Seeking a Remedy for Nursing Homes’ Ills

Your hairdresser had 1,600 hours of training. Your veterinarian’s assistant studied for two years. But the nurse’s assistant caring for your frail grandmother needed only 150 hours of instruction to get a state license--most of it gained on the job with scant government oversight.

Combine that with poor pay, the increasingly sick population of California’s nursing homes and huge patient caseloads--an average of 10 patients per assistant--and you have a combustible brew long ignored in nursing home reform efforts.

Disaster inevitably strikes, its human toll filling the pages of government citations against the homes: The nurse assistants drop your grandmother and bones break. They attach a bed restraint improperly and she suffocates. Or they neglect to wash their hands and she gets an infection that sends her to the hospital, or the morgue.

San Fernando Valley attorney Orrin Turbo chose a facility carefully after his mother’s stroke. Only later did he learn that the facility’s real nurses spent most of their time doing paperwork and distributing medicine, while the “nurses” caring for his mother were ill-prepared and poorly treated nurse assistants.

Still, Turbo was shocked to find the 76-year-old sitting up in her bed, naked from the waist up. Her fingernails had not been trimmed for more than two months. One day he found an open container of iodine in her doughnut box.

“I was told this was one of the best places,” said Turbo, who recently moved his mother to a smaller, better staffed home. “It made me wonder what the others were like.”

Amid mounting pressure from baby boomers with aging parents, nursing home reform is moving to a political front burner in California that it has not occupied in more than a decade. And for the first time, the focus is on the critical role of nurse assistants.

Democratic Assemblymen Kevin Shelley of San Francisco and Jack Scott of Altadena hope to upgrade the job with legislation to require more training, lighter workloads and more pay, which now averages $7 an hour. Shelley is seeking to increase that by at least 5%.

Even the nursing home industry--constantly hiring to replace the 80% of nurse assistants who quit annually--wants to get off the treadmill. A recent Los Angeles lawsuit alleged that one desperate nursing facility had recruited homeless people from Griffith Park.

“I don’t think there’s any argument from anybody that there needs to be more and better trained staff,” said David Helmsin, who represents the California Assn. of Health Facilities and is the industry’s top Sacramento lobbyist.

But there’s a catch: The industry wants the state to pay for the added costs by increasing Medi-Cal reimbursement from $88 a day--among the nation’s lowest rates. Industry estimates of $250 million to fulfill the bills’ requirements far exceed the $35 million now earmarked in the Legislature’s budget.

Nursing homes also oppose the additional penalties for poor care in Shelley’s bill, including the quadrupling of fines to a maximum $100,000 when a death occurs.

Instead, they advocate an incentive system to reward homes that do a good job. They also support Scott’s approach, which would force community colleges to train more nursing assistants--in fact, that bill was the industry’s idea.

Troubled Work Force

Nurse assistants are high school dropouts and immigrants, single parents, foot-sore waitresses and unemployed construction workers. A minority are also college graduates and nurses in training.

The dozens who talked to The Times shared two traits: They were dog-tired and dead broke. Many work double shifts or second jobs.

Gloria Melara, 53, is supporting an ill daughter, four grandchildren and her parents in El Salvador. She works at an Inglewood nursing home from 7 a.m. to 3:30 p.m. and speeds to another facility in Playa del Rey to work from 4 to 11:30 p.m. By the time she arrives home in Huntington Park, she has just enough time to shower and sleep four hours.

“Sometimes your body says no, but you push it to go to work,” said Melara, whose hip socket has degenerated so badly that her doctor recommends a hip replacement.

Nurse assistants’ wages may average $7 an hour in California, but many make minimum wage, and years of experience don’t necessarily count. After 21 years on the job, Melara makes $7.02 an hour at one facility, $9.42 at the other.

Administrators of nursing homes say that they cannot afford to pay more because Medi-Cal reimbursement--which covers two-thirds of California’s nursing home residents--is so inadequate.

“Everyone agrees that more staff will result in an increased quality of care,” wrote the administrator of a San Gabriel Alzheimer’s center in a letter to Shelley. “However, all the regulations in the world will not increase staff and meet payroll. Only money pays payroll.”

But reform advocates say that greed, not poverty, is the culprit, and they point to the multimillion-dollar compensation packages received by the nursing home industry’s top administrators.

Those nurse assistants lucky enough to be offered health benefits spend about a fifth of their earnings for the premiums, according to a study scheduled for release this summer by the UC San Francisco Center for the Health Professions.

For this, they strain their backs lifting patients, weather verbal attacks from the demented and find themselves constantly in contact with human waste.

They often lack essential tools such as soap, toilet paper and even diapers to keep patients and their beds dry. They have to buy their own uniforms.

