Inadequate staffing is common

Here is a very interesting story from a resident’s point of view.  Billy Bogardus, a retired engineer, said he received poor care while he was a patient in Haven Health Center of South Windsor earlier this year. “You had to beg and plead to get them to pay attention,” he said.  Bogardus of West Hartford went into a Haven Healthcare nursing home to recuperate from a hospital stay, but ended up fighting for his life.

For four days in April, Bogardus and his close friend, Leona Brenner, tried to convince the staff of the Haven Health Center in South Windsor that he was dying. Bogardus, who had sought nursing-home care after complications from heart surgery, was coughing, struggling to breathe and couldn’t walk the six steps from his bed to the bathroom, he and Brenner said.

Only after Brenner threatened to call 911 herself did the nursing staff finally summon an ambulance, the couple recounted. By the time the 69-year-old retired civil engineer arrived at St. Francis Hospital and Medical Center in Hartford, hospital records show, he was dehydrated and his kidneys were failing.

“If it wasn’t for [Leona], I’d be dead half a dozen times,” said Bogardus, who landed in the hospital several other times during his seven months in the nursing home — once when a blood test found his level of the medication Cumadin was five times higher than normal. “You had to beg and plead to get them to pay attention. I think I would’ve been better off out on the street.”

Bogardus’ complaints were not new. Last year, a state inspection report detailed numerous complaints from residents about the “difficulty they have experienced in obtaining staff assistance.”  The South Windsor home is one of 13 Haven Healthcare homes with staffing levels that fall below both state and national averages, according to the most recent federal data. Nationwide, nursing homes provide an average of 3.6 hours of care per resident per day — 1.3 hours by licensed or registered nurses, and 2.3 hours by certified nursing assistants. A study commissioned by the federal government recommends that each resident receive 4.1 hours of care a day.

But in Connecticut, nursing homes have had little incentive to boost staffing. The state’s minimum-staffing law, which has not been updated in more than 25 years, requires only 1.9 hours of nursing care a day per resident — less than half of what the Centers for Medicare & Medicaid Services’ study recommends.

Although the state’s public health code also requires that each facility has sufficient staff to ensure residents receive appropriate care, state public health officials have been reluctant to use that provision to penalize homes for understaffing, or to make demands on homes to add staff when deficiencies are found, records indicate.

Federal data show that Connecticut in 2006 cited only 2 percent of nursing homes, under federal rules, for failing to provide sufficient nursing staff — a lower rate than 27 other states. In 2005, its rate of citing homes for staffing deficiencies was among the lowest in the country — zero.

Haven Healthcare — which has the lowest staffing average of the state’s three largest chains, according to the most recent data — is one of many nursing home operators in Connecticut that stand to benefit from those policies. But it also provides some compelling examples of the consequences.

Many of Haven’s 15 homes in Connecticut have been cited in the last three years for bed sores and dehydration — two key indicators of understaffing, according to federal health officials and nursing home experts. In February, the chain’s Waterford home was hit with the largest penalty imposed by the state in three years — a $100,000 fine and two years’ probation — for neglecting a sore on a resident’s heel for so long that his leg had to be amputated, in addition to other violations.

But in most cases where Haven has been cited for bedsores or dehydration, state officials have not mandated any increase in staffing. Even in the Waterford case and two other Haven cases that triggered “consent orders” by the health department — the highest level of enforcement — the department did not require increases in staffing ratios.

In a number of cases where serious patient-care deficiencies have been found in Haven homes, follow-up state monitoring often consists of the assertion: “Staffing was reviewed and found to be in compliance with the minimum staffing levels of the public health code” — a certification that nursing home advocates say is meaningless.

Jennifer Keyes-Smith, an advocate for the elderly who formerly worked for the state as a regional nursing home ombudsman, complained in a letter last winter to the attorney general’s office that she had tried repeatedly several years ago to get the ombudsman’s office and the state Department of Public Health to address chronic understaffing at Haven’s New Haven home — without success.

“I continued to visit the facility and observed resident call bells going unanswered, residents not being fed, residents not being toileted, and staff treating residents disrespectfully,” she wrote last November. “With basic human needs not being met, I continually urged the program’s prompt intervention and DPH’s expedient response. I was then told to stop working on the case.”

Haven Healthcare CEO Raymond said he could not recall the state ever punishing the chain for understaffing or mandating higher staffing ratios.

Last week, state Attorney General Richard Blumenthal disclosed that state and federal officials were investigating whether Haven Eldercare, the chain’s parent company, improperly diverted government funds away from patient care. Termini said the company’s financial issues never impacted the level of care.

The public health code’s general rules on staffing mandate that nursing homes provide enough staff to ensure that each patient receives appropriate treatment, is “comfortable and well-groomed” and is protected from accident or infection. Federal rules also require sufficient staffing.

Nursing home owners have opposed increasing the minimum, complaining there is a shortage of qualified nursing personnel to work in the homes, and that state Medicaid reimbursements are not adequate to cover increased staffing.

But the numbers remain a key indicator of quality for federal officials and nursing home advocates. And other states do require troubled homes to increase their staffing levels when inspections find bedsores, dehydration or other signs of inadequate care.

Nursing home experts say bedsores and dehydration are often consequences of chronic understaffing. Federal health officials use the incidence of pressure sores as a measure of nursing home quality.

