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| A hall at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford. |
At the Veterans Affairs nursing home in Brockton, a severely impaired
veteran with dementia sat trapped in his wheelchair for hours, his
right foot stuck between the foot rests. Inspectors watched as staff
walked past the struggling man without helping.
In the
Cincinnati VA nursing home, one resident in six months developed five
bedsores, tissue injuries that happen when frail people are left in the
same position for too long. During their visit, inspectors said no one
moved the man or put cushions under him for hours.
At the Bedford VA, meanwhile, inspectors watched elderly veterans
smear their faces with food or drop much of their meals on the floor
because they couldn’t feed themselves and staff didn’t help.
Nine months after USA Today and The Boston Globe reported that
veterans received substandard care
at many Department of Veterans Affairs nursing homes, newly released
inspection reports paint a discouraging picture of the care that sick
and frail veterans continued to receive at these federal nursing homes.
From April through December 2018, outside inspectors found
deficiencies that caused “actual harm” to veterans at 52 out of the 99
VA nursing homes they reviewed. In three facilities, they found
veterans’ health or safety in “immediate jeopardy.” In eight, inspectors
found veterans both harmed and in jeopardy.
Non-VA nursing homes are rarely cited for causing actual harm to residents.
“That
is really bad. It’s really bad,” said Richard Mollot, executive
director of the Long Term Care Community Coalition, a New York-based
nonprofit advocate of nursing home care improvement. He added that it’s
difficult to compare VA findings with non-VA findings because those
inspections may not be as rigorous.
Inspectors found that staff at
more than two dozen VA nursing homes, including in Brockton, Bedford,
and Cincinnati, failed to take steps to ensure existing bedsores healed
or new ones didn’t develop.
Bedsores are “almost always preventable, and quickly treatable,” Mollot said. “So there’s just no excuse.”
In a statement issued when they released the inspection reports
earlier this month, VA officials said residents in their nursing homes
are more difficult to care for than residents in private facilities.
They said 42 percent of residents last year had conditions related to
military service, leaving them severely disabled.
“Overall, VA’s
nursing home system compares closely with private sector nursing homes,
though the department on average cares for sicker and more complex
patients in its nursing homes than do private facilities,” VA Secretary
Robert Wilkie said.
VA spokesman Curt Cashour said Wednesday that
non-VA nursing homes also have problems. He said that, by publicly
posting the VA reports for the first time, “we hope to drive
improvements throughout the system.”
But Mollot said VA officials have no excuse for poor care.
“You
don’t accept somebody in unless you have the ability to provide care
for them, period,” he said. “It’s incredible to me that one has to even
say that.”
The inspection results were made public nearly a year after the Globe
and USA Today disclosed that the VA possessed the reports as well as
the results of a star-based rating system for VA nursing homes. The
reports’ release provides valuable information for the 41,000 elderly
and infirm veterans who stay in the homes each year, as well as for
their families.
“The results of these independent inspections
show that serious deficiencies in care remain at VA nursing homes in
Brockton and Bedford, among others,” said Senator Elizabeth Warren of
Massachusetts. “We must keep conducting rigorous oversight until
performance and quality of care issues are fully addressed and our
veterans are receiving excellent care across the board.”
Widespread deficiencies
Across the country, inspectors found that VA nursing homes
failed in one of their most fundamental duties: taking steps to prevent
and control infection.
At two-thirds of VA nursing homes, they
found staff often didn’t follow simple protocols, such as wearing
sterile gowns and gloves when treating residents.
In Des Moines,
inspectors found that managers didn’t ensure staff adequately cleaned a
veteran, who contracted six urinary tract infections in seven months.
Reviewers found residents weren’t properly monitored or were subjected
to hazardous conditions at more than 50 VA nursing homes.
Water
used for washing hands and bathing was so dangerously hot at nursing
homes in Carrollton, Ga., Martinsburg, W.Va., and St Cloud, Minn., that
it could scald residents — particularly those with dementia or other
conditions that make them less sensitive to pain or heat. The high
temperatures — up to 128 degrees — were designed to kill legionella
bacteria, but were too high to be safe, inspectors said.
In
Bedford, inspectors concluded veterans were in “immediate jeopardy”
because a resident with dementia who was physically unable to hold,
light, or extinguish a cigarette was allowed to go outside to smoke by
himself. And it wasn’t the first time. Previously, he had returned with
burn holes in his clothing and on the seat cushion of his wheelchair.
In
an e-mail to congressional aides earlier this month, Bedford VA
director Joan Clifford said that the new findings were better than the
last inspection in 2017 because inspectors identified only six problem
areas compared to nine the previous year. However, the six remaining
deficiencies were serious, including three that caused actual harm or
immediate danger to residents.
In Chillicothe, Ohio, the VA
allowed a family to hire a private aide to care for a patient with
Parkinson’s disease. As the aide lay on the man’s bed looking at a
cellphone, the veteran leaned dangerously forward. He had fallen four
times in less than two months, once sustaining a head injury that the
aide said required stitches.
The same aide was supposed to feed
the man a semi-liquid diet because he had trouble swallowing, but the
aide often fed him fast food. When confronted by inspectors, facility
leaders agreed to immediately stop allowing untrained aides to feed
residents.
The nursing home in Jackson, Miss., performed the worst
of all the facilities, with failures cited in 12 areas. Residents
suffered in serious pain. A veteran didn’t have a bowel movement for
days, but staff didn’t tell doctors until his temperature spiked to more
than 100 degrees. Veterans languished without staff-assisted exercise
to help them gain or maintain muscle tone.
In just seven cases, VA
nursing homes passed inspections with no identified problems. Those
facilities are in Topeka and Wichita, Kan.; Orlando; Houston; Miles
City, Mont.; Fargo, N.D.; and New Orleans.
Uneven transparency record
Despite the vast public investment in VA nursing homes — more
than $3.6 billion in 2018 — the agency until recently had kept the
findings of its annual inspections of its nursing homes confidential.
The Globe and USA Today revealed last June that the VA had quietly
tracked the quality of care at its nursing homes through inspection
reports as well as star ratings.
Under pressure from the Globe and
USA Today, the VA pledged to release the inspection reports. But that
did not happen until this month, when the VA posted the reports for 99
of its nursing homes. The agency said in a release that it planned to
post the remainder — 35 more reports — by October.
The news
organizations reported that more than 100 VA nursing homes scored worse
than private nursing homes in 2017 in quality ratings. At more than
two-thirds of the homes, residents were more likely to have serious
bedsores, as well as suffer serious pain.
The newly released
inspection results add more depth to those findings and chronicle the
misery of some veterans such as the Augusta, Maine, patient whose back
wound had penetrated to the bone and who did not receive adequate
medication.
“The resident moaned throughout the wound care and the
moaning increased during wound cleansing and measuring,” noted an
inspector who witnessed the episodes in July.
Experts say
caregivers should be assessing and adjusting medications or trying other
methods to make sure residents get pain relief.
“There’s very
little quality of life” when you’re in constant pain, said Robyn Grant,
director of public policy and advocacy at the National Consumer Voice
for Quality Long-Term Care. “And veterans have gone through so much, the
last thing that they should be facing is relentless pain, especially if
it could be mitigated.”
Full Article & Source:
Bed sores, smeared faces, helplessness: New reports paint dismal picture of care at VA nursing homes
