Fourteen of the incidents — resulting in four deaths and one injury — were at area facilities.
Those nursing homes are in Montgomery, Greene, Butler and Clark counties.
Despite limited funding, state officials are taking steps to improve nursing home care, and at the same time make such facilities a last resort. Gov. John Kasich wants to shift more long-term care to home- and community-based settings.
That effort comes as a first-of-its-kind AARP study released Thursday rated Ohio 35th for quality of long-term care services and supports for the elderly, people with physical disabilities and family caregivers. AARP’s report expressed a need for improvement not only in Ohio’s nursing homes, but also in its home health services.
Many of Ohio’s nearly 1,000 nursing homes — home to about 80,000 residents in 2009 — have long dealt with negative public perceptions.
“In any human endeavor, you’re going to have situations that don’t go the way they should,” said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents nursing homes. “We feel like overall the facilities are quite safe and do a good job.”
Avoidable deaths?
Patient abuse by staff or other patients, poor handling of patients’ emergencies, medication errors, elopement and accident hazards led to more “immediate jeopardy” violations at Ohio’s nursing homes than any other causes, according to the newspaper’s review of an online public database of Ohio Department of Health documents at ltcohio.org.
An “immediate jeopardy” finding is the most serious violation nursing homes can receive from the state health department, which conducts annual nursing home surveys plus inspections on behalf of the Centers for Medicare & Medicaid Services. CMS reimburses nursing homes for care provided to the poor and elderly, and can fine or terminate the facilities from Medicare and Medicaid.
Some deaths and injuries resulted from falls and nursing home residents’ own actions, but state officials found the homes had some degree of culpability. In other cases, such as those involving medication errors, nursing home staff inadvertently but unquestionably caused the deaths.
The newspaper was conservative in counting 22 “immediate jeopardy” deaths from August 2007 to May 2011. For example, it excluded fatalities in which staff failed to perform CPR after residents exhibited no vital signs.
Of the 14 immediate jeopardy cases in Montgomery and surrounding counties, 11 occurred at for-profit facilities and three happened at nonprofits. In Ohio, about three-fourths of nursing homes are for-profits.
In most local cases, nursing homes paid fines ranging from $3,250 to $54,500, though those fines were sometimes cut by 35 percent if nursing homes chose to forgo a hearing.
In two of the 14 cases, the nursing homes were not fined. One of those cases stemmed from an incident in June 2008 at the Vandalia Park nursing home, where a resident ate a peanut butter sandwich, contrary to a requirement that he have a pureed diet. The resident choked on the peanut butter and died.
Three months later, another Vandalia Park resident on a physician-ordered pureed diet also choked and died on peanut butter given to him by a staff member. The person with that resident’s power of attorney had signed a “refusal to consent to treatment” form declining to follow a physician-ordered diet, and the resident’s wife kept peanut butter in his dresser.
Vandalia Park did not return calls seeking comment.
Other factors in the deaths of nursing home patients include elopement and medication errors.
In November 2007, a resident of the Oaks of West Kettering was struck by a vehicle while crossing West Dorothy Lane, apparently on her way to a convenience store. The facility, which did not return a call seeking comment, was not fined, according to the state.
In April 2009, a registered nurse at Eaglewood Care Center in Springfield administered a full dose of the wrong medication to a patient, who died shortly after.
Eaglewood called the incident “tragic” but “isolated.” The nurse who administered the wrong medication was fired, and the facility gave its staff additional training on the proper administration of medicine.
Stephanie Hess, Eaglewood’s executive director, said the incident was the facility’s first “immediate jeopardy” finding in its 26-year history, and the facility has had no deficiencies in its nursing department in follow-up surveys.
Other cases
On March 13, the husband of an employee at Bethany Village allegedly raped an 85-year-old resident at the facility. The resident reported the incident to her caregiver, the rapist’s wife, who did not report the incident. When confronted, she said she had forgotten to do so.
The man, David H. Howson, 64, of Dayton, was convicted in May of rape and sexual imposition.
In a prepared statement, Bethany Village described the incident as “deplorable” and “isolated,” and said it “mars an otherwise highly distinguishable 65-year history.”
“Have we learned from it? Absolutely,” the statement reads. “Will it ever happen again? Not if there is any way on Earth that we can prevent it.”
