Shining A Light On Abuse

The guilt children feel about putting a parent in a nursing home can sometimes lead them to blame others for the death of their loved one. But what Leslie Oliva saw as her mother moved through three California nursing homes during the last three years of her life is part of a bigger, shocking tale the Federal Government will tell this week. The account is based on the most detailed look in more than a decade at some of the nation’s nursing homes. “My mother experienced beating, malnutrition, dehydration and neglect,” Oliva says quietly. “All three of the nursing homes are responsible for her death.”

In a written statement provided to the Senate Special Committee on Aging, Oliva says her mother Marie Espinoza, who was suffering from a degenerative brain disease, had bruises, bedsores and a broken pelvis within months after her 1995 arrival at the Orangetree Convalescent Hospital. Food was often left at the foot of her bed, out of her reach. She began to lose weight. “She always seemed to be starving or begging for water,” says Oliva in her official account. At Extended Care Hospital, Espinoza suffered severe dehydration and bedsores. Last January she entered Palm Terrace Convalescent Center. The nursing home said she died after choking on food, but Oliva plans to tell the committee that this makes no sense: Espinoza was supposed to be fed through a tube. All three nursing homes deny any wrongdoing.

Oliva’s tale will put a human face on a damning study by the General Accounting Office that will be the subject of hearings by the Committee on Aging this week. The panel has summoned two insiders–a former California nursing-home nurse and a current nursing-home inspector for the state–to offer firsthand accounts of the horrors. The women–called “Clara B.” and “Florence N.” by the committee–will speak from behind a screen to shield them from retaliation by the powerful nursing-home industry and the agency that provides care to California’s elderly.

“If they didn’t eat fast enough, the food got taken from them,” the former nursing-home employee told TIME. She says she would falsify records to show that the residents had eaten everything on their plate. Things would improve for a while when state inspectors showed up for their predictably timed annual visit. “The attitude was to put a Band-Aid on it until the state left, and then it’d go right back to the way it was,” she says. The inspector, who has been visiting California nursing homes for years, told TIME her complaints are regularly ignored because of the “cronyism” that exists between the state overseers and nursing-home operators. “Once we write down violations, the nursing homes complain and our superiors keep us from going back or else they dismiss our citations,” she says. This has led to “hopelessness” among inspectors like herself, she says.

And, according to the GAO, it has contributed to a litany of abuses. One resident lost a third of his body weight over seven weeks. During this time, the nursing home failed to weigh him, give him prescribed painkillers or alert his doctor to his worsening condition. Another resident had a bedsore, and the doctor ordered the bandage to be changed twice a day; it was unchanged for nearly two weeks. A third nursing-home resident was brought to a hospital, where the patient was found to have had a broken leg for at least three weeks and the nursing-home records were missing. A woman whose four bedsores were exposed to the bone and required daily cleaning was rarely given the prescribed pain medicine before the procedure.

The GAO report, following up on a story that appeared in TIME last fall, says more than half the suspicious deaths studied in California nursing homes were probably due to neglect, including malnutrition and dehydration. The study says that nearly 1 in 3 California nursing homes has been cited by state inspectors for “serious or potentially life-threatening care problems” and that the same problems probably exist across the nation. These are likely to grow as the baby boomers become grandparents and the rocketing elderly population puts even greater pressure on the nation’s nursing homes. Senator Charles Grassley, the Iowa Republican who chairs the Committee on Aging, argues that much of the blame for the flawed nursing-home system can be pinned on the Federal Government, which has the economic leverage to insist on improvements. Last year the Federal Government spent $28 billion on nursing-home care through Medicare and Medicaid. “It’s been too permissive and too forgiving in its enforcement,” Grassley told TIME.

In the face of such stinging criticism, President Clinton announced last week that his Administration is cracking down on abuses in the 17,000 nursing homes across the nation that house 1.6 million of the old and disabled. “We are failing our parents, and we must do more,” Clinton said. The President said repeat nursing-home violators need to be fined quickly and stopped from avoiding payment by pledging to fix the problem. He urged states to stop conducting nursing-home inspections during business hours at precise one-year intervals “so there is no time to hide neglect and abuse.” And he wants more nursing-home workers trained to give residents food and water.

The nursing-home industry reacted coolly to Clinton’s punitive tone, saying a “collaborative effort” is needed to solve the problems. “Enforcement activity alone is not the answer,” said Paul Willging, executive vice president of the American Health Care Association. “In fact, a single-minded emphasis on enforcement will ultimately hurt quality.” But the GAO report argues that many nursing homes have become dangerous places largely because they are understaffed–and underregulated. Nursing homes spend 2 out of every 3 dollars on payroll, so the most tempting way for them to increase profits is to cut personnel. And the Federal Government isn’t halting this practice, says the GAO. The “forgiving enforcement stance” of the Health Care Financing Administration “helps explain how some homes can repeatedly harm residents without facing sanctions.”

TIME reported last fall on a study by Palo Alto, Calif., attorney Von Packard and investigators Robert Bauman and Dina Rasor of the death certificates of all Californians who died in nursing homes from 1986 through 1993. In more than 7% of the cases, lack of food or water, untreated bedsores or infections were listed as a cause of death. This probe led Grassley to order the GAO to California to investigate. The GAO’s medical review of 62 residents who died in trouble-prone California nursing homes showed that 34 of them received poor care that probably contributed to their demise. Applying the GAO’s percentage of negligent California deaths to the nation’s nursing-home population suggests that close to 20,000 U.S. nursing-home residents are dying prematurely or in unnecessary pain, or both.

“Everyone knows that profits and good care are not compatible” is how Pat McGinnis, executive director of California Advocates for Nursing Home Reform, explains the persistence of nursing-home abuses. But a recent spate of multimillion-dollar jury awards to nursing-home residents and their families because of poor care may force some homes to improve. A California woman won a $95 million verdict after the jury was told how she broke her shoulder and shattered her hip (last month a judge cut the award to $3 million), and a jury awarded $6.3 million to the family of a Florida man who wandered from his nursing home and drowned in a pond.

While regulators are supposed to ensure that standards are met, many of the rules are weak or unclear. The Federal Government, for example, doesn’t specify how much staffing a nursing home needs. That imprecision and split responsibility can be exploited by the nursing-home industry, which in many states is a powerful lobby with lots of cash to spread among sympathetic lawmakers. Last year California levied $2.6 million in fines, but it has collected only $518,000 from recalcitrant nursing homes.

Evidence like the GAO report is sure to encourage even more lawyers to file suits seeking damages for alleged wrongdoing by nursing homes. And if jurors keep awarding multimillion-dollar verdicts to grieving families, nursing homes could end up embracing stiffer rules and penalties as a way to deter such claims.