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Dangerous settings
Rhode Island's aging population represents big bucks for the assisted-living industry. But some elderly residents face hazards because of greed, limited oversight, and a lack of public understanding
BY STEVEN STYCOS

Illustration by Mark Reusch

In May, the state Department of Health determined that 19 residents at the Village at Hillsgrove in Warwick -- including an incontinent 85-year-old woman who smears feces in her hair -- had medical conditions too severe to be handled by an assisted-living facility.

In February, the health department's inspector discovered a confused 93-year-old woman at St. Francis House in Woonsocket. Although it was 10 a.m., the woman was wearing only a brief and urine was on the floor of her room. According to the staff, she was once found in the shower at 3 a.m. This woman was also found to be improperly placed in assisted-living.

In January, the health department determined that six people at Bay Spring Village in Barrington were too incapacitated to be in an assisted-living facility. One was an elderly man with Alzheimer's who hit a female resident three times over a three-month period and once went in her shower while wearing his shorts.

Advocates point to these kinds of instances in describing how senior citizens are increasingly at risk in assisted-living residences. The problem is worsened, they add, by weak state regulations, the lust of some owners for higher profits, and because family members and doctors don't understand the limitations of assisted-living facilities.

Some of the facilities "run very legitimately," says Roberta Hawkins, executive director of the Alliance for Better Long Term Care. "There are some that provide very good services." In fact, 14 of the 69 assisted living facilities in Rhode Island were found problem-free during their most recent inspection by the health department. At the same time, Hawkins lambastes the management of some facilities for manipulating the elderly to maximize their profits.

Even Robert Henry, spokesman for the Rhode Island Assisted Living Association, an industry group, says the improper placement of frail seniors in assisted-living "is a concern," although he contends the situation has been overstated.

With the number of Rhode Islanders who are over the age of 85 growing by 30 percent in the last 10 years, according to the US Census, the assisted-living business is booming. A decade ago, only 716 Rhode Islanders dwelled in assisted-living facilities. Now, according to the health department, there are 3350. During the same 10-year period, the number of elderly people in nursing homes has remained stable, at about 10,000.

For people who are too infirm to live alone, but not sick enough for a nursing home, assisted-living can provide support, independence, and privacy in a pleasant setting. Because nursing homes are viewed as the last step before death, sending a loved one to an assisted-living facility also helps family members to avoid the guilt of not keeping a relative at home. The attractions of assisted-living, however, can lead to the misplacement of frail or demented elders who need medical services.

"Where do you want to send Mom?" asks Wayne Farrington, chief of the health department's Division of Facilities Regulation, as he describes the lure of assisted living. "The middle of Central Falls [to Carties Health Center, a nursing home] or up to a nice little lake up in Smithfield [to the Village at Waterman Lake, an assisted-living facility]?"

Although family members and some doctors assume that the two types of facilities are similar, they are not. As health-care facilities, nursing homes are required to have a registered nurse on duty at all times, with other nurses and certified nursing assistants (CNAs) working under her supervision. Assisted-living facilities are required to have just a monthly visit by a nurse, so skilled care is usually unavailable if a resident becomes sick. Nurses and CNAs at nursing homes will also notice changes in patients that require a doctor's attention, Hawkins notes, but untrained staff at an assisted-living facility may not.

Some assisted-living facilities have nurses on regular duty, Farrington notes, but state regulations bar them from providing health-care there. Other assisted-living facilities try to skirt that rule, the state official adds, by saying they provide "personal care," not health-care.

Assisted-living is cheaper, typically costing two-thirds as much as a nursing home, Henry estimates. Prices vary, depending on which personal care services -- such as help with bathing, dressing, and walking down to dinner -- are provided. Some assisted-living residences charge as much as $5000 a month and must be very profitable, Farrington suggests, because, by comparison, Medicaid pays nursing homes about $3300 a month for providing health-care as well as room and board.

Understaffing is also a problem at some assisted-living facilities. Residents of Bay Spring Village certainly didn't get quick responses when they called for help, according to the facility's January inspection report. Interviews with five residents wearing "call buttons" around their necks revealed that they wait 30-45 minutes for assistance after pushing the button. "If people have health-care needs," summarizes Farrington, "they shouldn't be looking to assisted-living."

Nevertheless, Farrington says, some assisted-living facilities "are taking on people that are well beyond their ability to take care of and it has been disastrous."

