On a good day, Olga Vasquez would dress up in the morning, apply makeup
and stand in the hallway at her Hialeah Gardens nursing home, helping
other residents get in and out of wheelchairs or offering unsolicited
advice. On a bad day, her depression got the best of her and she would
remain in bed in her nightgown.
May 31, 2012, was a very bad day.
Vasquez — who hadn't seen a psychiatrist in weeks despite instructions
to the contrary — hoisted herself out of the window of Room 310, and
hurled herself to the concrete courtyard 39.4 feet below.
This is the type of thing you might want to know about before your mom,
dad or spouse moves into a nursing home. And such documented events
were readily available on the website of state health regulators.
They aren't anymore — part of the latest erosion in what is supposed to be ready access to public records in Florida.
A little under three months ago, the state scrubbed its website. No
longer can you go online and view the 83-page report that found
Vasquez's death to be the result of misconduct and that determined other
residents of Signature Healthcare of Waterford were in "immediate
jeopardy."
The document can still be obtained from the state Agency for Health
Care Aministration, although you have to know what to ask for and whom
to ask — and you may be required to pay and wait.
Online, AHCA now
refers consumers to a separate website managed by the federal Centers
for Medicare and Medicaid Services, though that site does not include as
much material as the state previously provided. AHCA does maintain
spreadsheets online that rate homes on a host of criteria, and allow
consumers to compare.
For many years, AHCA's website included links to inspections of nursing
homes, retirement homes and hospitals. They were available with a few
keystrokes with very few redactions. The agency then began to heavily
redact the reports — eliminating words such as "room" and "CPR" and
"bruises" and "pain" — and rendering the inspections difficult to
interpret for families trying to gauge whether a facility is suitable
for a loved one. AHCA says the redactions were necessary to protect
medical privacy, though patients were identified only by number. Vasquez
was "Resident 239."
In the past year, the state spent $22,000 for redaction software that
automatically blacks out words the agency says must be shielded from the
public. Those same words were available on a federal website
unredacted. Elder and open-government advocates said the newly censored
detail did more to protect the homes than patients.
In September, 13 frail elders died miserable deaths at the
Rehabilitation Center at Hollywood Hills in the sweltering aftermath of
Hurricane Irma, which knocked out the home's cooling system. The Miami
Herald and other media wrote extensively about Hollywood Hills'
troubling regulatory history. And the Herald also reported on AHCA's
decision to heavily redact reports.
Soon after, with no announcement or notice, AHCA wiped its website
clean of all nursing home inspections, shielding the industry to the
detriment of consumers.
"I'm just stunned," said Barbara A. Petersen, who is the president of
the First Amendment Foundation in Tallahassee, an open-government group.
"Government serves the people. They are doing a disservice, and one
with potentially grave consequences."
In recent weeks, Petersen needed to find a nursing home for her
96-year-old father in Colorado. The assisted living facility where he
lived had become inappropriate, and Petersen had only 48 hours to move
him.
"If I was in that situation here, and I had to do that without the
information that used to be online, I'd have to submit a public records
request for it. And, as we know, it takes a long time for them to
produce public records. Meanwhile, I'd be stuck with the hardest
decision I've ever made in my life without any information."
"We put a tremendous amount of trust in these homes, and we need to
make the best decisions for our families. Honestly, this makes no
sense," Petersen added.
A spokeswoman for the healthcare agency said both AHCA's website and
the federal site at Medicare.gov allow consumers to compare homes along a
range of indicators, including quality of life, nutrition, dignity and
abuse.
"AHCA goes above and beyond Florida law in the amount of information we
make available online," said spokeswoman Mallory McManus. "AHCA's
website www.FloridaHealthFinder.gov allows consumers to compare nursing
homes by their inspection rating. Consumers can search by county, Zip
code and even by services offered at every nursing home in Florida. This
gives families more information to make informed healthcare decisions
for their loved ones."
"In fact," McManus added, "in 2016 FloridaHealthFinder.gov won a
Digital Government Achievement Award from the Center for Digital
Government in the "Government-to-citizen State and Federal government"
category, showing that Florida is a leader in getting information about
healthcare facilities to consumers. FloridaHealthFinder.gov is an
excellent tool for consumers, and a national leader in transparency."
The award was given before the state removed nursing home inspections from AHCA's site.
The Herald was unable to speak with administrators at the Hialeah
Gardens home. Representatives from the corporate Signature HealthCARE
did not return requests for comment. McManus said health regulators
removed the "immediate jeopardy" label from the nursing home days after
Vasquez's death after administrators demonstrated they had improved the
home's safety. "Our Agency expected quick action to remove the potential
risk to others. During a revisit on July 5 [2012], it was determined
that the facility had implemented measures that removed the threat of
serious risk to patients," McManus said.
