According to the Chicago Tribune, a young woman in Arizona, woke up from surgery to hear that her doctors had performed an unauthorized pelvic exam on her. She was no longer just a patient but a victim of sexual assault. This actually happens more than anyone expects. A practice intended to teach medical students to look for cervical and vaginal abnormalities, seemingly does more harm than good to women. This could easily be avoided by simply waking and asking the women if they could examine them for the purposes of educating students.

This practice continues to happen because the controversial examinations do not seemingly get enough attention. In 2003 the American College of Obstetricians and Gynecologists went against the accepted assumption that the examination of anesthetized women was moral. Soon the Association of American Medical Colleges found that these “teaching exams” are unethical and unacceptable. From the testimonies of residents, students, legal experts, California, Hawaii, Iowa, Oregon, and Virginia have made it illegal to examine patients without their consent.

So why don’t the healthcare professionals just ask, instead of treating female patients like cadavers? Well they state that they don’t ask because women would be more inclined to say no than to agree to an examination. Which is actually not the truth, lots of women consent to pelvic exams for educational purposes. The healthcare professionals also justify the examination by stating that these examinations are appropriate after a surgical procedure.

No matter the excuse or reason, healthcare professionals need to ask women before they conduct pelvic exams. Unfortunately, it takes massive movements, like the Me Too movement, in order for something to be done about sexual assault nationwide. Healthcare professionals should just ask, and aim to heal women, not harm them.

There is a constant issue with under-staffing within nursing homes around the country especially in South Carolina. According to the New Haven Register, Connecticut is finally doing something about it.

The state has ordered that nursing homes set a minimum staffing ratio and hire an independent nurse consultant to help with resident care. The Advanced Center for Nursing and Rehabilitation was ordered to meet the safe minimum requirements due to multiple safety violations during inspection. The purpose of the nurse consultant is to evaluate staff and the care residents are receiving.

So why is Connecticut taking action? Well according to the New Haven Register, during the years of 2015-2018, Connecticut nursing homes were cited for hundreds of violations and resident injuries. There were multiple cases of neglect, broken bones, and falls. The issue isn’t that staffers don’t want to do their jobs, it’s simply that they are swamped with tasks making it impossible to provide quality care to the residents.  Due to this, there is still staff turnover within Connecticut’s nursing home facilities; and still many of them rated below average in terms of care. There have been promising improvements in Connecticut due to the new staffing minimums and independent nursing consultants. But will it be enough to improve nursing home care in Connecticut and the country?

“If Connecticut is doing better than most states, that doesn’t mean it’s doing well enough” (Cara Rosner, New Haven Register).

Understaffing is a common problem in many nursing homes. Residents in these facilities often must wait long periods to be taken to the bathroom, have their diapers changed, to be turned and repositioned to prevent pressure injuries, for call bell response, or receive assistance in being fed.  The Buffalo News recently did an analysis of staffing in nursing homes in N.Y., and discussed new legislation.

Known as “Safe Staffing,” the legislation has the support of the elder advocates, staffing experts, and nursing home employees.  The proposed bill would require nursing homes and hospitals to maintain specific minimum staffing ratios for nurses and certified nursing assistants. At present, these facilities are required only to have “sufficient” staffing levels based on the needs of the residents.

Under the bill, each nursing home’s registered nurses, licensed practical nurses and certified nursing assistants would have to spend a total of 291 minutes a day with each resident, on average or 4.51 hours per patient day (HPPD).  The minimum safe staffing is 4.1 HPPD according to previous studies. The national average is 234 minutes or 3.9 HPPD

Only 49 of the 619 nursing homes in New York State — or 8 percent — now meet the proposed law’s ratio, according to data from the federal Centers for Medicare and Medicaid Services.

Minimum staffing ratios are necessary to ensure quality health care in the region’s nursing homes because many of them have been sold to for-profit companies, said Assemblywoman Crystal D. Peoples-Stokes, D-Buffalo, a co-sponsor of the bill.

“Your bottom line becomes more important. You do things to keep your budget in order and that might not always be in the best interest of residents,” said Peoples-Stokes, who said she believes there will be increased attention to the bill in 2019. “I think it is a conflicted model to say you can have a for-profit business that delivers quality care for the people who are least able to do for themselves.”

State Sen. Timothy M. Kennedy, D-Buffalo, a co-sponsor of the bill, says minimum staffing ratios are necessary to improve the quality of care for residents and working conditions for nurses and CNAs.

