By NOAM LEVEY for NPR News, July 28. From KHN.

ROCHESTER, N.Y. — Lucille Brooks was stunned when she picked up the phone before Christmas two years ago and learned a nursing home was suing her.

“I thought this was crazy,” recalled Brooks, 74, a retiree who lives with her husband in a modest home in the Rochester suburbs. Brooks’ brother had been a resident of the nursing home. But she had no control over his money or authority to make decisions for him. She wondered how she could be on the hook for his nearly $8,000 bill.

Brooks would learn she wasn’t alone. Pursuing unpaid bills, nursing homes across this industrial city have been routinely suing not only residents but their friends and family, a KHN review of court records reveals. The practice has ensnared scores of children, grandchildren, neighbors, and others, many with nearly no financial ties to residents or legal responsibility for their debts.

The lawsuits illuminate a dark corner of America’s larger medical debt crisis, which a KHN-NPR investigation found has touched more than half of all U.S. adults in the past five years.

Litigation is a frequent byproduct. About 1 in 7 adults who have had health care debt say they’ve been threatened with a lawsuit or arrest, according to a nationwide KFF poll conducted for this project. Five percent say they’ve been sued.

The nursing home industry has quietly developed what consumer attorneys and patient advocates say is a pernicious strategy of pursuing family and friends of patients despite federal law that was enacted to protect them from debt collection. “The level of aggression that nursing homes are using to collect unpaid debt is severely increasing,” said Lisa Neeley, a Massachusetts elder law attorney.

In Monroe County, where Rochester is located, 24 federally licensed nursing homes filed 238 debt collection cases from 2018 to 2021 seeking almost $7.6 million, KHN found. Several nursing homes did not file any lawsuits in that period.

Nearly two-thirds of the cases targeted a friend or relative. Many were accused — often without documentation — of hiding residents’ assets, essentially stealing. The remaining cases targeted residents themselves or their spouses.

Nursing homes have gone after some families for tens of thousands of dollars. In a few cases, debts surpassed $100,000.

In Monroe County alone, one nursing home sued the daughter and granddaughter of a former resident. The daughter pleaded with the court to release the granddaughter, promising she would pay the $5,942 debt. Another home sued a woman twice, for her husband’s and her mother’s debts. Yet another claimed a woman owed $82,000 for her mother’s care. The resident was, in fact, a cousin, according to court papers.

“I get calls all the time from people who are served with these lawsuits who had no idea that this was even a remote possibility, who call me crying and frantic,” said Anna Anderson, an attorney at the nonprofit Legal Assistance of Western New York who has represented defendants in such suits, including Brooks. “They believe not only that they’re going to lose their own income and their own houses and assets, but also they’re concerned that their loved ones who are still in the nursing home may be potentially kicked out.”

The legal strategy is often rooted in admissions agreements, the piles of paperwork that family or friends sometimes sign, not realizing the financial risks. “The world of nursing facilities is a black hole for most people,” said Eric Carlson, a longtime consumer attorney at the nonprofit Justice in Aging. “This happens in the shadows.”

In most cases reviewed by KHN, the people sued didn’t have an attorney, which can be expensive. In nearly a third, the nursing homes won default judgments because the defendants never responded, a common phenomenon in debt cases. In many cases, lawsuits sought interest rates as high as 18% on top of the debt.

Long-term care officials and attorneys say they must use the courts when bills go unpaid. “It would be a disservice to the hospital’s residents, and to Monroe County’s taxpayers, to allow residents who have assets not to pay what is owed,” said Gary Walker, a spokesperson for Monroe County, which operates Rochester’s largest nursing home, Monroe Community Hospital.

From 2018 to 2021, the county filed 60 debt collection cases, including the lawsuit against Brooks, KHN found.

Nationally, Beth Martino, a spokesperson for the American Health Care Association, the largest nursing home industry group, said lawsuits against families are “not a common occurrence.”

But consumer attorneys in California, Illinois, Kentucky, Massachusetts, New York, and Ohio said they regularly see lawsuits against family and friends.

In 2020, Washington, D.C., secured an agreement with two nursing homes to stop what authorities called “deceptive billing practices.” The homes had sued at least 15 family members, the attorney general found.

Ahmad Keshavarz, an attorney who documented debt lawsuits around New York City, said nursing homes see adult children as more appealing targets than older residents. “Sons or daughters are more likely to have assets,” he said. “They have wages that can be garnished.”

In Ohio, Robyn King, a former teaching assistant from Cleveland, was sued for more than $70,000 by a nursing home where her mother had been a resident. “The lawsuit made no sense to me since I told them I would not be personally responsible for my mom’s medical expenses,” King told a U.S. Senate committee in March. “The stress was unbearable. I thought, ‘I will not be able to afford my mortgage.'”

Trapped by Paperwork

In upstate New York, Brooks faced a smaller yet shocking bill: $7,967.05.

“People like us live on a fixed income,” Brooks said. “We don’t have money to throw around, especially when you don’t see it coming.” She was so worried she didn’t tell her husband at first.

Brooks initially thought there had been a mistake. She and her brother, James Lawson, were part of a big family that moved north from Mississippi to escape segregation in the 1960s. Lawson, who was a gifted athlete despite losing an arm as a child, spent his career at the Rochester Parks and Recreation Department. Brooks worked in insurance. They lived on opposite sides of the city. “My husband is somewhat disabled, and that keeps me pretty busy,” said Brooks, who is also active in her church. “My brother always took care of his own business.”

“People like us live on a fixed income,” says Lucille Brooks of Pittsford, New York, who was sued for nearly $8,000 by a nursing home that had taken care of her brother. “We don’t have money to throw around, especially when you don’t see it coming.”

In summer 2019, Lawson was hospitalized after experiencing complications from a diabetes medication. The hospital released him to the county-run nursing home, and Brooks only found out a few days later. She visited her brother several times. No one talked to her about billing, she said. And she was never asked to sign anything.

After two months, Brooks’ brother went home. A year later came the lawsuit.

The county alleged that Brooks should have used her brother’s assets to pay his bills and that she was therefore personally responsible for his debt. Attached to the suit was an admissions agreement with what looked like Brooks’ signature.

Such agreements, which can run multiple pages, have long been standard in the long-term care industry. They often designate whoever signs as a “responsible party” who will help the nursing home collect payments or enroll the resident in Medicaid, the government safety-net program.

Many lawyers say making a family member financially liable is unfair. “If you bring your child to a doctor, you should pay for the child’s medical care. But if your adult child brings you to a nursing home and you’re 80, the law doesn’t bind you to pay those bills,” said Paul Aloi, a Rochester attorney who has represented all sides — patients, hospitals, and nursing homes — in debt collection cases.

Federal laws and regulations prohibit homes from requiring a resident’s relatives or friends to financially guarantee the resident’s bills. Facilities cannot even request such guarantees.

But consumer advocates say nursing homes slip the admissions agreements into papers that family members sign when an older parent or sick friend is admitted. Sometimes people are told they must sign, a violation of federal law. Sometimes there is barely any discussion. “They are given a stack of forms and told, ‘Sign here, sign there. Click here, click there,'” said Miriam Sheline, managing attorney at Pro Seniors, a nonprofit law firm in Cincinnati.

When Chris Ferris helped admit his mother to Kirkhaven nursing home in Rochester in 2019, he said, he asked the staff whether any papers he had signed made him financially liable for her care. “They said ‘no,'” he said.

Ferris, who was estranged from his mother, had no legal control over her finances. She had been managing her own affairs. Nevertheless, the nursing home sued Ferris two years later for nearly $11,000. “It’s not right,” said Ferris, who is no longer speaking with his mother.

In more than a third of the cases that nursing homes filed in Monroe County against friends and relatives, the people sued had no power of attorney, limiting their access to residents’ money to pay bills.

Accused of Stealing

Court records show Rochester-area nursing homes also frequently accuse family and friends of hiding residents’ money and property to avoid paying the debts. The allegation is known in debt law as “fraudulent conveyance.” But it is commonly interpreted by those being sued as an accusation of theft, which can be very frightening, consumer attorneys say.