"Our Agency held this facility accountable, and all deficiencies were corrected," McManus said.
The home's plan of correction included a long list of actions
administrators took to improve safety, including a comprehensive review
of all residents' medical records, new policies to ensure doctors'
orders are carried out, better monitoring of the symptoms of psychiatric
patients, and an audit of records for all patients on mental health
drugs to "ensure that they were seen by the psychiatrist as ordered."
Though reports on Vasquez's death are no longer available on AHCA's
website — or that of the federal Medicare program — a copy of the
inspection obtained by the Herald is heavily redacted. The words
"neglect" and "abuse," for example, are removed from one of the report's
findings — and the definition of abuse from the Florida statutes is
redacted.
A separate 50-page AHCA report on the same incident recites a portion
of Florida law: "[Redacted] means any willful act or [redacted] act by a
caregiver that causes or is likely to cause significant [redacted] to a
[redacted] adult's physical, [redacted] or emotional health. [Redacted]
includes acts and omissions." The portion is drawn directly from the
state's elder abuse law, a public record, and is the definition of
abuse.
AHCA's move is far from the only restriction in what records the public
can see. The Herald wrote about an emergency management plan from the
Hollywood Hills rehab center that was filed with — and approved by —
Broward County, which included portions that were copied and pasted from
a prior year, and failed to say how residents would be kept cool during
a power outage. Broward and Palm Beach counties then refused to release
any plans, though both had originally said they were public record.
Miami-Dade released 54 plans, all heavily redacted.
Vasquez, who migrated to Florida from Cuba, first began to suffer from
depression about a decade before her death, when her husband died,
relatives told the Miami-Dade Medical Examiner's Office. "Due to her
depression, she was placed in" the nursing home, the report said. In
addition to depression, Vasquez also was diagnosed with anxiety, chronic
insomnia, heart disease and hypertension.
AHCA's report on Vasquez's death, dated June 14, 2012, said the
82-year-old former factory worker last saw her primary psychiatrist on
March 1, 2012, for treatment of clinical depression. Staff at Signature
never told him, the report said, that Vasquez's condition had worsened.
Vasquez, the report said, "was very depressed at times."
Vasquez's primary doctor had ordered a psychiatric consultation around
April 30, 2012. But a constellation of lapses led to the home's failure
to ensure Vasquez actually was treated. The psychiatrist Vasquez was to
see left the nursing home, a report said, and the nurse who was trying
to help Vasquez never was told who would fill in. Meanwhile, a
psychiatrist who regularly saw patients on Vasquez's floor reported "he
never saw [her] and [she] was not on his caseload."
Complicating matters: there was a 15-day gap in nursing notes in
Vasquez's chart, the report said, and the home's administrator told an
AHCA inspector he "had no idea" why no notes were made during those two
weeks.
AHCA concluded: "There was no documentation to demonstrate the [psychiatric] consultation was completed, as ordered."
Three days before Vasquez died, the report said, she "was observed to
be sitting in the hallway or lying in bed; she was not wearing any
makeup, and the resident told [a nurse] she did not feel like doing
anything." Vasquez needed help to fill out her menus.
A short report from the Miami-Dade Medical Examiner said that, on May
31, 2012, a maintenance worker noticed that the window in Vasquez's room
was open. The widow was found in the courtyard underneath her bedroom
window, 14 feet from the building. The medical examiner's office ruled
Vasquez's death a suicide.
Six months before Vasquez plunged from her window, the U.S. Department
of Housing and Urban Development faulted the home for failing to
maintain the windows safely. Windows, HUD said, were secured only with
screws, and a corrective action plan required Signature to install
window locks within all residents' rooms.
The AHCA report is unclear as to whether the windows in Vasquez's room
were fixed, though an unspecified relative told AHCA she had noticed the
day before Vasquez died that "the window clamp was not in place."
A Hialeah Gardens police report confirms some of AHCA's account, noting
Vasquez wasn't breathing by the time she arrived at Palmetto General
Hospital. A doctor pronounced her dead at 4 p.m.
Vasquez's niece, Maria Salgado, who handled Vasquez's affairs, told
police she had been taking 10 medications for her depression, some of
which are listed in the AHCA report, though the names and dosages are
largely redacted.
Staff at the nursing home told Salgado that something happened to her
aunt while she was walking in the garden — exactly what Salgado was told
is redacted — according to the AHCA report.
Salgado, 53, called her aunt's death and the ordeal that followed painful to talk about.
She felt very close to her aunt, she said.
"It was such a horrible time," she said. With a long breath, she added, "I don't want to relive it."
Full Article & Source:
Florida spent $22,000 to remove online nursing home info from public view
2 comments:
The taxpayers should be outraged!
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