I worked as an occupational therapist in nursing homes and the things I have seen with my own eyes I hope never happen again,” said Kennedy, who took aim at for-profit nursing home operators. “They cut back on staff and ultimately the care residents are getting to boost up their bottom line. The bad actors need to be called out and I think this legislation will do that.”

Helen Schaub, an official with Local 1199 of the SEIU, which represents 40,000 nursing home workers in the state, said union members face unrealistic workloads and are frustrated that they cannot provide the quality care they know residents require.

“We fundamentally believe that there is a staffing problem in nursing homes where the bulk of work is done by certified nursing assistants. If you are one person and you are trying to take care of 20 residents and responding to urgent needs, helping people go to the bathroom, then you don’t have time to turn people,” Schaub said, referring to guidelines for repositioning residents every two hours to prevent pressure sores.

In 2004, California required nurse staffing ratios for hospitals and nursing homes. In July, it increased the amount of time certified nursing assistants are required to spend with nursing home residents. Under the revisions, CNAs must provide 144 minutes of the total 210 minutes that the nursing staff  is required provide to each resident daily.

The Centers for Medicare and Medicaid started requiring nursing homes to report staffing levels based on payroll records. Last week, the centers announced it had begun sharing the payroll information with states when potential low staffing issues are spotted. States, in turn, will be required to investigate.

In general, the new payroll-based staffing data shows most facilities have somewhat fewer staff on weekends, but some facilities have significantly lower weekend staffing,” the Centers for Medicare and Medicaid said in a statement.

Michelle Spencer, who worked in Buffalo area nursing homes for 25 years as a social worker, said she decided to leave nursing home work four years ago because she could no longer take working in a high-pressure system that she considers broken. She now works for a company as a geriatric care manager that sometimes takes her back into nursing homes.

As an outsider, she said, “I see that it is still a failing and broken system,” especially when it comes to staffing levels.

And that is why Spencer thinks the state requirement of sufficient staffing levels needs to change to minimum staffing ratios.

“Adequate staffing is in the eyes of the beholder,” she said. “It’s subjective.”

The federal government plans to crack down on nursing homes with abnormally low weekend staffing by requiring more surprise inspections be done on Saturdays and Sundays.  The federal Centers for Medicare & Medicaid Services will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. CMS will identify potential violators by analyzing payroll records that nursing homes are required to submit. Those records showed much lower staffing than what facilities had admitted to inspectors during their visits.

Medicare will instruct state inspectors to focus on those potential violations during visits.

Since nurse staffing is directly related to the quality of care that residents experience, CMS is very concerned about the risk to resident health and safety that these situations may present,” the agency said in a notification to state inspection offices.

Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan, welcomed the new edict but said it was only necessary because state inspectors have not been properly enforcing the rules already on the books.

“The basic problem is the states don’t take this seriously,” Mollot said. “How many studies do we have to have, year after year, decade after decade, saying it all comes down to staffing, and there are very few citations for inadequate staffing and virtually all of them are identified as not causing any resident harm?”

 

WSPA reported on the sad state of affairs in South Carolina nursing homes.  South Carolina ranks dead last of a Wallet Hub study when it comes to resources in place to help prevent elder abuse.  According to WalletHub, one in five U.S. residents will be retirement age by 2030, meaning more aging adults will eventually need assistance and could potentially become vulnerable to care takers.  Senior Action Executive Director Andrea Smith says that nearly 5 percent of our aging population will live in a nursing home at the end of their life.

Elder abuse and neglect is a growing issue, especially in nursing homes.  Mostly as a result of short-staffing at nursing homes.  Without sufficient staff to meet the needs of the residents, the nursing homes know that residents will suffer injuries.

State Rep. Garry Smith (R) Greenville is working to introduce legislation that will make it more difficult for abusers to go from one nursing home to the next without being tracked.  Right now, South Carolina allows nursing homes to police themselves and hope they do a proper background check.

“The agencies and departments do a real good job following up on the reports, but the legislature has done a very poor job. It’s also something that we need to do to protect those who cannot protect themselves,” Rep. Smith said in a phone interview.

“Giving not only support for the seniors but for the family members that are caring for them is another important thing that we as a community really need to get our arms around. How do we support the folks that are taking care of seniors,” Smith says.

