Next Avenue: The 5 vulnerabilities that led to the colossal failure of nursing homes

Next Avenue: The 5 vulnerabilities that led to the colossal failure of nursing homes

2021-04-08 00:24:00

Patricia Olthoff-Blank thought everything was fine at her mother's nursing home in rural Buffalo Center, Iowa. Virginia Olthoff had lived there for fifteen years, and the administration regularly communicated with her family about her concern.

Then Olthoff-Blank got a 3am call from a nurse in the emergency room. She was shocked to discover that her mother was severely dehydrated. An emergency room doctor told her, "This didn't just happen." He believed her mother had not had water for four or five days.

Several hours later, Virginia Olthoff was dead.

Her daughter recounted the events in a testimony before the Senate Treasury Committee in March 2019, telling them that a report from the Inspectorates and Appeals Department revealed that her mother had not eaten, drunk or received IV fluids for nearly two weeks. She was screaming in pain and had lost quite a bit of weight.

Despite repeated pleas from licensed nursing assistants to their superiors about her mother's condition, "nothing was done," said Olthoff-Blank.

The pandemic has exacerbated and raised awareness about the poor conditions in many nursing homes across the country. But those conditions existed before COVID-19 hit the US, and they likely will continue unless changes are made, experts say.

"There is an opportunity now because many eyes are on the nursing home industry," said David Grabowski, professor of health policy at Harvard Medical School. “One of my biggest concerns is that when things get back to normal … (people will say) we can just keep going. Business as usual didn't work before the pandemic, and it certainly didn't work during the pandemic. We need to make some real changes here. "

Why have nursing homes failed so dramatically during the pandemic? Experts point to five main factors.

1. Staff

Chronic staff shortages in nursing homes stretch existing staff to breakpoints. These first-line workers, such as Certified Nursing Assistants (CNAs), are often as difficult as retail and fast food and usually pay less (the average annual income for a CNA in a nursing home is $ 28,450). The result? Employees don't linger.

"We found a turnover of more than 100% in a calendar year, which means that basically the entire workforce turns around every year – and some nursing homes have a turnover of as much as three hundred percent," Grabowski said, referring to a study he and his colleagues published in March 2021 in Health Affairs.

“We don't pay those direct providers enough,” he said. "They are mostly women, many are colored people and immigrants, and they are in many ways overlooked when it comes to where we deploy resources in our health care system."

Inadequate staffing has a direct impact on residents, who not only receive poor care but also cannot develop relationships with employees when they are there one day and the next, Grabowski said.

"You talk to the residents and you ask them," What is it about this nursing home that you liked or disliked? "And it's always about the staff," he said.

Staffing at the professional nurse level is also vital, said Charlene Harrington, professor emeritus of social behavioral sciences in the School of Nursing at the University of California, San Francisco.

Harrington joined 21 other nursing experts publish a call to the Centers for Medicare and Medicaid Services (CMS) in March for a federal mandate for a stronger presence of registered nurses (RNs) in nursing homes.

CMS staffing rules currently require one RN who is employed in a nursing home for eight consecutive hours every day. Harrington and her colleagues said this should be expanded to include a 24-hour, seven-day RN on-site presence. There are no federal ratios for staff of any level.

“It's pure ageism that you can save older people and not have to buy and pay enough staff so that they are skilled and have experience,” said Harrington.

Pamela Mickens, a long-term care ombudsman in Dallas, said she sees the impact of under-staffing every day. But a comment from a resident's relative crystallized the issue of employee standards for her.

The family member worked in the prison system and pointed out that there are staff ratios for inmates, but not for those in nursing homes, Mickens recalls.

& # 39; That was a revelation to me, & # 39; she said.

2. Financing

Medicaid encompasses more than 60% of all nursing home residents, and Medicaid fees cover 70% to 80% of nursing home operating costs, according to the American Health Care Association, an industry group. It points to that funding gap as the culprit in & # 39; tight budgets & # 39 ;.

"Medicaid is not a generous payer," said Grabowski. "The way most nursing homes have made things work is by taking these short-lived, post-acute patients coming out of the hospital," as Medicare covers these patients for a limited time and at a much higher rate.

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That creates incentives to hospitalize long-term patients and bring them back, Grabowski said. "The margins on that side of the business are really quite high."

Harrington, of UCSF, said her research shows that the payment model for nursing homes is not the problem.