The practice can intimidate people with means into paying debts they may not even owe, said Anderson, the legal assistance attorney. “People see that on a lawsuit and they think they’re being accused of stealing,” she said. “It’s chilling.”

Families do sometimes prey on older relatives, taking their bank cards or selling their property, advocates for seniors say. But nursing home lawsuits in Rochester contain almost no documentation to support these claims.

Monroe County provided supporting records in only three of the 29 lawsuits it filed that included a fraudulent conveyance claim against a friend or relative of a resident. And Underberg & Kessler, a Rochester law firm that has represented the county and other nursing homes, attached documentation in only five of the 70 actions it filed with such claims. The firm has filed the most nursing home debt cases in Monroe County.

Anna Lynch, a partner, said the firm always has “factual and legal grounds” to file. “The fact that the complaint does not make reference to the specific evidence does not mean there is not evidence,” she said. “When we do institute legal action on behalf of a nursing home, the firm reviews the agreements between the parties and the facts to make sure there are grounds for claims against the persons who are legally responsible for payment.”

Barbara Robinson, an 81-year-old widow who lives alone outside Rochester, said that wasn’t her experience. She was sued by Monroe County three years ago for $21,000.

Robinson, who lives on a fixed income, signed papers for an older friend who was admitted to the county home, and she said she helped staff gather information to enroll her friend in Medicaid.

“As far as I knew, that was that,” Robinson recalled. After the friend died, however, the county accused Robinson of taking her friend’s assets. The county provided no documentation.

Robinson said there was no money to take, noting that her friend “had spent every single dime.” A court ultimately dismissed the case, first reported by WHEC-TV in Rochester. Judge Debra Martin admonished the county for the lack of evidence. “Plaintiff must allege some facts to support its claims,” she wrote, noting that the county’s case “does not meet the bare minimum requirements.”

Ferris, who was sued over his estranged mother’s debts, had his case dropped by the nursing home. Valerie King Hoak, a spokesperson for the Kirkhaven nursing home, said the facility “cannot discuss private resident information or potential litigation with third parties.”

Brooks is now in the clear, too, after the county dropped its case against her. She said she thinks the signature on the admissions agreement was forged from the nursing home’s visitor log, the only thing she signed.

The experience left her shaken. She now tells anyone with a friend or relative in a nursing home not to sign anything. “It’s ridiculous,” she said. “But why would you ever think they would be coming after you?”

By Dave Muoio, Fierce Healthcare, Nov 24, 2021.

Long-stay residents of nursing homes recently acquired by private equity firms are more likely to have ambulatory care-sensitive emergency department visits and hospitalizations compared to those staying at non-private equity for-profit nursing homes, according to a recently published national cohort analysis.

Residents at PE-acquired nursing homes also generate higher Medicare costs, the analysis found.

Across a sample of nearly 10,000 for-profit nursing homes and more than 250,000 residents, Weill Cornell Medical College researchers found mean quarterly rates of ambulatory care sensitive emergency department visits and hospitalizations to be 14.1% and 17.3%, respectively.

However, among those staying at 302 homes acquired by private equity between 2013 and 2017, the researchers saw an 11.1% relative increase in these emergency department visits and an 8.7% relative increase in hospitalizations.

Further, mean quarterly Medicare costs per resident were $8,050 across the full cohort. These also saw a relative increase of 3.9% after a facility was acquired by private equity, the researchers wrote.

“This cohort study suggests that [private equity] firm–owned nursing homes provided somewhat lower-quality long-term care than other for-profit homes based on two widely used quality measures and were associated with higher total per-beneficiary Medicare costs,” the researchers wrote in JAMA Health Forum.

Secondary analyses comparing antipsychotic use, severe pain and pressure ulcers found no significant differences between the two study groups.

The researchers wrote that previously published studies of nursing home quality and private equity ownership have been “inconsistent,” did not include a national cohort and reviewed different measures of quality.

Of note, one recent study published in 2020 found similar COVID-19 case counts and deaths between private-equity-owned homes and other facilities despite holding smaller supplies of personal protective equipment, they wrote.  

An estimated 5% of U.S. nursing homes are owned by private equity, the researchers wrote, but complex corporate structures often employed by these firms can make it difficult to discern whether they own an interest in these facilities.

These new data, along with the general increased pressure within private equity to secure a short-term return, “suggest that more stringent oversight and reporting of related entities may be warranted,” the researchers wrote. “Policymakers might consider making more detailed ownership information available in outlets that provide consumers with information on nursing home quality, such as Nursing Home Compare.”

Weill Cornell Medical College identified private-equity-owned homes using data from three proprietary and federal databases: S&P Capital IQ, Irving Levin Associates Health Care M&A and the Centers for Medicare & Medicaid Services’ Nursing Home Compare Ownership. They also collected Medicare fee-for-service claims and Minimum Data Set assessments to build their sample of nursing home residents.

The final cohort included 302 private-equity-owned nursing homes and 9,562 other for-profit homes, with 9,632 residents living in the former and 249,771 residents in the latter.

Assessments of private-equity-owned healthcare facilities’ performances are becoming necessary as these firms take on increasingly large stakes in the industry, the researchers wrote.

Beyond nursing homes, a recent study in Health Affairs found hospitals recently acquired by private equity tend to adopt profitable new services and technologies more quickly than their unacquired counterparts—an approach that could potentially backfire if novel services later reveal themselves to be less effective or more expensive.

Article link

By: Andrew Jacobs, The New York Times, Jul 24, 2020.

Expired surgical masks. Isolation gowns that resemble oversize trash bags. Extra-small gloves that are all but useless for the typical health worker’s hands.

Nursing home employees across the country have been dismayed by what they’ve found when they’ve opened boxes of protective medical gear sent by the federal government, part of a $134 million effort to provide facilities a 14-day supply of equipment considered critical for shielding their vulnerable residents from the coronavirus.

The shipments have included loose gloves of unknown provenance stuffed into unmarked Ziploc bags, surgical masks crafted from underwear fabric and plastic isolation gowns without openings for hands that require users to punch their fists through the closed sleeves. Adhesive tape must be used to secure them.

Health regulators in California have advised nursing homes not to use the gowns, saying they present an infection-control risk, especially when doffing contaminated gowns that must be torn off.

Some nursing homes have received masks with brittle elastic bands that snap when stretched. None of the shipments have included N95 respirators, the virus-filtering face masks that are the single most important bulwark against infection.

“People hate to complain about personal protective equipment they’re getting for free but many of these items are just useless,” said Brendan Williams, president of the New Hampshire Health Care Association, which has been fielding a flurry of calls about the defective gear from nursing homes it represents. “It’s mystifying that the government would think this is acceptable.”

The Federal Emergency Management Agency began shipping the masks, gowns and gloves this spring to 15,000 nonprofit nursing care facilities whose limited finances have made it difficult to buy protective equipment on the open market. The first cache of shipments was completed in mid-June, and the second round will wrap up by early August.

In a statement, FEMA said it had addressed the complaints about the first shipment of goods and had asked the private contractor that is providing the supplies to replace the tarp-like gowns with models more familiar to medical personnel. The agency said, however, that the original gowns sent out meet federal and industry standards.

“We have received complaints on less than 1 percent of the total PPE shipments to nursing homes,” the statement said. “We continue to engage with nursing homes to keep lines of communication and feedback open at all times.”

FEMA subsequently acknowledged in an email that the contractor has been sending out a small number of the older gown models.

The controversy over inadequate and low-quality protective equipment has come to embody what public health experts and nursing home executives describe as a halting and haphazard federal effort to protect the 1.5 million Americans who live in nursing homes and long-term care facilities.

More than 40 percent of all coronavirus deaths in the United States have been tied to nursing homes, according to a New York Times analysis, which found that the virus had infected 316,000 people at 14,000 facilities as of July 15. The virus has been particularly lethal to those in their 60s and older, more so for those in poor health, and it can rapidly spread through buildings where residents live in close quarters and workers move from room to room.

“The federal response to protect one of the most vulnerable populations in the country has been a dismal failure,” said Tamara Konetzka, a health economist at the University of Chicago who has been studying the pandemic’s outsize impact on nursing home residents.