Andrea and her staff know that knowledge is power, so they teach those who visit the center how to take care of themselves, emotionally, mentally and physically.

 

 

The Buffalo News reported that New York State gave licenses to operate at least 10 Buffalo area nursing homes in the last decade to new owners who had been fined for providing poor care to residents at other nursing homes. Advocates for nursing home residents say the state must do more to prevent nursing home owners providing low-quality care from buying more long-term care facilities.

“It is a real problem with people getting ownership of facilities when they have a poor record of care in other nursing facilities,” said Toby Edelman, a senior attorney at the Center for Medicare Advocacy. “To me the biggest predictor of how a person will do is, how that person did in other facilities the person already owns?”

Sixteen of the 47 nursing homes in Erie and Niagara counties have been bought since 2007 by for-profit, out-of-town owners. Many of those homes are among the region’s worst rated.  The state allowed some of the out-of-town investors to buy more nursing homes, despite poor ratings and state and federal fines totaling at least $325,000 at ones they already operated.

For instance, in February the state allowed three new New York City area investors to become principals in the corporation that owns Comprehensive Rehabilitation and Nursing Center at Williamsville. The state knew when it approved the change that the new investors owned other nursing homes that had been fined $86,884 in the prior two years for providing poor care. It also knew the federal government was considering an additional $173,110 penalty against one of the homes for failing to protect a disabled resident from abuse.

New York City resident Israel Sherman was part of an ownership group that started the trend of out-of-town investors buying Buffalo-area nursing homes in 2007. He now has an ownership interest in six nursing homes in Erie and Niagara counties, including ones operating as part of the Absolut Care chain.

In 2011, a company owned by Sherman, his relatives and another business partner bought Niagara Rehabilitation and Nursing Center in Niagara Falls.  The state Public Health and Health Planning Council approved that purchase even though three other nursing homes in which Sherman had an ownership interest had been cited by state health investigators for four violations in 2009-2011, resulting in $30,000 in fines.

The federal government’s rating of Niagara Rehabilitation has dropped since the state approved the purchase. Niagara Rehabilitation is rated as a one-star facility, or “much below average,” the lowest possible rating. It was a two-star home when Sherman acquired his ownership interest in 2011.

“I don’t believe the Health Department is living up to its mission to protect the health and safety of New Yorkers if they permit the operators of low-performing and dangerous nursing homes to acquire even more facilities,” said Mary Brennan-Taylor, a local patient safety advocate who lectures at the University at Buffalo, D’Youville College and Niagara University. “If a nursing home is not where the governor would want to have his mother go and live her final years, unsuspecting families should not have to entrust their loved ones at those facilities.”

A nursing home employee from Indiana, accused of raping an elderly dementia patient, appeared in court.  David Garcia, 35, covered his face as he was walked to court in handcuffs. Prosecutors say Garcia was a Certified Nursing Assistant at the Hanover Nursing Center. He’s accused of raping a 74-year-old woman who suffers from dementia. The victim told investigators she had sex with a man and pointed toward her groin. Garcia denied having sex with the patient, explaining away evidence investigators found on a blanket in the room. The alleged assault happened December 1.

A judge entered a not guilty plea on his behalf and appointed him a public defender. Garcia is being held on a $50,000 cash bond. The case is scheduled to go to trial in March.

Private equity firms have taken a keen interest in the skilled nursing industry over the past decade according to the Skilled Nursing News.  “It can lead to a lot of challenges down the road if you’re not investing in the business, you’re not investing in the people, and you’re not approaching it the right way,” Frank Small, chief investment officer at Greystone Healthcare Investments, told Skilled Nursing News.

After his real estate investment trust (REIT) purchased the properties associated with ManorCare’s operations earlier this year, Welltower Inc. CEO Tom DeRosa made a strikingly similar argument when describing the buildings as attractive targets for investment.

“Don’t confuse over-levered skilled nursing deals that were done by private equity groups with the operating viability of this post-acute care business platform,” DeRosa said. “Remember, post-acute care is a very viable and important component of health care delivery. Because of the leverage that private equity firms who owned these businesses put on these businesses, the operations became unsustainable.”

The problem comes from the fact that certain standard aspects of the private equity playbook — streamline operations by cutting costs, layer on high amounts of leverage, and hopefully sell for a profit — just don’t work when the end product is health care delivered to vulnerable, elderly residents. But the financing structure also has a distinct set of advantages that, experts tell Skilled Nursing News, can create real advantages when deployed properly — and with a health care-first mindset.

