homes are able to deliver,” he said.