The Trump administration’s largely hands-off approach to personal protective equipment, or P.P.E., has forced states, cities and big hospital chains to compete for limited supplies, leaving nursing homes at a disadvantage as prices have soared.

The recent spike in caseloads across the South and the West has reinvigorated calls for President Trump to use his authority and compel domestic manufacturers to produce desperately needed gear.

“We’re extremely disappointed with the government’s response,” said Katie Smith Sloan, the president of LeadingAge, an industry group that represents nonprofit senior service providers. “Folks on the ground are desperately trying to save lives and protect their staff, but we’re leaving them in the dust.”

The crisis is likely to intensify as the virus gains a foothold in nursing homes across the Sun Belt. Infections at long-term care centers in hot-spot states have jumped by 18 percent since late June, according to an analysis by Kaiser Family Foundation. Florida recorded a 51 percent rise, and Texas saw its cases climb by 47 percent.

The federal government has not said whether it plans to provide nursing homes with additional personal protective equipment in the months ahead.

The Centers for Medicaid and Medicare, which oversees nursing homes, earlier this month said it would supply every adult care facility in the country with rapid, point-of-care test kits but the rollout is expected to take months. In the meantime, the vast majority of nursing homes in the United States are unequipped to regularly screen their employees and residents for the coronavirus.

Without widespread testing, health experts say medical-grade gowns, single-use gloves and respirator masks are among the few tools that can protect nursing home residents from devastating outbreaks that often begin with asymptomatic staff members who unknowingly introduce the virus from the surrounding community.

“It’s really mind-boggling and frustrating that five months into this pandemic we still can’t get facilities the P.P.E. they need,” said David C. Grabowski, a professor of health care policy at Harvard Medical School. “I don’t know whether it’s a matter of incompetence or just indifference about older adults and the people who care for them.”

In a call with nursing home providers last month, Col. Brian Kuhn, director of operations at the Defense Logistics Agency, blamed Federal Resources Supply Company, the private contractor that is providing the goods, and the Department of Health and Human Services, which officials said sent out some of the expired and cloth masks as part of a different initiative.

The contract calls for the provision of 1.2 million pairs of protective eyewear, 13 million medical gowns and 66 million pairs of nitrile gloves.

“They just kind of carte blanche shipped them all out,” Col. Kuhn said, according to a recording of the call posted online. He said that the masks made from underwear fabric were not intended to be used by staff members — only by nursing home visitors — and that the expired respirator masks should never been distributed. “It was one of those things, I’ll be honest, that just slipped through the cracks,” he said.

In response to the complaints, FEMA directed the Federal Resources Supply Company to produce an instructional video explaining how the gowns should be donned and doffed. The contents of each shipment are determined by the number of employees at each care center.

Federal Resources, which is based in Stevensville, Md., did not respond to questions sent by email.

In interviews, nursing home executives and employees that have received their second shipments say the contents are an improvement over the first batch but that many problems remain.

Nursing homes in New Hampshire have received face masks with flimsy paper ear loops instead of elastic bands. In Arizona, some facilities have been sent gloves that are either all large sizes or all extra small.

At the Los Angeles Jewish Home, workers were heartened two weeks ago to receive about 1,000 disposable gowns, 187 pairs of eye goggles and 12,000 gloves in a range of sizes. But they were dismayed to also find 2,000 of what employees dismissively referred to as “trash bag gowns.”

“It’s outrageous that they are still sending these gowns,” said Dr. Noah Marco, the chief medical officer of Los Angeles Jewish Home, which has 1,200 beds and 1,650 employees. “And it’s insulting and inappropriate for the federal government to say we just don’t know how to use them.”

Even nursing homes expressing gratitude for the supplies say they are often mismatched to their needs, while others say the amounts are paltry given how quickly nursing home employees churn through single-use protective gear as they tend to dozens of patients a day.

“If I’m being totally honest, I’d describe these as a token offering,” said Sondra Norden, the chief executive of St. Paul’s Elder Services in Wisconsin. “If we had a major outbreak, we’d burn through these supplies in a few days.”

Virginia Mennonite Retirement Community, a 120-bed nursing home in Harrisonburg, received its second shipment two weeks ago. It contained a mix of gowns — several hundred of the standard and highly coveted isolation gowns and a similar amount of the problematic gowns.

“I’m not sure how we would even use those,” said Jan Emswiler, a nurse educator who trains employees on the proper use of protective gear. She was especially confounded by a packing slip claiming the boxes contained 3,500 pairs of gloves. There were only 1,000 pairs, she said.

“Oh god, even before Covid, we were going through 3,000 pairs in a day,” Ms. Emswiler said. “We appreciate what we’ve gotten but we could really use a lot more.”

As for the gowns without arm holes, Ms. Emswiler said they had been placed in a storage closet.

“I hope we never have to use them,” she said.

Correction: July 28, 2020

The Los Angeles Jewish Home has 1,650 employees. An earlier version of this article incorrectly reported that it had 50.

Updated July 28, 2020.

Article link: https://www.nytimes.com/2020/07/24/health/coronavirus-nursing-homes-PPE.html

At least half of U.S. states will not meet a White House goal on nursing home testing due to costs and a lack of resources, an Associated Press analysis found, in another indication of the patchwork response to the pandemic in the absence of a coordinated national response.

Nursing homes have been ravaged by the virus outbreak, as the disease has had a disproportionately lethal effect on the elderly; on May 9, the New York Times reported that one-third of all U.S. virus deaths were in nursing homes. 

Almost two weeks ago, on May 11, the White House recommended — but did not order — governors ensure all nursing home residents and staff get tested for the coronavirus in the next 14 days, in a message relayed by Vice President Pence on a video conference call with the nation’s governors.

“We really believe that all 1 million nursing home residents need to be tested within next two weeks as well as the staff,” Dr. Deborah Birx, the White House task force coordinator, told the governors on the call.

Nearly two weeks later, the Associated Press found that at least half of the states will not meet the White House threshold; only a few, including West Virginia and Rhode Island, have indicated they reached the goal already.

Many states said they lacked the logistics, costs and personnel to conduct such an effort in such a short time span. 

Other states, such as Nebraska, told the AP they were not going to try and reach the goal and were instead sticking to Centers For Disease Control guidelines, which call for testing individually when nursing home residents show symptoms or if there is a new confirmed virus case in a home. 

When asked why he was not making the nursing home test goal an order on May 11, Trump said he would “consider it.” “I would certainly consider that”, he said during a press conference. “I will mandate it if you’d like.”

Nebraska Chief Medical Officer Dr. Gary Anthone told the Associated Press that it was “fairly useless” to test every nursing home resident because the state would need to test everyone daily for it to be effective. Right now, most states don’t have the capacity to do that. 

A lack of testing has beset the U.S. since the beginning of the outbreak, an issue federal officials said, was the result of supply chain issues and a botched rollout by the Centers for Disease Control. Many governors argued that the federal government should have done more to help states get the materials they needed to ramp up testing in the early weeks of the outbreak.

Health officials say widespread testing is crucial to reopening safely because it allows states to identify and trace outbreaks as they happen. But experts say most states are still not testing enough people to prevent a surge in cases. 

The cluster of illness is the first of its type in the U.S., where 2.2 million people live in long-term care settings and may be at heightened risk because of age and underlying health conditions.

“We are very concerned about an outbreak in a setting where there are many older people,” said Dr. Jeff Duchin, health officer for the Seattle and King County public health agency.

The American Health Care Association, which represents 13,500 nonprofit and for-profit facilities for seniors and disabled people, issued updated guidelines Saturday, in response to the Washington outbreak. The new virus is thought to spread primarily via droplets in the air, and the guidelines largely echo strategies recommended to stem the spread of other respiratory viruses, such as influenza. That includes frequent hand sanitation among staff and visitors, grouping people who become ill in the same room or wing, and asking family members who are sick to avoid in-person visits.

But members had been anticipating cases of the new virus, said Dr. David Gifford, AHCA’s chief medical officer and senior vice president of quality and regulatory affairs.

“Clearly, it signaled that it’s here and that what people knew was likely to come is closer to them than before,” he said.