And with the Patient-Driven Payment Model (PDPM) taking effect next fall, private equity — with its emphasis on finding value in upheaval — will likely take up an even greater share of the marketplace in 2019 and beyond.

“Any kind of new regulatory environment is a big opportunity,” Chad Elliott, managing director of mergers and acquisitions at investment and advisory firm Lancaster Pollard, told SNN. “I expect to see private equity come in pretty big here in the next six to 12 months.”

 

 

A new report published in the Dec. 7 issue of The Gerontologist shows that in a good economy, the care at U.S. nursing homes falls because it’s harder to attract and keep staff.  For the study, the researchers examined data from 2001 through 2015, including employment statistics and state annual re-certification of all Medicare- and Medicaid-certified nursing homes (about 15,000) in the United States. The analysis revealed a link between higher unemployment rates and better quality of care at nursing homes.

“During economic downturns, many people are willing to take positions with work environments they may not prefer because there aren’t many options,” said principal investigator Sean Shenghsiu Huang. “But when the economy is good, there are plenty of employment opportunities, and taking a nursing home job may not be that attractive,” added Huang, an assistant professor at Georgetown University’s School of Nursing and Health Studies, in Washington, D.C.

The U.S. unemployment rate fell to a 49-year low in September and October, which means it could be challenging for nursing homes to maintain adequate staff levels, Huang and his colleagues said in a Georgetown news release.

During periods of high unemployment, nursing homes had better health regulation compliance [or there is less regulatory enforcement], the findings showed. Also, nursing home residents were less likely to have bedsores, be physically restrained or have significant weight loss — all measures of quality of care.

When unemployment rates were low, nursing homes had fewer staff members, higher employee turnover and lower staff retention rates, the researchers found.

Most nursing home care is provided by nurses and aides, so maintaining an adequate and stable workforce is important for delivering high-quality care, according to the study authors.  For example, high turnover of staff inhibits the ability of nursing homes to consistently assign staff to the same resident, a practice that is associated with quality care. However, nursing homes have high turnover rates. Given today’s low unemployment rates, it will be challenging to maintain or even attempt to lower the turnover rates, say the investigators.

PennLive reported their big win in Court. The Pa. Department of Health has been directed to turn over the lease agreements of nursing homes to PennLive. Nursing home operators typically submit the leases to the health department, which regulates the industry. The state Office of Open Records directed the department to release the records within 30 days. PennLive has been aiming to obtain the leases for the nursing homes formerly managed by Golden Living. PennLive sought the records as part of an investigation which found that problems persist at many of those homes, even under new management.

PennLive reporter Daniel Simmons-Ritchie initially sought the leases as part of a special investigation examining the quality of care in nursing homes.  The state Office of Open Records ruled this week that the health department must provide the leases within 30 days.

Several months ago, PennLive asked the health department for the leases of 36 nursing homes that had previously been owned by the Golden Living chain. Golden Living sold its nursing home licenses to other operators but the company still owns the properties.

The health department rejected PennLive’s request for the documents, saying the records contained confidential information. PennLive appealed to the office of open records.

In its special report published last month, PennLive’s investigation found that many homes formerly owned by Golden Living continue to offer substandard care, even under new management. PennLive has been aiming to obtain the lease agreements because they could provide more insight into the operations of the homes.

Matt Yarnell, president of the SEIU Healthcare of Pennsylvania, told Pennlive that nursing home leasing deals make it difficult for the public to understand what companies own which homes. And Yarnell said that makes it hard to know what influence those companies may be exerting behind-the-scenes. The union represents 45,000 health care workers in Pennsylvania.

I think Pennsylvanians want to know where their tax dollars are going,” Yarnell said. “We need to know the financial arrangements behind these homes.”

David Marks, a Texas-based attorney who specializes in elderly care litigation, said some nursing home companies include very strict requirements in their leases.

Marks cited a case he’s litigating that involves a major assisted living chain. That chain, like Golden Living, leases nursing homes to other operators. Marks said the chain exercises a great deal of control over the operators through its leases.

The lease agreements are pretty shocking,” Marks said. “The leaser effectively controls operations, approves the budget, receives financial forecasts and – if the financial forecast is not agreeable – has the right to modify the budget.”