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Tightly regulated, nursing homes still deal with issues

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Cleburne County Nursing Home

Cleburne County Nursing Home. (Anniston Star photo by Laura Camper)

At an Anniston nursing home, administrators fired a worker accused of verbally abusing a resident, but only after state inspectors intervened.

In Oxford, nursing home staff failed to tell a resident's family members when an employee reported that one resident sexually abused another.

And at more than one Calhoun County nursing home, residents’ unexplained bruises sometimes didn’t get reported to state officials or family members as possible signs of abuse.

An Anniston Star review of state nursing home inspection records, some of them going back as far as 10 years, showed that despite close watching by state officials, nursing homes have sometimes struggled to handle reports or indications of resident abuse properly.

And Calhoun County's nursing homes aren't alone. Officials of the Alabama Nursing Home Association say they've been in talks with state officials this summer, seeking guidance on what violations nursing homes should report and when.

"We’ve had some nursing homes that have had confusion over what they need to report," said John Matson, a spokesman for the association.

The Star examined state inspection records for Calhoun County nursing homes after a nursing home in neighboring Cleburne County was prohibited from admitting new Medicaid patients after failing a state inspection.

"The nursing home industry is the third most-regulated business in the country," John Matson, a spokesman for the Alabama Nursing Home Association.

The nursing home’s latest report, triggered by a complaint,  stated that staff failed to follow a doctor’s instructions about treating a patient’s surgical wound, with nurses leaving the incision open to the air on several occasions. The patient was later hospitalized with an infection.

Abuse of residents wasn't at issue in the Cleburne County case, and The Star found no Calhoun County nursing homes in danger of facing state sanctions.

But records did reveal several incidents, some dating back as far as 10 years, in which nursing home staff seemed to drop the ball on investigating and reporting signs that residents were being abused.

Tightly regulated

"The nursing home industry is the third most-regulated business in the country," Matson said. "That's after the nuclear industry and airlines."

The Alabama Department of Public Health sends teams of inspectors to each of Alabama's 230 nursing homes, unannounced, at least once every 15 months, plus additional inspections when residents file complaints. In all, the inspectors make about 500 visits per year, said Dr. Walter Geary, director of the Bureau of Health Provider Standards for the state health department.

Their reports document in detail the sometimes harsh lives of people in nursing homes — where residents, most of them elderly, have medical issues that keep them from being able to live alone. Reports often show improperly stored food or improperly washed silverware; patients with bedsores; noisy conditions when residents are trying to sleep and various intrusions on privacy in rooms that are typically shared by pairs of residents.

They also document the difficulty of operating nursing homes to state standards. Inspectors judge everything from the temperature of food to length of privacy curtains to amount of water in bedside pitchers.

"When the surveyor walks in, there are 1,500 deficiencies they can cite,” said Jerry Culberson, director of Preferred Health Services in Centre, the company hired to identify problems at Cleburne County Nursing Home.

Culberson says one nursing home he runs was written up because a cook didn't precisely measure the amount of pimento cheese in each sandwich. Even Geary, the head of the inspection program, says the regime is tough.

“It’s very rare for an institution to have no deficiencies at all,” he said.

Most infractions get fixed quickly, or else. Inspectors typically return within a month to see if issues in an inspection are corrected. If they’re not, a nursing home can find itself facing sanctions from the state. Most deficiencies are fixed promptly, Geary said.

Abuse allegations

Still, there's one kind of problem that can't be easily remedied: the intentional abuse of residents, either by staff or by other residents. Reports on Calhoun County's nursing homes show a few substantiated allegations of abuse over the past 10 years, plus several incidents when nursing home staff failed to promptly report indicators of possible abuse to state officials.

In August 2010, a member of the staff at Beckwood Nursing Home was fired on grounds of verbal abuse after allegedly calling a resident a "crippled bastard." But that happened only after state investigators intervened. State inspection records showed the nursing home didn't report the incident to the state until a week after it happened, nor did it suspend the staffer or begin an investigation into the allegation before state inspectors got involved.

According to state reports, Beckwood administrators said the failure to investigate was "a bad judgment call."

It wasn't Beckwood's first time to be called on the carpet for not investigating abuse claims. In 2004, state investigators cited Beckwood for simply telling a staff member to stay away from a resident after the resident accused the staff member of putting a hand on his thigh. State inspectors, who later stepped in to investigate, seem to have cleared the staffer of any wrongdoing.

Ratings on Medicare's Nursing Home Compare

Facility Overall Rating Health Inspection Staffing Quality Measures Beds
Beckwood Manor (Anniston) 2 1 4 5 85
NHC Healthcare (Anniston) 3 2 4 4 151
Golden Living Center (Oxford) 2 2 3 4 173
Jacksonville Health and Rehabilitation Center 3 2 3 5 167
Piedmont Health Care Center 5 4 4 5 91

Based on a scale of 1 to 5, with 5 being the best. 

Beckwood director Clayton Cox said he wouldn’t comment on the 2010 incident, and said he didn’t recall the 2004 report, noting it was made 10 years ago. He said the nursing home passed recent inspections earlier this month, and welcomes those inspections.