Bethany said it immediately put in place security precautions to cover “all the bases” following the incident, including new internal policies, staff education and advanced security technology.
In May 2009, a resident of Bellbrook Rehab & Healthcare Center repeatedly fondled the breasts of another patient. The facility was fined $17,150. It did not respond to a request for comment.
Similarly, Kingston of Miamisburg was cited for failing to assess a resident for inappropriate behavior, though he had previously touched staff inappropriately. The male resident in December 2008 sexually abused another resident at the nursing home.
While immediate jeopardy findings are of great concern, Beverley Laubert, Ohio’s long-term care ombudsman, said they often result from isolated incidents. “A lot of nursing homes are trying very hard to provide good quality of care,” she said.
Pulling licenses rare
Ohio has rarely put nursing homes out of business in the past decade, instead using incidents that hurt or kill residents as leverage to force the facilities to adopt better practices, said Bob Applebaum, director of the Ohio Long-term Care Research Project at Miami University’s Scripps Gerontology Center.
The Centers for Medicare & Medicaid Services also maintains a list of “special focus” facilities — nursing homes that have had a pattern of serious, persistent problems. The facilities are inspected twice as frequently as other nursing homes (usually twice a year). More stringent enforcement actions are taken if problems persist. The list, updated quarterly, always contains nine Ohio nursing homes. None of the homes on the current list is in the Dayton area.
Bad operators aside, Applebaum said, it is preferable for the state to work to reduce variability between the worst and best nursing homes. Stiffer fines don’t necessarily accomplish that, he said, and could even undercut patient care if they have a significant impact on a facility’s bottom line.
Immediate jeopardy findings should be considered when people research nursing homes, though they are not necessarily good barometers of a nursing home’s quality, Applebaum said. Experts say resident and family satisfaction are key measures, and added there’s no substitute for a visit to a nursing home to see how staff and residents interact.
“There are instances where very good homes could have immediate jeopardy, and they’ll fix it immediately,” Applebaum said. Sometimes, “it’s just the bad luck of the draw.”
What cuts will mean
Long-term care advocates worry that nursing home safety will become a bigger issue in the future because of reimbursement cuts for nursing homes in the new state budget. The Ohio Health Care Association, which ran television advertisements critical of the Medicaid rate cuts, earlier this year estimated the Medicaid overhaul’s 5.8 percent rate cut to nursing homes would cost the industry 5,600 jobs. It has documented at least 500 job cuts so far, though many of those jobs are support jobs, not caregiver positions.
While the state mandates minimum staffing requirements and the current state budget provided some regulatory relief for staffing, industry watchers say any staff reductions could have implications for patient safety.
“The one thing that we do know about quality is that staffing matters,” Applebaum said. “It is somewhat logical to at least ask the question, ‘If nursing homes do indeed have to cut back on direct care staff as a result of changes in the reimbursement system, will that have an impact in the future on quality?’”
The state ombudsman and state officials said they will be on guard.
“We are going to be monitoring this very closely to see if we see any slippage,” said Steve Wermuth, the state Department of Health’s chief operating officer.
Despite reductions in the ranks of state workers who survey and inspect nursing homes, Laubert said the implementation of a new survey process — the Quality Indicator Survey — should make the state’s oversight more robust and patient-focused.
Besides looking at clinical data, “now they’re really looking at the residents’ experience,” she said.
In July 2012, the per-patient payment that nursing homes automatically receive will be further reduced, but under a proposal set to go before the state legislature, nursing homes could recoup the losses if they meet five of 20 benchmarks. Those facilities that meet more than five benchmarks could qualify for an additional payment — money forfeited by nursing homes that don’t meet five benchmarks.
Van Runkle disputes criticism he’s heard that too many of the 20 benchmarks are “give-me’s” that many nursing homes would have no trouble attaining. The benchmarks set a tone and chart a new course for the state’s nursing homes, he said.
AARP’s Bill Sundermeyer said the proposed quality benchmarks need to be monitored to see if they’re rigorous enough. But they are a step forward, he said. He believes Ohio’s long-term care system will compare more favorably with those of other states thanks to the Kasich administration’s efforts.
“This is the first time that the state has said, ‘We need to take a look at this from the standpoint of the quality of the care provided to the consumer,’ ” he said.
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