“All nursing homes say they don't have enough money, but in reality they (for-profit nursing homes) are making outrageous profits on the back of their low-paid workforce,” she said.

3. Company structure

Those profits, Harrington said, lie behind the often Byzantine corporate structure that underpins for-profit nursing homes, which make up 70% of the total.

A article Kaiser Health News revealed that it is increasingly common for nursing homes to outsource goods or services to companies they control or in which they have a financial interest. Some even rent their buildings back from a sister company. The result: The owners can transfer profits that are not reflected in the nursing home's books.

An added benefit to nursing homes is that the plaintiffs often have difficulty collecting when sued because the assets are not held with the licensee, Kaiser reported.

"They have set up these complex structures and they are raising so much money from their related party organizations … there is no more money for staff and services," said Harrington. She argues for more transparency and financial accountability in nursing homes.

4. Lack of supervision and enforcement

Nursing homes agree to follow minimum standards of care when participating in Medicaid and Medicare programs. Federal regulations demand that they "provide the necessary care and services to achieve or maintain the highest attainable physical, mental and psychosocial well-being" of their residents. That includes maintaining proper hydration – something Patricia Olthoff-Blank's mom certainly didn't get.

After Virginia Olthoff's death and that of another resident of the same nursing home, CMS fined the facility $ 77,462, and the families sued.

But federal measures against nursing home neglect are often insufficient, and too many nursing homes are allowed to function while constantly falling below minimum standards and then jumping back up.

Related: Destroyed nursing homes in COVID-19 – here are safer, more cost-effective options

"There is a segment of the industry with what we call 'yo-yo compliance' because they are constantly coming in and out of compliance," and rotating through various shortcomings, said Lori Smetanka, executive director of National Consumer Voice. for high-quality long-term care. "And they just aren't held accountable."

"We see ongoing and routine non-compliance" with laws and regulations, said Eric Carlson, director of attorney at Justice in Aging, a nonprofit fighting poverty among older Americans. "There are facilities with business practices that violate the law – they treat Medicaid patients worse, for example, and there is a federal statute that says you shouldn't discriminate based on reimbursement sources."

Too often, he said that CMS "does not recognize the violation, or if it does, it does not impose a penalty."

5. Aging buildings

The physical environment of nursing homes has become another source of problems. Traditional nursing homes built 30, 40 or 50 years ago were often modeled after hospitals, with long corridors and small, shared rooms.

“There's a warehouse mentality that's communicated through that kind of floor plan and architecture,” said Carlson. "For most people, our lives aren't organized around our beds … we don't sleep three feet away from strangers."

The Green house The model of nursing care and the like, on the other hand, consists of small-scale, domestic units that are limited to groups of 10 to 12 elderly people, each with its own room. These models often work with a "more enlightened" staffing scheme, with nurse assistants working consistently with the same residents, Carlson said.

A culture change

Mickens, the Texas ombudsman, said an ongoing challenge in nursing homes is the lack of recognition that residents have rights.

"They have a voice, and their voice and their preferences may conflict with what the nursing home staff, including the doctor, wants for them," she said.

Even if it's something as simple as taking a shower in the evening instead of & # 39; At 6 a.m. in the morning, the nursing home should strive to include that preference in the resident's care plan.

Carlson agreed. He compiled a list, available through Justice in Aging, called 25 Common Nursing Home Problems and How to Solve Them

In addition to enforcement, everyone involved in the system – from hospital discharge planners to staff and family members to the residents themselves – must have higher standards, Carlson said.

Read more: Aging at home instead of in a nursing home? Consider this first

That's the idea behind the guide, he said. If an institution says it won't honor a request "because it's going to be too much of a hassle," noted Carlson, the consumer may say, "No. Unacceptable."

It takes a culture change, he said. And if the facilities aren't doing it themselves, he added, consumers should say, "We're going to change your culture for you. Because what you're doing now isn't good enough."

Emily Gurnon is the former Senior Health and Care Content Editor for Next Avenue. Her stories include a series of articles about it abuse of guardianship which was funded by the Journalists in Aging Fellows Program. Previously, she spent 20 years as an award-winning newspaper reporter in the San Francisco Bay Area and St. Paul. Reach her through her website

This article is part of The Future of Elder Care, a Next Avenue initiative with support from The John A. Hartford Foundation. This article is reprinted with permission from, © 2021 Twin Cities Public Television, Inc. All rights reserved.

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