Unfortunately, the health department is poorly equipped to catch mistakes and abuses. Gail Hebert, the lone full-time inspector of assisted-living facilities, hustles to conduct a surprise inspection once in two years at every assisted-living facility in the state. In contrast, 22 nursing home inspectors, working in teams of four, inspect Rhode Island's 101 nursing homes at least four times each year.

In addition, the state regulations for assisted-living are much less strict than federal nursing home rules. A Phoenix review of inspection reports found that Hebert often cites the same assisted-living facilities for the same problems year after year. Under federal law, the health department has fined Rhode Island nursing homes $362,722 since 1995 for substandard care. But the department cannot fine assisted-living facilities. State law enables Farrington to use only the maximum penalty -- the closing of an establishment -- to sanction an assisted-living facility.

A committee of regulators, assisted-living owners, and advocates for patients is reviewing regulation of the industry. Working as a sub-committee of Lieutenant Governor Charles Fogarty's Long-Term Care Coordinating Council, the work group is drafting legislation for the next session of the General Assembly. Although the proposal has yet to be drafted, Maureen Maigret, chairwoman of the subcommittee, predicts, "I think it will be a comprehensive revision."

MISHANDLED MEDICATIONS are a major problem area for some assisted-living facilities. At a September meeting of the working group, Farrington related the story of an elderly resident of the Pavilion at the Summit who was given an anti-depressant for three weeks instead of the antibiotic prescribed by the doctor. According to the inspection report, the two medications have similar sounding names and a nurse failed to check the drug against the doctor's prescription when it arrived from the pharmacy.

Other problems with drugs, including unsecured storage and incomplete orders from doctors, are regularly noted in Hebert's inspection reports.

Drugs were certainly out of control when Hebert inspected North Side Manor in North Providence in September. Of the medical records she examined for 16 residents, none included physicians' orders for medications. More than paperwork was missing, however. One resident did not receive her daily dose of the seizure medication Dilantin for two weeks and then suffered a seizure. A doctor doubled another patient's thyroid medication from 150 micrograms once a day to 100 micrograms three times a day, but records indicate that she continued to receive the 100-microgram pill just once a day. According to Hebert's report, administrator Angela Squillante confirmed both errors.

Pharmacy records for two other North Side residents indicate that their anti-psychotic drug supply had run out for two weeks, but patient records stated the drug was given regularly during that period.

Drug control problems have happened before at North Side. In June 1999, the facility was cited for inadequate records and the handling of medication by uncertified personnel. A follow-up inspection in January 2001 indicated that three patients' medications were not accounted for, including 10 pills of Oxycodone, a Vicodin-like painkiller and a popular street drug.

Drug problems are also present at other facilities, according to inspection reports. In October 2000, for example, officials at Bay Spring concluded that a resident with Alzheimer's disease and a history of severe and major depression was capable of taking her own medication. Twenty-two days later, she was sent to Butler Hospital for a "severe overdose."

Some assisted-living facilities repeatedly cut the same corners. Since 1999, the health department has forced the sale or closure of eight facilities for severe violations of state regulations, but short of that extraordinary action, regulators can only point out violations, ask for a plan of correction, and hope the situation improves.

Sometimes this approach doesn't work.

In June 2001, health department inspector Hebert found a resident with a walker and a wheelchair living at Beechwood Senior Living in Central Falls in a room only six feet and five inches wide. State regulations require an eight-foot width. Beechwood administrator and part owner Diana Lozowski responded by noting the resident was moved to a new room and added, "This is no longer a bed room."

But when Hebert returned in August, she found the tiny room was being used again. This time, Lozowski explained, she had temporarily placed a new resident in the closet-like quarters. "Time went on and we never moved her," she admitted in a written response to Hebert's inspection report.

Although assisted-living facilities are supposed to have at least one staff member on duty at all times, Herbert discovered that Warren Manor I's night shift worker slept on the job. She cited the Johnston assisted-living facility for that offense in November 2000, and again in January 2001. She doggedly returned in March, only to again hear reports of sleeping by the night staffer.

And there are other problems. At Warren Manor I, the food was lousy. In November 2000, the facility was cited for serving reconstituted Cremora instead of milk, and Kool-Aid instead of fruit juice. They also offered fruit only twice during a three-week period, and vegetables were served only once on 12 days during the same period, instead of the three to five times a day recommended by nutritionists.

