Who is caring for our elders?

Staffing shortages and funding plague local nursing homes, and it is our older family members that suffer

BY TRACY IDELL HAMILTON

Cindy Osgood’s mother, who suffers from Alzheimer’s, lost 200 pounds in one year at a nursing home in Anaheim.

"The plastic utensils were wrapped up," Osgood said. "Too often, no one bothered to unwrap them for her."

Osgood, who would drive from the Central Coast as often as she could to see her mother, found the conditions unacceptable. She moved her mother up to Danish Care Center in Atascadero.

But she still couldn’t rest after what she’d seen in the home in Anaheim, so she volunteered with the county’s long-term ombudsman’s office to make unannounced visits to the county’s homes.

"The nursing homes here are 110 percent better than they are in Los Angeles," Osgood said. "But they still have a long long way to go."

Whether as a family member visiting her mother at Danish, or as a volunteer at other homes, Osgood said she regularly sees evidence of poor care: call buttons that have fallen to the floor where patients can’t reach them, calls that go unanswered for long periods of time, residents parked in hallways for hours, undergarments and diapers not changed, faces not kept clean of food or drool.

She thinks much of the neglect comes from severe short-staffing, and an almost constant turnover. "It’s because they don’t pay them anything!" she said. "And the workload is ridiculous. I’ve seen three nurses aides caring for sixty patients."

As Rep. Lois Capps heads off across the country in a van tour to bolster support for her Nurse Reinvestment Act, nursing homes in SLO County and around the state are struggling to find enough certified nurses aides, causing what one nursing home advocacy coalition has dubbed in it’s latest report, "A Crisis of Care."

The report, issued by Fix Nursing Homes Now!, a coalition of consumers, health care and senior advocates, and elected officials found, after an analysis of annual inspections by the Department of Health Services in 1999, that of the 25 nursing homes in SLO, Santa Barbara and Ventura counties, only 4 percent were in "full or substantial" compliance with federal residential care standards.

Of the other 96 percent, 40 percent of those had care violations resulting in direct harm to residents, and the rest had violations which could have caused actual harm.

Violations included administering unnecessary drugs, unwarranted use of physical restraints, failure to prevent infections, and failure to maintain adequate nutrition.

According to the coalition, many of these violations can be traced directly back to inadequate staffing levels.

Another recent report, this one by the Department of Health Services itself, found that at least 30 percent of homes statewide are not reaching minimally-mandated staffing levels.

Those shortages mean even more work for already overworked, and poorly paid Certified Nurses Assistants, or CNAs, said a spokeswoman for Fix Nursing Homes Now!, which collaborated on the report with the Service Employees International Union. Higher patient loads mean less time with any individual resident–less time for bathing, feeding, turning, or just plain interacting with them.

Nursing home administrators say they would love to increase staffing levels, but they cannot find enough qualified CNAs. In an attempt to attract qualified workers, many homes run their own certification classes, and offer all manner of bonuses in their attempts to hire more potential CNAs.

"There are no unemployed CNAs in the county," said Matthew Lysobey, administrator for Woodside Nursing and Rehabilitation in SLO. "It’s a difficult time in this industry. We’re under a lot of scrutiny right now, and the public perception is not very good."

That perception makes it even more difficult to recruit, said Bryan Roldan, administrator for Cabrillo Care Center, also in SLO. "Skilled nursing facilities have really been demonized," he said, making it tougher to sell them as attractive places to work. Nursing homes must also compete with other skilled care facilities, hospitals and doctors’ offices, all which may pay higher, and have a less stressful workload, Roldan said.

Administrators also say that the amount of money they receive to care for residents (the state pays for roughly two-thirds of nursing home residents through MediCal), is rarely enough to pay for the actual cost of care.

Those complaints have led to increases in state and federal funds to nursing homes to the tune of about $470 million in the last two years, with much of that funding earmarked for increased wages.

But according to several published news reports, a substantial number of workers never saw those raises.