COVID-19 has been identified in more than 85,000 people worldwide and led to nearly 3,000 deaths, including the first U.S. death reported Saturday in another Washington state man in his 50s. That man was not associated with the Kirkland nursing center, officials said.

Studies of hospitalized patients in China suggest the median age of infection is in the 50s and that about 80% of COVID-19 cases are mild. However, a new summary in the journal JAMA reported that the virus has a case fatality rate of 1% to 2% overall — and as high as 8% to 15% in older patients in China.

That is alarming news for U.S. residents in long-term care settings, where illnesses caused by more common pathogens like norovirus and seasonal influenza often spread rapidly among residents, causing severe complications. Immune response wanes as people age, leaving them more vulnerable to infections of all types.

Dr. Karl Steinberg, a geriatrician who serves as medical director for two nursing homes and as chief medical officer for a chain of 20 others in Southern California, said the news of COVID-19 cases at the Washington state nursing center is worrisome.

“That’s very scary,” Steinberg said. “It worries me that once it gets going, it will be really hard to control the spread.”

The situation may be akin to the spread of coronavirus on cruise ships, such as the Diamond Princess that was quarantined off the coast of Japan, with one key exception, Steinberg said. People on cruise ships can be confined to their rooms with minimal interaction with staff and fellow residents. People in nursing centers are there because they need help with activities of daily living, he noted.

In the Washington state center, Duchin said, officials are advising health workers to separate cohorts of sick patients from those who remain well and to don personal protective gear, including eye protection, to avoid infection. “It’s a very challenging environment with so many vulnerable patients to manage an outbreak,” he said.

Duchin urged older people and those with health conditions such as heart disease, lung disease and diabetes to pay close attention to precautions such as washing hands frequently, keeping their hands away from their faces and avoiding people who show signs of illness.

Just-released guidelines from the Society for Post-Acute and Long-Term Care Medicine call for increasing hand hygiene, isolating infected patients and making plans to ensure that health care workers stay home if they’re sick. The guidelines also call for screening visitors and daily temperature checks for residents and staff.

Individual centers should remain in close contact with local health officials about appropriate actions, Gifford said. Authorities — and families — should think carefully before taking steps such as removing patients from nursing centers during an outbreak.

“Evacuating a facility is not a benign event,” he said, noting that moving can be traumatic to frail and elderly people.

The nursing home cases are examples of community transmission of the virus, meaning the patients did not have a known history of travel to other nations where the virus is spreading or contact with a traveler diagnosed with the illness. Community transmission has now been detected in multiple states, including California.

However, Seattle researchers reported late Saturday that new genomic analysis suggests the virus may have been spreading in Washington state since mid-January, when a 35-year-old Snohomish County man who had visited Wuhan, China, was confirmed as the first U.S. case of the infection.

“This strongly suggests that there has been cryptic transmission in Washington state for the past 6 weeks,” tweeted Trevor Bedford, a computational biologist at Seattle’s Fred Hutchinson Cancer Research Center, who is tracking the virus. He estimated there could be “a few hundred” infections in the state.

At least 70 cases of coronavirus infection have been confirmed or presumed positive in the U.S., and officials with the federal Centers for Disease Control and Prevention said Americans should expect to hear more reports of illness in the coming days and weeks.
The new Washington cases and the first reported U.S. deaths were identified only after the CDC expanded the definition of who could be tested for the virus and after states and hospitals were given more leeway and supplies to conduct their own tests.

“What that says to us is that as we test more, we’re more likely to find cases of the disease,” Duchin said.

A team from the CDC has been sent to help local and state health officials investigate the Life Care Center outbreak. “We have a large investigation ahead of us, a complicated investigation ahead of us,” Duchin said.

In the meantime, Steinberg said he and others will take precautions to prevent the possible spread of COVID-19 cases in long-term care settings and act swiftly to contain them, if necessary.

“I guess there’s not much to do but hunker down and hope it’s not too bad,” he said.

As huge swaths of California burned last fall, federal health officials descended on 20 California nursing homes to determine whether they were prepared to protect their vulnerable residents from fires, earthquakes and other disasters.

The results of their surprise inspections, which took place from September to December of 2018, were disturbing: Inspectors found hundreds of potentially life-threatening violations of safety and emergency requirements, including blocked emergency exit doors, unsafe use of power strips and extension cords, and inadequate fuel for emergency generators, according to a report released Thursday by the U.S. Department of Health and Human Services Office of Inspector General.

The nursing home residents “were at increased risk of injury or death during a fire or other emergency,” the report concluded.

The threat is not theoretical in a state that has been ravaged by natural disasters: One of the nursing homes that was inspected burned down in a wildfire afterward, so the report only includes results for the 19 remaining facilities, which it does not identify.

“The fact that one of the nursing homes inspected was later destroyed by a wildfire speaks to the grave danger residents are facing today,” said Mike Connors of the advocacy group California Advocates for Nursing Home Reform. He called the findings alarming but not surprising.

Even though the report didn’t name the nursing home that was destroyed, the California Association of Health Facilities, which represents most of the state’s skilled nursing facilities, identified it as one that burned down in the November 2018 Camp Fire, the deadliest wildfire in the state’s history.

Craig Cornett, CEO and president of the association, said all the residents were evacuated safely from that home — and from two others destroyed in the same fire. Hundreds of other nursing homes also have responded to emergencies in the past three years without loss of life, he said, which shows that “the deficiencies in the report do not reflect true facility readiness.”

The association is concerned about safely violations, he added, but “this is an example of bureaucracy equipped with blinders.”

The federal auditors said the violations occurred because of poor oversight by management and high staff turnover at the homes. But they also criticized the California Department of Public Health, the agency responsible for overseeing nursing homes in the state, for not ensuring the homes complied with federal safety and emergency requirements.

In some cases, the state’s own inspectors had previously cited nursing homes for the same problems but did not inspect the facilities again to ensure they had been fixed, the report said.

The department “can reduce the risk of resident injury or death by improving its oversight,” the report said. For example, it could “conduct more frequent site surveys at nursing homes to follow up on deficiencies previously cited rather than relying on reviews of documentation submitted by nursing homes.”

The public health department told the auditors it had followed up with the 19 remaining homes to ensure they were addressing the problems auditors identified. But the state disagreed with the auditors’ recommendation to inspect nursing homes more frequently, saying in a letter to the auditors that federal rules don’t require onsite visits to determine whether problems have been fixed — and that the agency simply does not have enough inspectors.

The department declined a California Healthline request for comment.

The Office of Inspector General is auditing nursing homes across the nation that receive payments from the public health insurance programs Medicare or Medicaid to determine whether the facilities meet the stricter federal safety and emergency guidelines that were adopted in 2016. 

The auditors did not choose the 20 nursing homes randomly out of the approximately 1,200 statewide, but rather selected those in fire- and earthquake-prone regions, as well as ones already on notice for health and safety violations.

The inspectors found a total of 325 violations at the 19 homes. Among them:

Two of the homes had pathways leading to emergency exit doors that were blocked, including one exit door blocked by a pallet. 16 had violations related to their fire alarm and sprinkler systems, including two that didn’t have their fire alarm systems routinely tested and maintained. 

All had violations related to electrical equipment, including using power strips that did not meet requirements or were unsafely connected to appliances or other power strips. Eight had not properly inspected, tested and maintained their emergency generators, which provide electricity for critical medical equipment during a power outage. Two didn’t have enough generator fuel to last 96 hours. Generator power has become critical for nursing homes in recent months amid widespread power shutdowns aimed at preventing wildfires. Three nursing homes’ emergency plans didn’t address evacuations.

“We don’t want reports like this,” said state Sen. John Moorlach (R-Costa Mesa). “It sounds like maybe we need to ask the state auditor to see if the site visits done by the state are being done thoroughly.”

Photo Credit Jeenah Moon for The New York Times.

Drug-resistant germs, including Candida auris, prey on severely ill patients in skilled nursing facilities, a problem sometimes amplified by poor care and low staffing.

By Matt Richtel and Andrew Jacobs, The New York Times. Published Sept. 11, 2019 Updated Sept. 12, 2019.

