Restraints, Drugging Rife in Nursing Homes : Health: Industry admits 68% of patients are involved, while critics say 80%. State is not enforcing new U.S. law.

On any given day, an estimated 80,000 elderly patients are tied down or drugged in nursing homes across the state. A new state study reports that this treatment often hastens their demise, but neither they nor their relatives have the right to withhold consent under California law.

Medical experts say that overdosing and misuse of powerful psychoactive drugs are common in nursing homes across the nation, provoking terrible side effects and doing little to improve behavior. Similarly, they warn that the widespread practice of tying patients to their beds or chairs can lead to loss of basic body functions from restricted mobility, painful skin sores and a broken, demoralized spirit.

Federal nursing home reforms that went into effect in October have reduced the use of restraints in nursing homes across the country by 25%, according to the National Senior Citizens Law Center.

But in California, where the law has not yet been enforced, there has been no such decrease.

In a much-publicized tug of war with the federal government, California officials have held up implementation of the law. Gov. Pete Wilson contends that the guidelines for implementing the law are unnecessary, costly and illegally promulgated.

However, a blue-ribbon watchdog panel of experts has released to The Times a comprehensive report that paints a compelling picture of misery and suffering in California nursing homes. The panel has called for the full and immediate implementation of new federal reforms--especially in the area of patient restraints--and a stronger enforcement system to penalize poor care providers in California.

The 90-page report prepared during the last year by the Commission on California State Government Organization and Economy (also known as the Little Hoover Commission), says that between 68% and 80% of California’s 120,000 nursing home patients are put in restraints. Either they are physically restrained by straps, mitts, vests and other devices or chemically restrained by potent sedatives, tranquilizers and antipsychotic drugs.

Through inspection of nursing home records and from testimony, the commission documented cases since 1988 of abuse and neglect of patients.

Relatives of patients testified how psychotropic drugs turned their loved ones into drooling, incontinent zombies, often left lying unattended for hours in urine and caked feces.

They described the terror and frustration that swept over elderly patients immobilized by physical restraints and told of physical side effects such as painful bedsores. A San Bruno woman said that her father was repeatedly drugged and tied down so tightly that his wrists swelled and “he screamed in pain” when he was touched. Much later, nursing home staff concluded that he was allergic to the antipsychotic drug he had been given.

A Sonoma woman testified that her husband “just hated being tied up like an animal. It was so degrading.”

A Palo Alto woman said that her husband “had to eat lying in excrement” and that drug overdoses “paralyzed his hands” and other body parts.

Another woman testified that her father was killed when a faulty bed rail permitted him to fall out of bed and strangle on a Posey restraint that was supposed to confine him.

The report also pointed to a facility where staff slapped and pushed patients, dragged one across the floor and verbally assaulted others. They forced syringes between patients’ teeth and stripped a patient of clothes to keep her in her room.

Nathan Shappell, the commission’s president, said after hearing the testimony: “These nursing homes are like warehouses that people are thrown into to die. It’s a shame on everybody. A shame on the industry. A shame on the lobbyists that they can’t clean this up for once and for all.”

State Health Services Director Ken Kizer says California has made progress in reducing nursing home reliance on drugs to control the behavior of its elderly patients. State officials have long maintained that California leads the country in providing quality nursing home care to the elderly.

But in the report, the commission stated that the percentage of patients chemically or physically restrained in California’s nursing homes “greatly exceeds any other state’s.”

Patient rights advocates estimate 80%, while the nursing home industry estimates 68%.

“If one accepts the nursing home industry’s own figure, that translates to more than 81,000 elderly Californians being tied down and/or drugged on any given day,” the report stated.

State law does not give nursing home patients the right of informed consent, or permission, before restraints are applied. The panel called for immediate implementation of the federal nursing home reforms, which give patients this right. The commission pointed out that even the mentally ill, the developmentally disabled and those who are incarcerated in California now have such a right to control their own treatment.

Patients should be assured that they “will not be tied down or drugged against their wishes, but that alternative methods will be found to protect their safety and deal with their dysfunction problems,” the commission concluded.