In response to both monetary and staffing concerns, the state Legislature is currently debating a bill that would raise the number of hours per day a resident should have contact with a caregiver from 3.2 to 4.13, change the current method of measuring that time to a straight staff-to-patient ratio formula, and hold nursing homes more accountable for the federal and state money they receive.

AB 1075 passed the Assembly 47-24 in June, and began debate in the Senate Health Committee on July 11. Nursing home reform advocates said they will have a better idea how the bill might fare after a meeting with Health Committee leader Sen. Richard Polanco.

"But we’re hopeful," said Diane Edwardson of Fix Nursing Homes Now!

Edwardson said the current way nursing homes measure staff time with residents is tough to verify. State law mandates 3.2 hours of staff time per patient per day. That level is already higher than the federal minimum, but nursing home advocates say it’s not enough. They point to studies that recommend 4.13 hours per patient per day.

AB 1075, introduced by Assemblyman Kevin Shelley, wouldn’t measure staff time with residents by hours per day, however. The bill calls for a straight staff-to-patient ratio of one CNA to five patients during the day, 10 during the evening, and 15 at night.

Requiring a ratio instead of the old method of hours per patient per day, lawmakers and advocates hope to make it easier for family members, inspectors, and residents to tell whether a home is meeting the minimum standard.

The Department of Health Services, in its study that found staffing shortages in 30 percent of homes statewide, stopped short of backing higher staffing ratios, saying there was not enough empirical evidence to prove more staff meant better care.

Pat McGinnis, executive director for California Advocates for Nursing Home Reform, scoffs at the notion that increased staff doesn’t mean higher quality of care. "I think anyone who has ever been in a nursing home knows that more staff you have the more likely you are to get quality of care," she said. "Do we really need one more study to tell us this? We’ve been studying it for 20 years."

Numerous studies do back up her claim, including one from the National Academy of Sciences Institute of Medicine which found, in 1996, that "the relationship between nurse staffing and the quality of patient care has been clearly established for the nation’s nursing homes."

The Institute concluded that inadequate levels of CNAs increased risk of medical complications, resident discomfort, and psychological deprivation. Another study, prepared for state Rep. Henry A. Waxman, concluded that chronic staff shortages lead to a variety of quality of care problems, including failure to adequately treat and prevent pressure sores, which is the most frequently cited violation causing actual harm statewide.

Increased staffing ratios sounds great to Cabrillo’s Roldan, but he wonders where this increased staff will come from.

"I think we’d all like the maximum number of staff," he said. "People [in the industry] don’t want to staff at minimum levels. No one wants that reputation, to be in the headlines. But you can legislate all you want, and if there are not CNAs or RNs to hire, there just aren’t."

Advocacy groups have argued for professionalizing CNAs and requiring more training, while paying higher wages and improving working conditions by lowering patient loads. Right now, it takes 60 hours of classroom training and 100 hours of on-the-job training to become a CNA. By contrast, it takes 1400 hours of training to be licensed as a manicurist in the state of California.

The median wage for CNAs statewide is $8.57 an hour–that’s $17,826 annually. And while most full-time CNAs in SLO County receive benefits, many in the state do not.

"We need to pay people more, to provide incentives for them to move up," said McGinnis. She also takes issue with administrators who say they cannot find enough qualified help. "They can find them, they just can’t keep them," she said. Poor pay and demanding working conditions contribute to a turnover rate of 100 percent in nearly a third of the state’s homes, according to the Crisis of Care report.

Lysobey agrees that CNAs ought to be paid better, with more training and lower work loads. But he wonders where that money will come from. Lysobey says that our society is going to need to decide whether it wants to adequately fund what it really costs to take good care of our elderly. If it is a priority, he said, we must, as a nation, set aside funds to do so.

He said that far from rolling in profits, many health care companies that own nursing homes are barely breaking even, that the money they take in from private insurance, MediCal, and MediCare is barely enough for companies to stay afloat.

