Earlier this month, a New York Times story highlighted data from the Kaiser Foundation that tracked how many hours various nursing home staffers would spend with an individual resident each day. It illuminated problems with staffing in many facilities across the country.  The Tampa Bay Times reported on Florida’s nursing home staffing.  In most places across America, nursing homes are facing an acute shortage of workers to take care of the country’s growing population of aging and disabled patients. But not in Florida.

A Kaiser Family Foundation report published last month found that while most nursing homes in other states states fail to employ enough staff including nurses, Florida’s staffing levels exceeded the national average and met or exceeded industry expectations. According to Kaiser, Florida reported an average of 4.55 in total nurse hours per resident per day, which is higher than the national average of 4.05. Only Alaska, Idaho, Oregon and Utah averaged more hours than Florida.  These states show that staffing above the safe level of 4.1 can be done.

Florida faces shortages in other medical sectors. Nurses who work at five Florida hospitals owned by Hospital Corporation of America picketed last week to raise awareness about what they said were unsafe staffing ratios. The nurses demonstrated in front of Northside Hospital, St. Petersburg Hospital, Blake Medical Center in Bradenton and Doctor’s Hospital of Sarasota.

In December, the Safety Net Hospital Alliance of Florida identified another growing shortage: the number of doctors practicing in Florida is not keeping up with the state’s surging population growth. More money is needed to recruit physicians and keep them here, hospital officials say, especially in the specialty areas of urology, thoracic surgery, nephrology and ophthalmology.

In addition to these speciality services, the alliance’s report cited a “severe shortage” of primary care physicians in Southwest Florida, an area extending from Naples to Sarasota.

 

The New York Times had an incredible article titled “‘It’s Almost Like a Ghost Town.” Most Nursing Homes Overstated Staffing for Years”.  Most nursing homes had fewer nurses and caretaking staff than they had reported to the government for years, according to new federal data, bolstering the long-held suspicions of many families that staffing levels were often inadequate.  The article explains how unreliable and inaccurate the staffing numbers provided by nursing homes are because they are self-reported and not checked by regulatory agencies.  It is a disgrace.

The records reveal frequent and significant fluctuations in day-to-day staffing, with particularly large shortfalls on weekends. On the worst staffed days at an average facility, the new data show, on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.

The data, analyzed by Kaiser Health News, come from daily payroll records Medicare only recently began gathering and publishing from more than 14,000 nursing homes, as required by the Affordable Care Act of 2010. Medicare previously had been rating each facility’s staffing levels based on the homes’ own self-reported and unverified reports, allowing the industry to game the system.

The payroll records provide the strongest evidence that over the last decade, the government’s five-star rating system for nursing homes  exaggerated staffing levels and rarely identified the periods of thin staffing that were common. Medicare is now relying on the new data to evaluate staffing, but the revamped star ratings still mask the erratic levels of people working from day to day.  Of the more than 14,000 nursing homes submitting payroll records, seven in 10 had lower staffing using the new method, with a 12 percent average decrease, the data show. And as numerous studies have found, homes with lower staffing tended to have more abuse, neglect, and health code violations — another crucial measure of quality.

Nearly 1.4 million people are cared for in skilled nursing facilities in the United States. When nursing homes are short of staff, nurses and aides are unable to deliver meals, assist with feeding residents, properly clean residents, transfer residents to the bathroom and respond to alarms and call bells. Essential medical tasks such as offloading and turning and repositioning a patient to avert pressure injuries (bedsores) can be overlooked when workers are overburdened, sometimes leading to avoidable hospitalizations.

Volatility means there are gaps in care,” said David Stevenson, an associate professor of health policy at Vanderbilt University School of Medicine in Nashville, Tenn. “It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe and to eat every single day.”

In April, the government started using daily payroll reports to calculate average staffing ratings, replacing the old method, which relied on homes to report staffing for the two weeks before an inspection. The homes sometimes anticipated when an inspection would happen and could staff up before it.  The new records show that on at least one day during the last three months of 2017 — the most recent period for which data were available — a quarter of facilities reported no registered nurses at work.