“Nursing homes want to resolve issues,” he said. “When a survey team comes in and they leave a list of deficiencies, that’s the feedback that you want.”

Preventing abuse

In a 2010 incident at Golden Living Center in Oxford, a staff member saw a resident touching another resident's breast against that resident’s will, state reports show. Staff didn't tell the resident's family members about the incident until the next April, after state inspectors intervened.

That same April, the resident accused of sexually abusing another resident also accused a Golden Living nurse of waving a finger in his face and saying "someone might teach him a lesson." According to an inspection report, the resident had cursed at another nursing home employee —  the accused nurse’s wife —  just before the incident.

Golden Living suspended the nurse, allowing him to return later. But state inspectors took a different tack, ordering re-training for all employees of the facility and regular interviews with residents and staff members to ensure the compliance with abuse prevention standards. Administrators also fired the nurse after state officials re-investigated the claim and found discrepancies between what the he told the facility director and what he told state inspectors.

Warning signs

State inspectors have also cited area nursing homes for a number of other lapses in compliance with state policy for catching resident abuse. At Jacksonville Health and Rehabilitation in 2011, staff weren't sure about the cause of a fracture in a patient with osteoporosis, but couldn't show inspectors any evidence that they'd investigated whether the fracture was caused by members of the staff. Piedmont Health got a similar citation in 2010, when a patient's unexplained fracture wasn't reported to the state. NHC Health Care in Anniston was also cited for not reporting a patient’s bruise to family members. State inspection records don’t show any findings of abuse in any of the cases, but the nursing homes were cited for not reporting them properly.

“We are confident and stand by the care provided in this incident from 2011,” Jacksonville Health and Rehabilitation director Brantley Newton wrote in an e-mail to The Star.

Local nursing homes have also occasionally hired workers without checking them against the state's database of nurses — one place where past investigations of abuse would be recorded. Inspection reports show that since 2006, NHC Health Care in Anniston, Beckwood and Golden Living have each been cited once in the past 10 years for not running the checks, though there's no evidence the employees failed the checks when they were run later.

Becky Helton, director of NHC, said that while she takes every inspection seriously, issues tagged by inspectors often aren’t as hazardous as they might seem to readers unfamiliar with the reports. In the case of the background check, she said, staff had already run a criminal background check on the new staffer before the staffer’s first day of work.

“They started work, and we checked the nursing registry the same day,” she said.

In the case of the unreported bruise, she noted, there was no finding of abuse.

“It was miscommunication, not abuse,” she said.

Run over

“We’ve had instances where a resident reported ‘Somebody ran over me with a truck last night,’” said Matson, the nursing home association spokesman. “Even if that’s obviously not true, the nursing homes have to investigate it.”

Matson said federal rules now require nursing homes to investigate every report of abuse. Many residents of nursing homes, he noted, are there because of dementia or mental illness. Nursing homes, he said, have asked the state’s Department of Public Health for clearer guidance on how to approach reports made by those residents.

In the broader community, people often don’t report elder abuse because they simply don’t know how to recognize it, said sexual assault counselor Trace Fleming-Smith, who works for Second Chance women’s shelter in Anniston. Fleming-Smith is coordinating a new program to train local residents and officials on how to handle elder abuse.

Also helping report problems of abuse are staff members with the regional agency of the Alabama Department of Senior Services.

Randy Frost, director of the senior services department covering a 10-county region in eastern Alabama, oversees two full-time workers, called ombudsmen, who act as advocates for nursing home residents. He said the two workers are on the road every day of their work weeks, visiting the nursing homes in the area.

Frost said that if the ombudsmen receive a complaint or spot abuse, they immediately get to work, talking with the resident, his or her family and nursing home staff to mediate the issue.

The ombudsmen also go to residents’ councils and family councils at each facility and make sure residents and the people responsible for them know their rights and know how to report abuse or any other problems.

“We try to maintain a presence,” he said.  

But even some nursing home staff aren’t sure how to handle some cases, Fleming-Smith said. She cited a call she received from a nursing home in a neighboring county in which a resident reported sexual abuse.

“She said, ‘I know the protocol for handling this, but I’ve never had to do the protocol,’” Fleming-Smith said.

Culberson, the consultant who’s working with Cleburne County to resolve its problems, said training, or the lack of it, is the source of most problems in inspections.

"When we run into problems, it's usually because of staff training and education," Culbertson said.

Frost said that’s why another part of the ombudsmen’s duties include training nursing home workers in areas such as abuse prevention. For example, he said, his staff often has role-playing sessions with workers to help them better handle situations that could lead to abuse.

Matson, the Alabama Nursing Home Association spokesman, said more guidance from the state would help nursing homes get a handle on the problem.

“The more Public Health can do to help us understand what to report, the better,” he said.

Capitol & statewide reporter Tim Lockette: 256-294-4193. On Twitter @TLockette_Star.

I'm the assistant metro editor for The Anniston Star. I edit, post online stories and write the occasional story.