In its report, the commission said that within the medical world, there is a growing awareness of problems involving restraint of elderly patients.

Researchers who have studied the effects of restraints on elderly patients have enumerated a “range of serious effects and consequences of restraints and immobilization in this age group,” according to a 1989 research article in the Journal of American Geriatrics.

The University of Pennsylvania scientists who authored the report said restraints can lead to bowel problems, pneumonia, circulatory obstruction, cardiac stress, skin abrasions, poor appetite, dehydration and even accidental death by strangulation.

“And what happens to the spirit of the resident who has been tied up?” Kathy Badrak, president of California’s Long Term Care Ombudsman Assn., asked in testimony before the Little Hoover Commission.

She cited the fear, demoralization, anger and rage that can be aroused, and quoted one patient as saying: “‘I felt like a dog and cried all night. It hurt me to have to be tied up.”’

In calling for curbs on chemical restraints of the elderly in nursing homes, the commission cited the research of Dr. Mark Beers, professor of geriatric medicine at UCLA Medical School. He and others have concluded that nursing homes commonly overuse or misuse strong tranquilizers such as Dalmane and Valium as well as antipsychotic drugs such as Haldol and Mellaril to control behavior rather than treat a specific psychiatric illness.

“If we knew that these medications were safe and effective, then there wouldn’t be much controversy here,” he said in a telephone interview. “But 45% of the patients get side effects” that range from allergic reactions to tremors and repulsive facial ticks which make them look like they are chewing gum and chomping their lips.

“The bottom line is that a lot of people get sick from these medications, not a whole lot get better and those that do, don’t get much better. That’s (one reason) why (the new federal nursing home law) came into being,” Beers said.

The new federal law requires that nursing home patients be restrained only for medical symptoms and not for discipline or convenience. Controversial guidelines that spell out how the law should be enforced say that inspectors should check to see that patients or their legal representative have given informed consent to any physical or chemical restraint.

California officials say that while they do not oppose the concept of informed consent, the new federal nursing home law can not legally be interpreted to give patients this new right. For that reason, they recommended to federal officials in a letter last week that the informed consent provision be erased from the law’s interpretive guidelines.

Pat McGinnis at the Bay Area Advocates for Nursing Home Reform in San Francisco denounced the state’s position, saying: “They’re negating vital patient protections. They are gutting the whole intent of the new law. They’re going back to the dark ages.”

Kizer, state health services director, retorted: “That’s utter nonsense.”

He said the reason federal guidelines should be changed is to make them compatible with the law and to give his inspectors greater “flexibility and judgment” in enforcing the rules.

In its report, the commission repeated earlier calls for a “meaningful” enforcement system in California that will “put teeth into the state’s efforts to control the quality of care provided to the elderly.”

As it exists, the state’s system of citations and fines has not deterred poor quality care in California nursing homes, the commission charged. “A review of the system . . . shows it has been undermined by massive amounts of uncollected fines, a pattern of non-responsiveness to complaints, and some systemic barriers to efficient and effective enforcement,” the commission concluded.

During one year, state health inspectors levied fines of $5.8 million but only $558,000 was collected, the report said. Numerous cases are cited in the report where nursing home operators paid far less than the fine levied:

* A woman whose leg was broken when she was dropped by nursing home staff languished for 21 days before her doctor was notified. The nursing home was fined $8,000 but paid half that.

* A semiconscious, dehydrated, malnourished elderly woman was found to have languished for hours with pill fragments and unchewed food in her mouth. The nursing home was fined $7,500 and paid half that.

* An 80-year-old man had to have his leg amputated below the knee because nursing home staff neglected his infected toes. The facility was fined $10,000 and paid half.

State health official David Markell said that the object of writing citations and fining nursing homes is “not to make a profit” but to improve care.

The commission recommended numerous reforms to streamline the citation process and increase its deterrence value. Among other things, the commission suggested that instead of halving fines if facilities pay without appealing them, the fines should be automatically doubled if a facility chooses to appeal and then loses.

Times staff writer Irene Wielawski contributed to this story.