Maria Davila lay mute in a nursing home bed, an anguished expression fixed to her face, as her husband stroked her withered hand. Ms. Davila, 65, suffers from a long list of ailments — respiratory failure, kidney disease, high blood pressure, an irregular heartbeat — and is kept alive by a gently beeping ventilator and a feeding tube.

Doctors recently added another diagnosis to her medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it arrived in the United States four years ago, with half of patients dying within 90 days.

At least 38 other patients at Ms. Davila’s nursing home, Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been infected with or carry C. auris, a germ so virulent and hard to eradicate that some facilities will not accept patients with it. Now, as they struggle to contain the pathogen, public health officials from cities, states and the federal government say that skilled nursing facilities like Palm Gardens are fueling its spread.

“They are the dark underbelly of drug-resistant infection,” said Dr. Tom Chiller, who heads the fungal division at the Centers for Disease Control and Prevention, speaking about skilled nursing facilities, particularly those with ventilated patients, but not Palm Gardens specifically.

Such nursing homes are playing a key role in the spread in New York, where 396 people are known to be infected and another 496 are carrying the germ without showing symptoms, according to public health officials. In Chicago, half of patients living on dedicated ventilator floors in the city’s skilled nursing homes are infected with or harboring C. auris on their bodies, said Dr. Allison Arwady, the acting commissioner of the city’s Department of Public Health.

Much of the blame for the rise of drug-resistant infections like C. auris, as well as efforts to combat them, has focused on the overuse of antibiotics in humans and livestock, and on hospital-acquired infections. But public health experts say that nursing facilities, and long-term hospitals, are a dangerously weak link in the health care system, often understaffed and ill-equipped to enforce rigorous infection control, yet continuously cycling infected patients, or those who carry the germ, into hospitals and back again.

“They are caldrons that are constantly seeding and reseeding hospitals with increasingly dangerous bacteria,” said Betsy McCaughey, a former lieutenant governor of New York who leads the nonprofit Committee to Reduce Infection Deaths. “You’ll never protect hospital patients until the nursing homes are forced to clean up.”

The story is far bigger than one nursing home or one germ. Drug-resistant germs of all types thrive in such settings where severely ill and ventilated patients like Ms. Davila are prone to infection and often take multiple antibiotics, which can spur drug resistance. Resistant germs can then move from bed to bed, or from patient to family or staff, and then to hospitals and the public because of lax hygiene and poor staffing. 

These issues have also vexed long-term, acute-care hospitals, where patients typically stay for a month or less before going to a skilled nursing home or a different facility.

A recent inquiry by the New York State Department of Health found that some long-term hospitals grappling with C. auris were failing to take basic measures, such as using disposable gowns and latex gloves, or to post warning signs outside the rooms of infected patients. At one unnamed facility, it said, “hand sanitizers were completely absent.”

Officials at the 240-bed Palm Gardens did not respond to repeated requests for comment. Over the past year, the number of patients who were infected with or were carrying C. auris there grew to 38 from six, according to a nurse there and public health officials. The tally has now fallen into the high 20s after some patients died or moved elsewhere.

The New York health department issued a statement in response to queries from The New York Times: “The Department of Health has made controlling the spread of C. auris a high priority and has conducted extensive training and education on infection control policies and procedures for Palm Gardens and other nursing home providers throughout this region. The health and well being of nursing home residents is our primary concern and we take complaints regarding quality of care very seriously.”

Scientific research on nursing homes and drug resistance is sparse, but some recent studies offer evidence of the problem. A study published in June in the Journal of Clinical Infectious Diseases found that patients and residents in long-term care settings have alarmingly high rates of drug-resistant colonization, which means they carry the germs on their skin or in their bodies, usually without knowing it, and can pass them invisibly to staff members, relatives or other patients. Elderly or severely ill people with weakened immune systems who carry the germ are at high risk of becoming infected. (Health officials in New York state said 14 percent of those now infected started out carrying it and then developed symptoms).

The study, which focused on Southern California, found that 65 percent of nursing home residents in that region harbored a drug-resistant germ, as did 80 percent of residents of long-term acute-care hospitals, where their “status is frequently unknown to the facility.” By comparison, only 10 to 15 percent of hospital patients carried such germs, the study found.

Ms. Davila and her roommate at Palm Gardens both have been infected with C. auris.

The phenomenon is global. A study published in 2017 found that elderly residents of long-term care facilities in Britain were four times as likely to be infected with drug-resistant urinary tract infections as elderly residents living at home. Soaring levels of resistance were found in long-term care facilities in Italy, a 2018 paper found. And a 2019 study found that long-term care facilities in Israel are “a major reservoir” of carbapenem-resistant Enterobacteriaceae, or CRE — a major family of drug-resistant germs — contributing to their “rapid regional dissemination.”

Experts said the problem is pronounced in the United States, given changing economics that push high-risk patients out of hospitals and into skilled nursing homes. The facilities are reimbursed at a higher rate to care for these patients, they said, providing an economic incentive for poorly staffed or equipped facilities to care for vulnerable patients.

C. auris, which is resistant to major antifungal medications, was first identified in 2009 in Japan and, as of July 31, had infected 796 people in the United States, largely in New York, Chicago and New Jersey, since its arrival here in 2015, according to the C.D.C. Another 1,540 people have been identified as carrying the germ on their skin or in their bodies without showing symptoms.

C. auris up close

Ms. Davila resting in a Brooklyn hospital in August, where she was rushed after a routine blood test found her white cell count plummeting.

On Palm Gardens’ second floor, where Ms. Davila and other ventilated patients reside, signs posted outside nearly every room warn visitors and staff members to wear gloves, gowns and masks — a state requirement for those infected with C. auris.

But during two recent visits to Palm Gardens by a Times reporter, accompanying Ms. Davila’s husband as his guest, orderlies and nurses moved in and out of her room without the required protection.

“The nurses and janitors are just spreading this thing from room to room,” her husband, Anthony Hernandez, said on a visit in August, shortly after a nurse, who was wearing gloves but no mask or gown, poured liquid nourishment into his wife’s feeding tube. During a brief interview in the lobby, Pamela Delacuadra, the center’s director of nursing, said employees had initially struggled with the infection-control protocols required for C. auris.

“It was overwhelming at first but with help from the health department, we’ve gotten much better,” she said.

Ms. Davila’s medical records, reviewed by The Times, do not identify the specific date when she got C. auris. But a chart written by a Palm Gardens doctor in December 2018 includes a note listing her as a carrier of the fungus.  She was put in isolation for C. auris patients, and her records subsequently referred to her as having the infection and taking antifungal medications for it.

Palm Gardens occupies a nondescript seven-story brick building in a working-class neighborhood in central Brooklyn. Magenta banners promote its dialysis center and adult day care services, as well as a “respiratory pavilion” for patients on mechanical life support.

Information about infections, including C. auris, in a hallway at Palm Gardens.

A high-level official from a local hospital that has seen a number of C. auris patients from nursing homes said Palm Gardens was a major source. He declined to be named because his employer had not authorized any comment.

Palm Gardens’s performance is poorly rated by the federal government; it received two stars, a below-average rating for staffing and overall care, from the Centers for Medicare and Medicaid Services, an agency that ranks nursing home care on a scale from one star to five. In 2018, the agency investigated the deaths of two ventilator patients at Palm Gardens, finding that employees had failed to turn their ventilators back on after performing mechanical checks. The patients died within minutes of each other, the report said.

C.M.S. declined to comment on Palm Gardens.

The ownership of Palm Gardens is controlled by someone identified as Shimon Lefkowitz, according to public filings.

Mr. Lefkowitz did not respond to efforts to reach him through Palm Gardens. Calls to several law firms that represent Palm Gardens in lawsuits were not returned.

Not all Palm Gardens residents with C. auris contracted the germ there, and it is not clear how many did. One patient who died was infected at Maimonides Medical Center in Brooklyn, according to the man’s family.

A changing role in health care

Skilled nursing homes and long-term care facilities have been playing an increasingly important role in caring for seriously ill patients who used to stay longer in hospitals.

Advances in medical technology have made it possible to prolong the lives of desperately ill patients, while changes in Medicare reimbursement rates created a financial incentive for the expansion of such facilities, said Neale Mahoney, an economist at the University of Chicago who studies the industry’s growth. There are now about 400 long-term care hospitals across the country, up from about 40 in the early 1980s, he said.