McGinnis and others argue that for-profit companies benefit from lower staffing levels, because it keeps costs down. "We need to create incentives for them to staff at maximum levels," she said.

Lysobey took great umbrage at the suggestion that a corporation would intentionally staff down to increase profits. "People who are in this industry aren’t in it for profits," he said. "If they’re in this industry, they’re committed to this population. My name is on the license here. Not just the company, but me. I am personally liable. I can tell you that ethically and morally, people just aren’t short-staffing to increase profits."

McGinnis is not so sure. She noted that larger corporations like Beverly Health Care have had to pay back millions in Medicare fraud. "There’s no financial crisis," she said. "Corporations, when they got money from Medicare, they didn’t invest it into nursing homes, or increase CNA pay, they bought more companies."

She said even Capps’ Nurses Reinvestment Act, which would do things like increase public service announcements about the nursing profession, establish nursing recruitment grants, and establish a national nursing corp, is not the way to go.

Pure and simply, they just need to be paid better, she said, with better working conditions. Nursing is a lot like the teaching profession, she noted–the pay is low, the scrutiny is high. Many nurses who have left the profession blame the managed health care movement for increasing work loads and keeping pay stagnant.

While the Legislature allocated millions for the specific purpose of increasing pay and benefits for nursing home workers over the past two years, many of those workers have not received raises.

According to the Sacramento Bee, more than $1.6 million in wage increases for care workers never made it to their paychecks. A recent audit by the Department of Health Services found that as many as 30 percent of California nursing homes may not have passed along the pay increases. The audit is ongoing.

Advocates of AB 1075 say the bill would hold nursing homes more accountable for state and federal funds it receives in the future, to make sure they’re used for care and wages, not increased profits.

Increased accountability is something Geraldine E. Champion would like to see. Champion practices elder law and estate planning in SLO. She’s also a nursing home consultant and advocate.

The nursing homes in the area have improved greatly over the last several years, Champion said. But more legislation can only do so much, she said. Continued accountability is key, but not necessarily from state or federal regulators.

Family is the key to quality care, Champion said.

"I don’t care what law is in place, if family members are not taking the time to drop in on their loved one, or drop in unannounced on the facility," they are shirking their duty, Champion said. "Quality of care is also based on family input."

Champion said she would feel comfortable putting her mother in any home in the county, because she would take the time to make sure her mother was getting the best care possible, through unannounced visits and inspections of the home.

When family members do have complaints or concerns about a facility or practice, and they are getting no satisfaction from a home, there is somewhere they can turn before calling a lawyer.

Karen Jones is the county’s long-term care ombudsman. "We’re here to promote the highest quality of life," for those in long-term care facilities, Jones said. Volunteers from her office, such as Osgood, make unannounced visits, as well as turning over complaints to the Department of Health Services, which licenses nursing homes. "We get calls from a lot of sources," with concerns about possible care violations, she said. People can call their office at 772-3059 with concerns.

Osgood, as a family member of a resident, said she agrees with Champion that family members can make sure their loved one is getting the best care possible by visiting, but she warns that family members can’t do it alone. Staffing ratios must improve, she said, and the way to do that is by better pay, and less onerous workloads. "I see these people running like chickens with their heads cut off," Osgood said. "And it means patients are not getting treated like people."

Overworked CNAs are something Jones said she sees all too frequently, also. "Sometimes, we’ll visit, and things will just be a disaster," she said. "Other times, the staff is just handling everything beautifully. They are such a dedicated population."

Like Lysobey, Jones thinks nursing home problems go beyond a CNA shortage, and will require greater support from society as a whole. Nursing homes scare people, Jones said, and they don’t like to think about them. But many, many people will spend at least a portion of their lives in a nursing home or other skilled care facility. "These are not just places people go to die," Jones said. "We’d better, as a society, start supporting them adequately."

Staff writer Tracy Hamilton may be reached at [email protected]