The workers, technically known as certified nurse assistants, beg for better training--for far more than the additional 10 hours in the pending legislation. Duties as important as taking blood pressure are not adequately covered, they complain, and when they reach the nursing homes, little additional help is offered.

At a Los Angeles nursing home, Elba Posada’s hands-on training never materialized, she said. The first day on the job, she was given five patients, the second day seven and the third day, the full 10, she added.

“They didn’t even tell me where the gas turnoff was, where the fire extinguisher was,” she said.

Just three state employees oversee training programs provided for 15,000 nurse assistants annually at 800 locations, where students are given 50 hours of classroom training in topics ranging from hand washing to taking temperatures. That small staff restricts itself to a review of class curriculum and instructors’ credentials, focusing more closely only on programs with low passage rates on the state certification exam.

Although the Shelley legislation would pump up the required curriculum, neither pending bill would augment state oversight.

Further, nurse assistants say, the in-service training required every two years to maintain their certification rarely provides them with the new skills they need to treat ever sicker patients.

Thanks to earlier hospital releases and treatments that keep people alive longer, nearly one in 10 California nursing home residents is bedridden, twice the number in 1991, according to federal statistics. Also on the rise are patients with catheters, IVs and respirators.

Posada is afraid of accidentally dislodging the unfamiliar tubes. She worries for the patients, and for herself. Only after a patient with tuberculosis died were she and other nurse assistants taught how to prevent the spread of TB and tested for exposure, she said.

Former nursing home nurse Charlene Harrington, now a behavioral sciences professor at UC San Francisco, believes inadequate care may be one reason California nursing home patients are sicker.

“The only people who should be in bed are the terminally ill, [but] more and more people are in bed,” Harrington said. Nurse assistants are “not getting them up and properly taking care of them.”

A Tragic Case History

The answering machine at the McDonoughs’ house says, “You have reached the number for Joe and Gwen,” but for a year that has been wishful thinking.

Since May 13, 1998, Joe, 76, has resided at St. Joseph’s Medical Center in Burbank, recovering from sores he developed at a Canoga Park nursing home that were so deep they exposed his Achilles tendons on both ankles. Gwen has spent their life savings to keep him hospitalized ever since.

A state citation of Canoga Care Center, where Joe lived from March to May last year, indicates he was placed in a bed too short for his 6-foot-2 frame. His feet hung over the edge and the backs of his ankles rubbed on its raw wood edge, opening up wounds that grew to be nearly 7 inches long.

The retired Los Angeles County sheriff’s lieutenant had landed at the nursing home for several weeks of physical therapy after a series of strokes and long-undiagnosed Parkinson’s disease.

There were hints of trouble early on, Gwen said. One day she found Joe dressed in his roommate’s too-small sweatpants; another time he was shivering in a bed, covered only by a sheet, she said. Joe got thinner-- she would later discover he had lost 55 pounds.

Though Gwen pleaded for a bigger bed, she said she was told inflated booties would do the trick. It was not until she noticed the booties on the floor one day, stained with blood, that Gwen began to realize what was happening.

“I told the nurses he had wounds,” Gwen said. “Why didn’t the [nurse assistants tell them]?”

Afraid to Complain

No one is more acutely aware of the poor level of care they provide than the nurse assistants.

They know it’s bad when food arrives cold for patients who are already at risk of malnutrition; they see some starve to death.

They watch bed sores erupt when patients are not turned every two hours, then see the sores fester when patients lie in their own waste. In the worst cases, they observe patients trying to treat their own wounds.

Most are afraid to complain because they need their jobs. But from time to time their frustration explodes into public view.

Such was the case with a 1993 letter written by a nurse assistant to one of the nation’s largest nursing home companies, Beverly Enterprises:

“We are overworked and overstressed,” wrote Carol Ensele, who then worked at Beverly Manor in Yreka. “We are jeopardizing the safety of our residents as well as our own. Due to our workload, there is not enough time to use gait [restraint] belts, glove up or wash hands between patients. It is a matter of time before a tragedy occurs.”

Ensele appears to have been right. A year ago, jurors in Siskiyou County awarded a record $95 million to a 66-year-old stroke victim whose hip and shoulder were broken in 1995 when an aide, unable to find help, tried to move her from a bed to a chair.

During discovery for the trial, plaintiff’s attorney Michael Thamer concluded that the nurse assistant was set up for failure and won his case on the premise that the home was understaffed. “It’s like telling someone to drive 100 miles and giving them 50 miles worth of gas.”

A Vicious Cycle

This is the vicious circle of nursing home staffing, reported by nurse assistants but also acknowledged by the industry: Large patient loads and low pay lead to poor morale and high absenteeism, which raise patient loads.

