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