Medicare’s payroll records for the nursing homes showed that there were, on average, 11 percent fewer nurses providing direct care on weekends and 8 percent fewer aides. Staffing levels fluctuated substantially during the week as well, when an aide at a typical home might have to care for as few as nine residents or as many as 14.

Vox published an interesting and informative article on the consequences of different Medicaid Expansion programs. “This provides us a unique opportunity to assess the consequences of these different policies, and new research published in Health Affairs this week is maybe the most detailed portrait yet of what happens under these various approaches.”

The Harvard researchers, led by Benjamin Sommers, surveyed people who would be eligible for Medicaid expansion in three states: Ohio, Indiana, and Kansas.

  • Ohio expanded Medicaid in 2014, using its traditional Medicaid program.
  • Indiana expanded Medicaid in 2015, using a federal waiver. It required beneficiaries to make a monthly contribution to a health savings account or they could lose certain benefits. Some enrollees could even be locked out of coverage entirely if they failed to make those payments.
  • Kansas has not yet expanded Medicaid.

This chart summarizes their findings nicely.

medicaid chart

Ohio and Indiana had higher levels of Medicaid coverage and lower uninsured rates for the expansion population than Kansas did.

In Indiana, with its cost-sharing requirements and lock-out provision, the Medicaid expansion population was substantially more likely to delay care because of its cost or to have trouble paying their medical bills compared to the same population in Ohio, which did not ask expansion enrollees to pay much out of pocket.

The unavoidable suggestion is, as the researchers wrote, that “Indiana’s waiver program led to less affordable care than Ohio’s traditional expansion of Medicaid did.”

The Harvard researchers asked a few more detailed of their Indiana respondents. They found that four in 10 Medicaid expansion eligible people had never heard of the health saving accounts they were supposed to pay money into in order to receive full coverage (including vision and dental and more generous prescription drug benefits), and 25 percent said they knew about those accounts but still didn’t contribute money.

Among the people who knew about the Medicaid health savings accounts but who weren’t making payments:

  • 30 percent said they couldn’t afford it.
  • 22 percent said they did not think the payments were worth it.
  • 19 percent said that they were confused about the accounts.

Among the uninsured in Indiana who were not enrolled in the Medicaid expansion program:

  • 30 percent said it was unaffordable.
  • 20 percent said they thought they didn’t qualify.
  • 17 percent said it was too complicated.

“Taking into account the substantial confusion about Indiana’s program and its cost-sharing requirements, it is perhaps not surprising that difficulties affording care were higher in Indiana than in Ohio, which implemented a traditional Medicaid expansion with minimal cost sharing,” the authors wrote.

Jason Lewis from Strongwell.org was kind enough to write the following guest article.

Nowadays, people are more aware than ever of the importance of nutrition, exercise, and self-care for good mental and physical health. For many older adults who grew up as part of a less health-focused generation, it can seem like they missed the boat on wellness.

However, this doesn’t have to be the case. Taking control of your health can be straightforward, and it is never too late to start doing it. No matter how old you are right now, you can benefit from implementing these practices into your routine to boost your quality of life.

 

Exercise Regularly

It’s easy to feel like your body becomes less capable of regular exercise as you grow older, but this is simply not true. According to the National Institute on Aging, people tend to lose their mobility as they age not because of a natural deterioration of the body, but because they tend to become less active. It’s up to you to take a proactive attitude toward your health and to find the workouts that fit in with your lifestyle.

Though ailments like weak joints, back pain, and poor balance are all relatively common in older adults and can limit mobility, there are many forms of exercise that can accommodate this. Focus on low-impact workouts like yoga, walking, and strength training, take it slow at first, and respect your body’s limits. You will soon find yourself stronger and more energetic, as well as less prone to anxiety.