According to various surveys, the ratio of nurse assistants to patients in California nursing homes hovers around one to 10 on the day shift, but nurse assistants report that no-shows regularly bump the ratio up to one to 15 or more. On a recent night shift in Marin County, one nurse assistant said he alone was handling 56 patients.

Official records make the staffing appear fatter because registered nurses count double, a loophole the state created in 1974 to encourage nursing homes to hire more registered nurses.

But nurse assistants say the nurse hours do not lighten their load because registered nurses won’t do the same kind of work they do.

On a recent short-staffed shift at a Petaluma nursing home, a nurse interrupted Larry Rickards as he was feeding patients to tell him another patient had soiled herself. When Rickards suggested the nurse take care of it, he recalled, she tugged on her RN name tag and said, “This is my license not to change diapers.”

Shelley’s bill would do away with the double-counting. It would also require that every patient receive 3.2 hours of care a day, up from the current 2.8-hour average. That would grow to 3.5 hours by 2003.

A report issued in December by nursing home experts from across the United States recommended nearly 4.6 hours as optimal. The report cited numerous academic studies showing that when staff is sparse, patients eat less, are less active and have more skin and urinary tract troubles.

‘I’ll Be Back’

Carmen Ramirez’s upper lip glistens with sweat as she rushes to get her morning chores done at a Maywood nursing home. She and another nurse assistant are working as a pair, covering 23 patients.

Nursing home laws say that patients’ schedules must reflect their own preferences and needs, but that is not realistic in the assembly line atmosphere.

Showers are scheduled every three days--beds A go on Monday, B on Tuesday and so on. This particular day even that is not possible. By morning’s end, Ramirez is reduced to giving “bed baths”--”washing” the patient with a wet towel.

A patient screams when Ramirez begins to clean her. Ramirez is working so fast she accidentally wipes the woman’s food table with the dirty linen on her way out.

As she hurries down the hallway, Ramirez helps a woman struggling with a cup of milk take a longer drink, props up a newspaper so a patient sitting in a wheelchair can read it, then asks a woman who can walk if she wants coffee and guides her to the dining hall.

She passes open doors, where patients call out to her.

“I’ll be back, I’ll be back,” she says over her shoulder.

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Nursing Home Deficiencies

In 1997-98, California was among the 10 states with the highest percentage of nursing home deficiencies. A 1998 U.S. General Accounting Office report found that nearly a third of California’s nursing homes had been cited for serious violations between 1995 and 1998.

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Deficiency % California % National No comprehensive care plan for residents 42% 17% Not providing care that enhances dignity 38% 13% Storing, preparing and serving food in 41% 22% unsanitary conditions Not accommodating patients’ needs 28% 9% Inadequate assessment of residents’ problems 28% 17% No established plan to prevent infections 20% 9%

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Source: U.S. Health Care Financing Administration, 1998

The Human Toll

After investigations of complaints of abuse or neglect at nursing homes, state citations often touch on the poor preparation of certified nurse assistants.

Jan. 1, 1999: Kearny Mesa Convalescent and Nursing Home, San Diego

Violation: Resident suffocated after dangling over side of bed on an improperly attached roll belt. Nurse assistant had not been trained to use the belt.

Nov. 5, 1998: Country Villa Cheviot Garden Health Care Center, L.A.

Violation: No restraining belt secured a 92-year-old amputee while in a chair, causing her to fall and break her left leg. Employee said she had not been trained in how to use that particular chair.

Nov. 4. 1998: Vale Care Center, San Pablo

Violation: A staff member tried to move an 86-year-old resident with a mechanical lift meant to be operated by two people. The resident fell and received multiple injuries, some to the head.

Jan. 1, 1998: Sophia-Lyn Convalescent Hospital, Pasadena

Violation: Resident supposed to get daily walking assistance and training in using an artificial limb was not walked for three months because the prosthesis hurt. Aide had not been trained in applying prostheses.

Dec. 10, 1997: Integrated Health Services at Orange Hills, Orange

Violation: Staff failed to use masks and wash their hands before starting dialysis. Resident developed infection and died.

Dec. 4, 1997: Beverly Manor, Monterey

Violation: Staff failed to use an ankle alarm on a confused resident with a history of falls. Resident fell and leg fracture required surgery. The five certified nurse assistants who cared for the resident did not know how the alarm worked.

March 12, 1997: Applewood Specialties Inn, Redding

Violation: Facility failed to train and evaluate aides. Unsupervised aides had responsibility for as many as 20 patients. Call lights were not answered promptly and aides failed to wash hands between emptying a commode and handling ice.

July 3, 1996: Valley Manor Rehabilitation Center, Concord

Violation: 89-year-old resident died of dehydration. Facility failed to notify doctor of her poor fluid intake.

Source: California Department of Health Services and California Advocates for Nursing Home Reform, 1999