Other homes, including The Pavilion at the Summit in Providence, North Side, and Beechwood, failed to perform criminal background checks on their entire staff, as required by law. Still others are citied for not conducting an initial assessment of residents' needs and failing to develop the resident service plans required by law.

THE MOST SERIOUS problem, says Farrington, is the lack of understanding among doctors and the general public about what kind of residents are appropriate for assisted-living facilities. Combined with the greed of some owners, ignorance of the limitations of assisted-living can put frail elderly people in dangerous living situations.

Last November, Hebert found that a woman placed her demented and "extremely" confused grandmother at Blackstone Valley Assisted Living in Central Falls, despite advice from both a doctor and social worker that she needed nursing home care. Blackstone agreed on the need for the woman to be moved.

In April, Hebert found three residents at The Carriage House at the Elms in Westerly were too demented and disoriented for assisted-living and "in need of ongoing nursing monitoring, assessment, care plan development and plan implementation, which is beyond the level of service for which this facility is licensed."

Backed by the resident's doctors, the Elms disagreed. In a letter, the relatives of one woman -- who was found by Hebert to be incontinent, with a leg ulcer and gastrointestinal bleeding -- also urged that she be kept at the Elms because she was happy and the residence "is an extremely pleasant environment with open space and natural light and charming furniture (and stuffed animals, which she enjoys very much)."

The Elms cases have not yet been resolved, says Hebert, but the health department has prevailed in similar cases in the past. The Pavilion at the Summit in Providence took a different approach when 12 of the 35 residents reviewed by Hebert were found too ill to be in assisted-living. Administrator Lisa Kerzner-Sirois petitioned the health department to have 18 assisted living beds changed into independent living and then notified relatives that care would be provided by the Pavilion's home health-care agency. Hawkins calls the maneuver "a shell game," but Farrington says it is legal.

Money certainly has a major role in disagreements over whether people are too sick to stay in assisted-living. "The industry is probably a little over-built," observes industry spokesman Henry, "so there is competition. There's pressure to keep someone as long as you can."

Farrington agrees. During their monthly assessments of residents, nurses are under "tremendous economic pressure," to leave them in assisted-living, he says. Recommending transfer to a nursing home means a loss of income for the nurse's employer, Farrington explains, and could endanger the nurse's job.

By attracting the fittest elderly and keeping them as long as they can, assisted-living also skims the easiest to care for seniors and leaves the sickest for nursing homes. "The nursing homes are winding up with heavier, and heavier, and heavier care people," agrees Alfred Santos, spokesman for the Rhode Island Health Care Association, a nursing home industry group. "We're winding up with the kind of people who used to end up in hospitals years ago." Two nursing home administrators, who requested anonymity, add that their industry hasn't taken a stronger position on the competitive threat of assisted-living because nursing homes depend on the assisted-living facilities for patient referrals and since some nursing home owners also own assisted-living facilities.

At present, the future of the state's assisted living industry remains in the hands of Maigret's work group. Discussions have focused on allowing assisted-living facilities to provide limited health-care, she says, and setting new minimum staff and training rules. Additional requirements will also probably be proposed for assisted-living facilities serving demented or mentally ill seniors. Henry supports this general direction, but Santos says assisted-living facilities should not be permitted to provide nursing home care under a different name.

Giving the health department the power to fine assisted-living residences that regularly violate state regulations hasn't been discussed. Fines are not necessarily effective, Farrington explains, because they do not come out of the pocket of the person responsible for the problem. "If fines come out of the operating costs of facilities," he says, "the residents may have less staff taking care of them and hot dogs three times a week."

More important than penalties, he says, is ensuring that residents aren't endangered at assisted-living facilities. The work group will recommend hiring at least one more full-time assisted-living facility inspector, Maigret says, and she needs to be a nurse. That will require more state funds, Maigret adds, and possibly raising the cap on the number of health department employees established in the early '90s by then-Governor Bruce Sundlun.

The proposed legislation will also include requirements that assisted-living facilities provide comprehensive disclosure agreements that describe fees, which services will be provided, and what medical conditions will force a resident to move, Maigret predicts.

Agreeing with patient advocate Hawkins, Santos says government oversight is essential to protect elderly residents of institutions. "If [people] have medical problems," he says, "they need the oversight provided by state and federal regulations."

Issue Date: December 21 - 27, 2001