 

Keep Your Mind Sharp

Much like preventing physical decline is a matter of keeping your body active rather an inevitable effect of aging, mental decline is also more about keeping yourself sharp. The long-accepted theory that our memory, alertness, and cognitive function is just destined to deteriorate as we get older now no longer holds true, and we are seeing evidence that a healthy lifestyle and an active mind could be the secret to staying sharp.

Consider your hobbies and how you like to spend your free time. Are you spending a lot of time doing passive activities, like watching TV? Any hobby that keeps your mind engaged is a great way to keep exercising your brain and to keep yourself in control. Some people like logic-based activities like puzzles, crosswords, and games, while others prefer creative practices like painting, crafting, and sculpting. Your golden years are a great time to reconnect with hobbies that you once loved or even try new things you’ve always been curious about.

 

Create Social Connections

Loneliness is one of the biggest health issues for seniors, many of which find themselves in old age isolated from their friends and families. According to Forbes, 20 to 30 percent of all older adults report feeling lonely, and a 2015 study positioned loneliness as a bigger factor in early mortality than obesity.

The best thing you can do for yourself is to actively combat loneliness. You can join a group based around a favorite hobby, sign up for an exercise class, or start volunteering somewhere in your local community. If you are nervous about facing these scenarios alone, there are plenty of organizations dedicated to helping you, such as A Little Help, which connects seniors with neighbors of all ages. You can also consider finding a roommate to help fight loneliness.

It’s easy to feel like your health is outside your control once you start getting older, but this isn’t the case. You still have the power to take control over your body and your mind and to help yourself live to a happy, fulfilling old age: all you have to do is stay proactive, positive, motivated, and commit to living a healthier lifestyle.

The Anderson Independent Mail reported on the sad state of care at South Carolina’s Veteran Homes. The article discusses the issues at Veterans’ Victory House,  a nursing home in Walterboro whose sign says it is the “home of the greatest generations.”   It is operated by HMR Veterans Services, Inc. HMR receives nearly $36.5 million annually from the state to operate Victory House and the Richard M. Campbell Veterans Nursing Home in Anderson County, two veterans’ nursing homes that belong to the South Carolina Department of Mental Health. The company also manages seven other homes for veterans in Texas, Alabama and Maryland.

There have been some troubling incidents at the company’s facilities.  In May, a judge approved a $425,000 settlement involving the choking related death of an Air Force veteran at the Anderson home. According to a lawsuit, a latex glove was found lodged in his airway on Christmas Eve 2015. He died five days later.

According to another pending suit, a combat veteran of the Korean War died of injuries suffered when his roommate beat him with a shoe at an HMR-managed veterans’ home in Alabama. The veteran, William Bankston, lived at the Floyd E. “Tut” Fann State Veterans Home in Huntsville almost two years before he was attacked.  Court records show that in the past four years, settlements totaling $900,000 have been reached in three other cases involving the deaths of residents at Victory House.  The largest lawsuit settlement, $525,000, came in August 2014. It involved allegations that William P. Chrisanthis fell 18 times at Victory House between Nov. 18, 2008, and July 4, 2010, when he suffered a fractured left hip. He died two weeks later.

The veterans’ nursing home HMR manages in Maryland was fined $360,875 on Dec. 2, 2016. Federal records show the fine was imposed after a resident choked to death on a peanut butter sandwich. The facility also was faulted for its care of another resident’s bed sores and for allowing dehydration to contribute to a third resident’s loss of 16 pounds in 11 days.

 The frequency of liability claims for abuse and neglect against nursing homes and the costs associated with those claims are rising nationally. According to a biased report last year commissioned by the industry lobbyist American Health Care Association, the frequency of nursing home claims increased 54 percent from 2007 to 2017. The annual costs to providers from those claims nearly doubled during the same period, going from $1,170 per occupied nursing home bed in 2007 to $2,300 in 2017.
Staffing levels at Victory House and Campbell show that the amount of time licensed nurses at both homes spend with the residents each day is below state and national averages.