Since 2012, the number of skilled nursing homes with ventilator units rose to 436 from 367 — a significant jump but still a fraction of the nation’s 15,000 nursing homes — according to C.M.S.

“Ventilator units are the poster child, the best example of a place that has challenges,” said Dr. Alexander Kallen, an outbreak expert at the C.D.C.

The federal government reimburses facilities for ventilator patients at significantly higher rates than for other patients, according to C.M.S. Ventilated patients can bring in $531 a day compared to $200 for a standard patient. That’s about $16,000 a month compared to $6,000.

The reimbursement rates reflect the significant care required for vulnerable patients, and the cost of equipment.

C.M.S. contends the majority of skilled nursing homes do well with staffing and overall care. Yet roughly 1,400 nursing homes received a one-star rating for staffing in 2018 from the agency.

“It is impossible for them to do a good job with the way their staffing is,” said Dr. Mary Hayden, a professor at Rush Medical College who studies the rise of drug-resistant infections in health care, adding of the challenges of curbing drug-resistant infection: “The way they’re set up, they can’t do it.”

Ms. Davila’s path

Ms. Davila carried C. auris with her on her journey through the health care system.

In early August, after a routine blood test found her white cell count plummeting, she was taken by ambulance to Methodist Hospital in Brooklyn for a blood transfusion. Doctors discovered an infection and put her on two different antibiotics. Heavy use of antibiotics, while often necessary, can kill off the nonresistant infections and allow resistant ones to thrive.

Her condition stabilized after two weeks and she returned to Palm Gardens. It was one of at least a dozen trips she had taken to the hospital since she first arrived at Palm Gardens.

Her sharp decline began in 2017 after pain from a suspected hernia sent her to the hospital. A lifelong smoker, Ms. Davila had emphysema, which led to a litany of complications and infections, according to a review of her medical records.

Now she spends her days frozen in bed, serenaded by a Latin music radio station and the mechanical whir of her respirator.

Mr. Hernandez doubts his wife will recover. “If I can take her home to die that would be a blessing,” he said.

He pulled the blanket higher, turned up the radio and told his wife he loved her. Momentarily alert, she fixed her eyes on his and then mouthed: “I love you, too.”

By Fred Schulte, Elizabeth Lucas, Kaiser Health News and Joe Mahr, Chicago Tribune.

Shana Dorsey first caught sight of the purplish wound on her father’s lower back as he lay in a suburban Chicago hospital bed a few weeks before his death.

Her father, Willie Jackson, had grimaced as nursing aides turned his frail body, exposing the deep skin ulcer, also known as a pressure sore or bedsore.

“That was truly the first time I saw how much pain my dad was in,” Dorsey said.

The staff at Lakeview Rehabilitation and Nursing Center, she said, never told her the seriousness of the pressure sore, which led to sepsis, a severe infection that can quickly turn deadly if not cared for properly. While a resident of Lakeview and another area nursing home, Jackson required several trips to hospitals for intravenous antibiotics and other sepsis care, including painful surgeries to cut away dead skin around the wound, court records show.

Dorsey is suing the nursing center for negligence and wrongful death in caring for her dad, who died at age 85 in March 2014. Citing medical privacy laws, Lakeview administrator Nichole Lockett declined to comment on Jackson’s care. In a court filing, the nursing home denied wrongdoing.

The case, pending in Cook County Circuit Court, is one of thousands across the country that allege enfeebled nursing home patients endured stressful, sometimes painful, hospital treatments for sepsis that many of the lawsuits claim never should have happened.

My father was like my best friend. Most people go to their mom to talk and tell all their secrets, and for me it was my dad.

Year after year, nursing homes around the country have failed to prevent bedsores and other infections that can lead to sepsis, an investigation by Kaiser Health News and the Chicago Tribune has found.

No one tracks sepsis cases closely enough to know how many times these infections turn fatal.

However, a federal report has found that care related to sepsis was the most common reason given for transfers of nursing home residents to hospitals and noted that such cases ended in death “much more often” than hospitalizations for other conditions.

A special analysis conducted for KHN by Definitive Healthcare, a private health care data firm, also suggests that the toll — human and financial — from such cases is huge.

Examining data related to nursing home residents who were transferred to hospitals and later died, the firm found that 25,000 a year suffered from sepsis, among other conditions. Their treatment costs Medicare more than $2 billion annually, according to Medicare billings from 2012 through 2016 analyzed by Definitive Healthcare.

In Illinois, about 6,000 nursing home residents a year who were hospitalized had sepsis, and 1 in 5 didn’t survive, according to Definitive’s analysis.

“This is an enormous public health problem for the United States,” said Dr. Steven Simpson, a professor of medicine at the University of Kansas and a sepsis expert. “People don’t go to a nursing home so they can get sepsis and die. That is what is happening a lot.”

The costs of all that treatment are enormous. Court records show that Willie Jackson’s hospital stays toward the end of his life cost Medicare more than $414,000. Medicare pays Illinois hospitals more than $100 million a year for treatment of nursing home residents for sepsis, mostly from Chicago-area facilities, according to the Medicare claims analysis.

Sepsis is a bloodstream infection that can develop in bedridden patients with pneumonia, urinary tract infections and other conditions, such as pressure sores. Mindful of the dangers, patient safety groups consider late-stage pressure sores to be a “never” event because they largely can be prevented by turning immobile people every two hours and by taking other precautions. Federal regulations also require nursing homes to adopt strict infection-control standards to minimize harm.

Yet the failures that can produce sepsis persist and are widespread in America’s nursing homes, according to data on state inspections kept by the federal Centers for Medicare & Medicaid Services. Many of the lawsuits allege that bedsores and other common infections have caused serious harm or death. The outcome of these cases is not clear, because most are settled and the terms kept confidential.

Cook County, where the private legal community is known to take an aggressive approach to nursing homes, has more of these suits than any other metro area in the U.S., KHN and the Tribune found by reviewing court data.

State inspectors also cite thousands of homes nationally for shortcomings that have the potential to cause harm. Inspections data kept by CMS show that since 2015 94 percent of homes operating in Illinois have had at least one citation for conditions that increase the risk of infection. These citations include care related to bedsores, catheters, feeding tubes and the home’s overall infection-control program.

“Little infections turn to big infections and kill people in nursing homes,” said William Dean, a Miami lawyer with more than two decades of experience suing nursing homes on behalf of patients and their families.

Much of the blame, regulators and patient advocates say, lies in poor staffing levels. Too few nurses or medical aides raises the risks of a range of safety problems, from falls to bedsores and infections that may progress to sepsis or an even more serious condition, septic shock, which causes blood pressure to plummet and organs to shut down.

Staffing levels for nurses and aides in Illinois nursing homes are among the lowest in the country. In the six-county Chicago area, 78 percent of the facilities’ staffing levels fall below the national average, according to government data analyzed by KHN.

Matt Hartman, executive director of the Illinois Health Care Association, which represents more than 500 nursing homes, acknowledged low staffing is a problem that diminishes the quality of nursing care.

Hartman blamed the state’s Medicaid payment rates for nursing homes — about $151 a day per patient on average — which he said is lower than most other states. Medicaid makes up about 70 percent of the revenue at many homes, he said.

Last October, CC Care LLC, an Illinois nursing home group that specializes in treating mentally ill patients on Medicaid, filed for bankruptcy, arguing that the state’s “financial troubles have been disastrous for all nursing homes.”

In a July court filing, CC Care creditors’ committee argued that the company couldn’t stay afloat relying on Illinois Medicaid payments, which it called “slow, erratic and significantly less than what we are due.”

Pat Comstock, executive director of the Health Care Council of Illinois, said nursing homes she represents “are operating in an increasingly difficult environment in Illinois, yet they continue to prioritize delivering the best care possible to residents in a safe and secure setting.”

A FESTERING COMPLAINT

Shana Dorsey remembers her father as a quiet but friendly man. He worked as a uniformed bank security guard and picked up extra cash fixing neighbors’ cars in an empty lot adjacent to his West Side apartment building. He was a stickler for detail, who relished teaching his granddaughter the state capitals and was always ready to lend a hand to help his daughter, who now works for a Chicago property management firm.