Bedsores are painful skin ulcers caused by constant pressure on a part of the body, common among people left in a bed or wheelchair for long periods of time. Nursing homes can prevent the sores by frequently changing a resident’s position or providing padding. In their early stages, the sores can be easily treated. But left unattended, they can infect underlying tissue, bones and joints.

The incidence of pressure sores “is a major barometer of quality of care. It’s one of our chief concerns,” said Roseanne Pawelec, spokeswoman for the Boston office of the Centers for Medicare & Medicaid Services. “It can be an indicator of several issues, including understaffing, poor training and insufficient monitoring of residents.”

State health officials in February imposed a “consent order” on Haven’s Waterford home for violations including the incident leading to amputation. The state found the home had failed to monitor and treat a blister on a resident’s heel for two months, as it erupted into a pressure sore. A state inspector visiting the home last November saw the wound, which was covered in a bandage saturated with dried blood and giving off a “foul odor,” and intervened.

On Dec. 4, the resident’s leg was amputated below the knee.

In the consent order issued to the Waterford home, state health officials made a reference to staffing. In addition to requiring weekly monitoring by a nurse consultant and the hiring of a wound control consultant, the order calls on the home to identify the number and qualifications of nursing and other staff “necessary to meet the needs of patients,” and to ensure that “sufficient nursing personnel are available.”

In addition to bed sores, the failure to monitor residents’ fluid intake has been a frequent finding.

In January 2004, a resident of Haven Health Center of West Hartford who was supposed to be watched for dehydration grew weak from lack of fluids and died, with inspectors finding that the resident’s fluid intake was not properly monitored.

Several lawsuits filed against Haven Healthcare make mention of bedsores and dehydration. The family of Carrie Tondalo, who resided in Haven-Soundview in West Haven in 2003, has a lawsuit pending that alleges the nursing home failed to monitor her fluid intake or skin sores for three months leading to her death, despite directives that those conditions be addressed. The health department’s investigative report into her death, which concludes that the home failed to properly monitor Tondalo’s condition, also mentions other cases in which residents’ bedsores were neglected.

Haven’s home in Norwich was cited in June for not tending to a resident who fell to the floor one night and complained of leg pain. The resident was not taken to the hospital for evaluation until late the next day, when an X-ray revealed a fracture.

The Cromwell home was cited last year for not responding when an oxygen line broke on a humidifier used by a woman with a tracheotomy, and she tried to alert the nursing staff that she couldn’t breathe. She was found unresponsive the next day and rushed to the hospital.

In a wrongful death lawsuit filed against the nursing-home chain, the family of a woman who resided in a Milford nursing home that was managed by Haven Health in 2003 alleges that she died because the home repeatedly ignored her severe bowel problems.

Geraldine “Gerri” Hart had entered Haven Health of Milford, formerly known as the Golden Hill Health Care Center, in July 2003, after the nearby Pond Point facility in which she had thrived had closed down. Hart, 56, required full-time care after a series of strokes. She was placed on pain medications known to cause constipation, with a treatment protocol calling for her bowel function to be monitored, the lawsuit says.

But the nursing staff failed to address her constipation for weeks, a state inspection report found. By the time she was rushed to Milford Hospital on Oct. 9, 2003, Hart was vomiting brown fluid, and more than a cup of fecal material was suctioned from her lungs. Within hours of admission, she was dead of a perforated bowel, resulting from fecal impaction.

“I could see when she went to Haven Healthcare, she was going downhill,” said Marilyn Tarczali, Hart’s younger sister, who brought the lawsuit. “It was just awful there. She was in bed all the time. The laughing had stopped. …

“Nobody ever said a word to me that she wasn’t going to the bathroom,” she added. “To die like that, because they were too lazy to give her a suppository.”

Tarczali’s lawsuit also targets Milford Hospital, which sent Hart back to the nursing home twice in the days before her death, even though X-rays showed she was suffering from fecal impaction.

Haven Health took over Golden Hill on Aug. 1, 2003, soon after Hart was admitted. It ended its management of the home on Nov. 30, according to state officials. The state health department fined the home $3,000 in 2004 for a number of violations, including the lapses in care that led to Hart’s death.

Haven officials would not comment directly on pending lawsuits, but pointed out that they had managed the Milford home and several others cited in negligence lawsuits for only a short time.

Making The Link

In 2006, Connecticut’s average staffing was 3.6 hours a day — slightly above the national average, but lower than 21 other states. Staffing levels among Connecticut homes swing widely, from less than two hours of care per day to more than four hours.

Charlene Harrington, a professor of sociology and nursing at the University of California-San Francisco and an expert on nursing home staffing, said some states, such as Florida and Maine, have set relatively high minimum-staffing standards. Florida requires 3.9 hours of nursing care a day.

But she said many states have no interest in policing staff levels, which can require more time and resources, as well as increases in Medicaid funding.

“It’s a lack of commitment, because they think if they go after the pressure sore, that’s enough,” Harrington said. “They don’t bother addressing the underlying problem” of staffing levels. “So the same problems just keep coming up. It never gets any better.”

Deborah Chernoff, spokeswoman for the New England Health Care Employees Union, District 1199, which represents workers at 11 Haven homes, said staffing levels at some of the homes had reached “disgraceful” levels in past years.

“It’s hard on our members,” she said. “There’s a very high injury rate when you don’t staff adequately.”