Lobbyists for Iowa’s nursing home industry called federal regulators last month and thanked them for lowering fines imposed on facilities that deliver substandard patient care and neglect their residents.  Iowa Health Care Association President Brent Willett told the regulators that prior fines were too much.  This gratitude coincides with complaints from senior advocates who say the Trump administration is putting the nation’s 1.5 million nursing home residents at risk by rolling back regulations and reducing fines.  Earlier this year, 12 U.S. senators — all Democrats or Independents — formally complained to CMS that the agency appeared “intent on rolling back or delaying enforcement of regulations that are meant to keep nursing homes safe for the patients they serve.”

During the call, Willett and his colleagues “thanked” the officials at the federal Centers for Medicare and Medicaid Services for revising the assessment tool they use to calculate fines against care facilities, according to a Health Care Association memo.  That memo also states that a CMS manager noted that while Iowa was now “trending downward overall” in terms of fines, it was still was an “outlier,” regionally and nationally, for the violations being cited.

A Des Moines Register review of the penalties imposed against Iowa nursing homes shows that federal fines increased dramatically from 2012 through 2016, then plummeted immediately after Donald Trump took office as president in January 2017:

  • Between 2012 and 2016, federal fines imposed on Iowa homes grew from $113,305 to $4.6 million annually — an increase of almost 4,000 percent. The individual fines were larger, but there also were many more of them, increasing from 26 in 2012, to 120 in 2016.
  • By 2016, nursing homes in Iowa were among the worst in the nation with regard to serious, repeat-offense violations that caused actual harm or placed residents in immediate jeopardy. Only six other states — including the two most populous states, Texas and California — were cited for more violations of that kind.
  • In 2017, the first year of the Trump administration, federal fines against Iowa homes dropped by half, to $2.3 million. While the number of violations that triggered fines had increased slightly, the penalties, on average, were half what they were in 2016.
 “None of that surprises me, unfortunately,” said Toby Edelman of the nonprofit Center for Medicare Advocacy. “The current administration has been marching in complete lockstep with the industry. And, really, the first thing they did was go after the enforcement system.”

“CMS needs to focus a lot less on what the nursing home industry wants and focus a lot more on what consumers and taxpayers want,” said John Hale, a consultant and Iowa advocate for the elderly. “Right now, it’s a horribly lopsided conversation, resulting in lopsided results that go in the industry’s favor.”

Seventeen state attorneys general, including Tom Miller of Iowa, have also objected to administration’s new approach to regulation, arguing the changes “threaten the mental and physical security of some of the most vulnerable residents of our states” and represent “an abuse of federal law.”

In the AHCA’s 2017 annual report to members, the organization boasted that it is a “powerful political voice” and pointed out that it has “worked closely with CMS to gain regulatory relief” and succeeded in having CMS curtail its use of large “daily fines” it once imposed for each day a nursing home failed to meet minimum standards of care.

Dean Lerner, the former director of the state agency that inspects Iowa nursing homes, stated “Iowans are put in harm’s way. Health, safety, and welfare of Iowa’s vulnerable seniors take a backseat to industry profits and interests.”

CMS is also discouraging its regional offices from fining nursing homes for serious, one-time errors — as opposed to ongoing, systemic issues or deliberate attempts to injure people — even if they contribute to a death.

At the industry’s request, CMS has also put a hold on fines for violations of eight new safety regulations, and relaxed a proposed Obama-era rule that would have required every nursing home to have a grievance officer that could handle complaints from residents and family members.

All of these regulatory changes coincide with new federal funding formulas and tax breaks the Trump administration says will save nursing homes $2 billion over the next decade and generate an additional $850 million in revenue for them this year alone.

“The nursing home message to state and federal government officials is a simple one,“ Hale said. “It is, ‘Give us more taxpayer money and leave us alone.’ That’s exactly what’s happening. They get more tax dollars flowing to them while the accountability for good use of these dollars becomes less and less.”