But age and declining health caught up with the Army veteran, who by his early 80s began to exhibit signs of dementia and moved into an assisted living apartment.

Dorsey knew her dad needed more specialized care when she found him sitting in his favorite peach recliner in his apartment, unable to get up and incontinent.

He required more intense medical and personal care as his kidney disease worsened and he became more confused, medical records show. In his last 18 months of life, he cycled in and out of hospitals eight times for treatment of septic bedsores and other infections, according to court records.

The Chicago law firm representing Dorsey, Levin & Perconti, provided KHN and the Tribune with medical records and additional court filings that cover Jackson’s care.

Jackson had two pressure sores in late November 2012 when he was first admitted to Lakeview nursing center from the Jesse Brown VA Medical Center in Chicago, according to lawyers for his daughter.

These wounds healed, but in late September 2013, Jackson spiked a fever and had an infected sore in his lower back that exposed the bone, causing what Dorsey’s lawyers called “significant pain.”

The nursing home transferred Jackson to Presence St. Joseph Hospital in Chicago, where surgeons cut away the dead skin and administered antibiotics. At that time, the sore was as wide as a grapefruit and had “copious purulent drainage, foul smell and bleeding,” Dorsey’s lawyers argue. Tests confirmed sepsis, and the wound had grown so deep that it infected the sacral bone in his back, a condition known as osteomyelitis, the lawsuit said.

In November 2013, Dorsey moved her father to another nursing home. He required three more hospital visits before Dorsey made the difficult decision to place Jackson in hospice care. He died March 14, 2014, from “failure to thrive,” according to a death certificate.

In her suit, Dorsey, 39, argues that Lakeview nursing staff knew Jackson was at “high risk” for bedsores because of his declining health. Yet the home failed to take steps to prevent the injuries, such as turning and repositioning him every two hours, according to the suit. That didn’t happen about 140 times in August 2013 alone, Dorsey’s lawyers said.

“My father was like my best friend. Most people go to their mom to talk and tell all their secrets, and for me it was my dad,” Dorsey said in a November 2015 deposition.

While Lakeview declined to discuss Jackson’s treatment, it has denied negligence and argued in court filings that its actions were not to blame for Jackson’s death. Lockett, the home’s administrator, said the facility “strictly follows” all regulations to minimize the effects of skin breakdowns that can occur naturally with age.

“We are grateful for the daily opportunity to enhance the lives of seniors and other chronically ill populations in our community,” Lockett said in a statement.

INFECTION CONTROL

Poor infection control ranks among the most common citations in nursing homes. Since 2015, inspectors have cited 72 percent of homes nationally for not having or following an infection-control program. In Illinois, that figure stands at 88 percent of homes.

Illinois falls below national norms for risks of pressure sores or failure to treat them properly in nursing homes. Inspectors have cited 37 percent of the nation’s nursing homes for this deficiency, compared with 60 percent in Illinois, according to CMS records. Only three states were cited more frequently.

Inspectors in November 2016 cited Alden Town Manor Rehabilitation and Health Care Center in Cicero, Ill., for neglect due to its care of an unnamed 83-year-old man with pressure ulcer sores that went untreated. Gangrene had set in by the time the staff sent him to the hospital, where surgeons ended up amputating his right leg above the knee, according to the inspectors’ report and citation. Alden Town Manor had no comment.

Dean, the Miami lawyer, said that nursing home staffs often miss early signs of infection, which can start with fever and elevated heart rate, altered mental status or not eating. When those symptoms occur, nurses should call a doctor and arrange to transfer the patient to a hospital, but that process often takes too long, he said.

“They don’t become septic on the ambulance ride over to the hospital,” Dean said.

There is little agreement over how much staff should be required in nursing homes. Federal regulations simply mandate that a registered nurse must be on duty eight hours per day, every day. In 2001, a federal government study recommended a daily minimum of 4.1 hours of total nursing time per resident, which includes registered nurses, licensed practical nurses and certified nursing assistants, often referred to as aides. That never became an industry standard or federal regulation, however.

Most states set requirements lower and face industry resistance to raising the bar. A California law requiring 3.5 hours per resident as of this July 1 is drawing intense criticism from the industry, for instance.

In addition, staffing can fluctuate, particularly over the weekends. A recent KHN investigation found that on some days, nursing home aides could be in charge of twice as many residents as normal.

At a minimum, Illinois requires 2.5 hours of direct care daily for residents. Yet federal nursing home payroll data show that at least 1 in 4 Chicago-area nursing home residents live in facilities that aren’t consistently providing that much care, KHN found.

Nationally, each aide is responsible for 10 residents on average; in the six-county Chicago area, the average is 13 residents per aide.

Federal officials have linked inadequate staffing to bedsores and other injuries, such as falls. If left unattended, even a small ulcer or sore can become septic, and once that happens, a patient’s life is in imminent danger.

In October 2014, Milwaukee-based Extendicare denied wrongdoing but paid $38 million to settle a federal False Claims Act lawsuit that accused it of not having enough staff on hand in 33 nursing homes in eight states, including Indiana, and failing to take steps to prevent bedsores or falls.

In other cases, federal officials have alleged that some nursing homes overmedicate residents — which can result in injuries such as falls from beds or wheelchairs and bedsores — rather than staff up to care for them properly.

Little infections turn to big infections and kill people in nursing homes.

In May 2015, owners of two nursing homes in Watsonville, Calif., agreed to pay $3.8 million to settle a whistleblower lawsuit alleging the homes persistently drugged patients, contributing to infections and pressure sores.

The suit alleged that an 86-year-old man who could barely move after receiving a shot of an anti-psychotic medication lost his appetite and spent most of the day in bed, “was not turned or repositioned and developed additional pressure ulcers.” He ran a 102-degree fever, but the staff failed to notify his doctor for three days, according to the suit.

Hospital doctors later diagnosed the man with sepsis and an infected pressure ulcer. The home did not admit wrongdoing and had no comment.

Personal injury lawyers and medical experts say that poor infection control often sends nursing home residents to hospitals for emergency treatment — and that the stress can hasten death.

Elderly people often “don’t have the ability to bounce back from an infection,” said Dr. Karin Molander, a California emergency room physician and board member of the Sepsis Alliance advocacy group.

That odyssey of multiple, stressful trips to the hospital is a common thread in negligence and wrongful death lawsuits involving sepsis or bedsores. KHN identified more than 8,000 suits filed nationwide from January 2010 to March of this year that allege injuries from failing to prevent or treat pressure sores and other serious infections.

Molander said serious bedsores indicate “someone is being ignored for an extended time period.”

“When we see patients like that we file [patient neglect] complaints with adult protective services,” she said.

Some of these cases led to million-dollar jury verdicts. In 2017, a Kentucky jury awarded $1.1 million to the family of a woman who suffered from bedsores and sepsis in a nursing home. In a second case last year, a jury awarded $1.8 million to a widow who alleged a Utah nursing home failed to turn her husband often enough to prevent bedsores, which led to his death.

Lawyers filed more than 1,400 of the cases from January 2010 to March of this year in Cook County Circuit Court, which tops all metro areas across the country in the KHN sample.

Nursing homes complain that garish billboards to solicit clients are a fixture in Chicago, where many attorney websites also boast of recent million-dollar verdicts from bedsore cases alone.

“We see an incredible amount of lawsuits out there,” said Hartman, of the Illinois nursing home association. “We feel we have a target on our backs.”

Trial lawyers counter that nursing homes often try to duck responsibility for poor care by creating complex corporate structures to limit their liability. Yet Hartman derided these suits as “cash cows” for law firms that can rack up six-figure legal fees as cases drag on. The nursing home industry supports tort reforms that would compensate injured persons but also bring a quicker resolution of claims, he said.

“That is something that needs to be fixed in Illinois,” Hartman said.

AVOIDABLE HOSPITAL TRANSFERS

In September 2013, the Centers for Medicare & Medicaid Services said it was working to reduce avoidable transfers from nursing homes to hospitals. CMS had previously called these trips “expensive, disruptive and disorienting for frail elders and people with disabilities.”

The plans came in the wake of a critical 2013 Department of Health and Human Services audit that found Medicare had paid about $14 billion in 2011 for these transfers. Care related to sepsis cost Medicare more than the next three costliest conditions combined, according to the audit.

The auditors have not checked in to see if Medicare has since reduced those costs and have no plans to do so, a spokesman for the HHS Office of Inspector General said.

However, Definitive Healthcare’s analysis of billing data, modeled after the HHS audit, shows little change between 2012 and 2016, both in terms of deaths and costs.

Wendy Meltzer, executive director of Illinois Citizens for Better Care, said that hospital trips caused by treatment for sepsis can be “emotionally devastating” for confused elderly patients.

“It’s not a choice anybody makes. It’s horrible for people with dementia,” Meltzer said. “Some never recover from that. It’s a very real phenomenon and it’s cruel.”

University of Maryland master’s student Chris Cioffi contributed to this report.

This story was jointly produced by Kaiser Health News and the Chicago Tribune by reporters based in Washington, D.C., and Chicago. Fred Schulte is a senior correspondent for KHN and Elizabeth Lucas is data editor. Joe Mahr is a Tribune reporter.

 Sep.06.2018

For further information about sepsis visit The Sepsis Alliance

The family of a woman who died just 100 days after being admitted to a nursing home have won their nursing home lawsuit, with the nursing home being found liable for the woman’s death. The estate sued the nursing home’s management company on grounds of negligence.

The woman had been admitted to the home for rehabilitation after she had fractured her leg. While in the home, she developed complications, including bedsores, which led to her losing her leg. She later died as a result of an infection.

The estate alleged that proper wound care was not undertaken by the nursing assistants, that those assistants lacked training, and that the nursing home was inadequately staffed. Following a trial, a Polk County Superior Court jury found that the management company was negligent and awarded $2,000,000 to the plaintiff.

June 29, 2014. 

Editor: Although the publication date of an article may not be current the information is still valid.

A study by Medicare’s inspector general of skilled nursing facilities says nearly 22,000 patients were injured and more than 1,500 died in a single month — a higher rate of medical errors than hospitals.

More than 1 million patients suffer harm each year while being treated in the U.S. health care system. Even more receive substandard care or costly overtreatment.

Too many patients suffer harm instead of healing in U.S. medicine. That’s why ProPublica’s reporters have investigated everything from deadly dialysis centers and dangerous hospitals to the failure of state boards to discipline incompetent nurses.

Doctors who reviewed the patients’ records determined that 59 percent of the errors and injuries were preventable. More than half of those harmed had to be readmitted to the hospital at an estimated cost of $208 million for the month studied — about 2 percent of Medicare’s total inpatient spending.

Patient safety experts told ProPublica they were alarmed because the frequency of people harmed under skilled nursing care exceeds that of hospitals, where medical errors receive the most attention.

“(The report) tells us what many of us have suspected ­­– there are vast areas of health care where the field of patient safety has not matured,” said Dr. Marty Makary, a physician at Johns Hopkins Medicine in Baltimore who researches health care quality.

The study by the inspector general of the U.S. Department of Health and Human Services (HHS) focused on skilled nursing care – treatment in nursing homes for up to 35 days after a patient was discharged from an acute care hospital. Doctors working with the inspector general’s office reviewed medical records of 653 randomly selected Medicare patients from more than 600 facilities.

The doctors found that 22 percent of patients suffered events that caused lasting harm, and another 11 percent were temporarily harmed. In 1.5 percent of cases the patient died because of poor care, the report said. Though many who died had multiple illnesses, they had been expected to survive.

The injuries and deaths were caused by substandard treatment, inadequate monitoring, delays or the failure to provide needed care, the study found. The deaths involved problems such as preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

One patient suffered an undiagnosed lung collapse because caregivers failed to recognize symptoms. The patient later had a reaction to medication and a blood clot and had to be transferred to a hospital.

Projected nationally, the study estimated that 21,777 patients were harmed and 1,538 died due to substandard skilled nursing care during August 2011, the month for which records were sampled.

Medicare patients “deserve better,” said Sen. Bill Nelson, D-Fla., chairman of the U.S. Senate Special Committee on Aging. Nelson said he would push for better inspections of the facilities. “This report paints a troubling picture of the care that’s being provided in some of our nation’s nursing homes,” he said.

The report said it is possible to reduce the number of patients being harmed. It calls on the federal Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services (CMS) to promote patient safety efforts in nursing homes as they have done in hospitals.

The authors also suggest that CMS instruct the state agencies that inspect nursing homes to review what they are doing to identify and reduce adverse events.

In its response to the report, CMS agreed with the findings and noted that the Affordable Care Act requires nursing homes to develop Quality Assurance and Performance Improvement programs. The agency’s quality improvement work includes a website for nursing homes that was launched in 2013.

A “skilled nursing” facility provides specialized care and rehabilitation services to patients following a hospital stay of three days or more. There are more than 15,000 skilled nursing facilities nationwide, and about 90 percent of them are also certified as nursing homes, which provide longer-term care.

As hospitals have moved to shorten patient stays, skilled nursing care has grown dramatically. Medicare spending on skilled nursing facilities more than doubled to $26 billion between 2000 and 2010. About one-in-five Medicare patients who were hospitalized in 2011 spent time in a skilled nursing facility.

John Sheridan, a member of the American College of Health Care Administrators, which represents nursing home executives, called the report valuable but noted that it sampled only a small number of patients. He questioned whether the findings apply broadly to skilled nursing facilities.

Sheridan also strongly disagreed with the report’s observation that there’s less known about patient safety in skilled nursing facilities compared to hospitals. He said Medicare has robust inspections of nursing homes it certifies – they take place annually or when there are complaints and are usually conducted by state contractors. Medicare also keeps detailed data on the violations, he said. (ProPublica’s Nursing Home Inspect makes it easy to search and view Medicare inspection reports.)

Sheridan agreed that skilled nursing facilities could improve, but said the caregivers face a daunting task and work diligently despite low reimbursements Medicare pays to the facilities.

“They don’t go to work every day to cause an adverse event,” Sheridan said of the providers. “They do it to care for the residents there. They do it with sacrifice and love.”

Dr. Jonathan Evans, president of the American Medical Directors Association, a group focused on nursing home care, said while he doesn’t dispute the estimates in the inspector general’s report, they are typical of problems that exist throughout the health care sector.

Evans said that patients receiving skilled nursing care are leaving hospitals sooner and that many are not medically stable and have more intensive needs. Nursing homes, originally designed for long-term patients who did not need intensive care, and have been slow to adapt, Evans added.

“You have a system of long-term care that’s trying to retrofit to be a system for post-acute care,” he said. “The resources to care for them and commitment from those sending them from one facility to another haven’t kept pace.”

Evans called the study significant and said he hopes it raises awareness and sparks improvements.

Makary, the Johns Hopkins’ doctor, said the patient safety movement has been more focused on problems at hospitals than in nursing homes.

A 2010 report by the HHS inspector general estimated that 180,000 patients a year die from bad hospital care, and other estimates have been higher. The patient safety research community has focused on reducing bloodstream infections and surgical errors at hospitals but has done less to address issues specific to nursing homes, Makary said.

Developing metrics to track improvement would be more effective than annual inspections, which don’t do a good job of capturing a facility’s everyday performance, Makary said.

Patient advocates said the study verifies what they’ve heard from skilled nursing patients and their families. Richard Mollot, executive director of New York’s Long Term Care Community Coalition, said he was “flabbergasted” by medication errors, bedsores and falls that were identified in the report.

They are prominent problems that nursing homes should be “well versed” to address, he said.

Mollot said the report should have more forcefully called for better enforcement of the existing standards in nursing homes.

States inspect nursing homes on behalf of Medicare every year and when there are complaints, he said, but some inspectors are tougher than others. Medicare’s current standards of care are good, he said, and “if they were enforced we wouldn’t have these widespread problems.”

About 40 percent of people over age 65 will spend time in a nursing home at some point, Mollot said. Hopefully, he said, the inspector general’s report will help the public see that care needs to improve.

“They are dangerous, dangerous places,” he said.

March 3, 2014