The Des Moines Register reported the shocking decision of Clayton County prosecutors who are asking an Iowa judge to dismiss all charges against two Iowa nurses caught on video neglecting an elderly nursing home resident.  Iowa, unlike several states, doesn’t expressly guarantee nursing home residents the right to use cameras and electronic monitoring to collect evidence of poor care.

Last year, the family of Cheryll Scherf grew concerned about the care she was receiving at the Elkader Care Center and installed a motion-activated camera in her room.  In March 2017, the “nanny cam” captured video evidence of workers repeatedly leaving Scherf in bed, naked from the waist down, with the door to the room left open.  The video also showed that while no nurses entered Scherf’s room for more than 17 hours, the staff wrote in her file that they tended to her needs during that time and administered physician-ordered medications.

The caregivers were criminally charged with wanton neglect, dependent adult abuse and tampering with medical records.  Now, Clayton County Attorney Alan Heavens is asking the court to dismiss the charges against the caregivers.

One of Scherf’s attorneys, Pressley Henningsen, said it’s his understanding that the Elkader Care Center is now asking residents to sign forms agreeing not to record their interactions with the staff.  “These videos show what they show,” Henningsen said. “They show what did happen, and what didn’t happen. They’re videos. And yet now this home is asking people not to record them.”

The states of Texas, New Mexico, Washington, Illinois, Maryland and Oklahoma expressly allow nursing home residents to install surveillance cameras in their own rooms, provided their roommates agree. Most state legislatures, including South Carolina’s, have not addressed the issue.

CNN had an article titled “The darker side of living to 100” which examined the costs associated with extreme ageing. The morbidities and infirmities that the extremely aged suffer are not so much ignored as abandoned to the efforts of medical services and social care.

“In Denmark, one of the few national surveys of nonagenerians was conducted around the turn of this century. The researchers found that the majority contacted had some disability and that women were more often affected than men. The same researchers also observed that “about 10% of the octogenarians and more than 55% of the centenarians live in nursing homes, while dependency rises from approximately 30% to 70%, and the prevalence of dementia rises from approximately 7% to 50%”.

Estimates suggest that chronic pain “in people aged 85 years or older is common”, affecting the majority of people from this age group.

In 2017, an 85 year-old woman was assaulted by a staff member at The Poplars nursing home in North Epping, Sydney. All if this was captured in a video which shows the 59 year-old Dana Maree Gray pulling off the woman robe, hitting her with her hand repeatedly and then taking a full garbage bag and attacking her with that. The assault continued with Gray pulling the elderly woman’s hair and dragging her body back and forth, and when she finally left the room, Gray left the bed in such a position that she was unable to properly sit or lie down. The video of the attack was shown to the court and it was found to be so disturbing that the magistrate would not release it to the public.

It should be noted that the elderly woman also had dementia, and though it was clearly evidenced through the video how horribly she was treated, she could not tell the story herself on account of being unable to remember.

Gray and her lawyers asked that her case be heard under the Mental Health Act in Australia, which could have helped make allowances for her behavior by siting a mental health problem as the cause of the even. But the magistrate refused to use the Mental Health Act, saying that would turn the attention away from the defendant’s gross conduct and allow the blame to be set away from her actions.

These cases don’t just happen in South Carolina, and they don’t just happen in the U.S. Across the world, the elderly are vulnerable to abuse and neglect at the hands of malicious workers who choose to hurt them instead of help in addition to corporations and systems which allow this kind of behavior or endorse neglect through understaffing and underfunding their own facilities.

William Strasner, a nursing home resident who was allowed to fall to his death after trying to climb down a makeshift rope from a third-floor window at Emerald South Nursing and Rehabilitation Center in Buffalo.  Patient windows normally don’t open more than 7 inches but a device used to secure Strasner’s window was apparently missing.  Where the heck were the staff?

Police say they believe Strasner was not being supervised when trying to leave the facility down a rope made from bedding and clothing he’d tied together when he fell more than 30 feet.  An employee found him. He died on the way to the hospital.

This incident is the second death at the nursing home in two years. In 2016, Ruth Murray was fatally beaten by a dementia patient.