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Health alarm raised about two state-operated veterans homes
By Walter F. Roche Jr.
Monday, January 25, 2010
After Pennsylvania health inspectors visited the 514-bed Hollidaysburg Veterans Home in February, they were clearly alarmed.
Inspectors saw patients screaming, biting and kicking as four attendants held them down for bathing or treatment. Often, the inspectors found, patients received improper doses of powerful psychotropic drugs to avert bedlam. And when a staff member reported concerns about physical abuse of a resident, inspectors determined no one investigated.
"The administrator and director of nursing were not fulfilling their essential job duties to ensure the safety and proper health care services for residents," the inspectors concluded in a 37-page report.
Experts the Tribune-Review interviewed say the use of drugs is not the first-line treatment for dementia patients with behavioral problems. What's more, state law mandates that hospital administrators investigate reports of suspected abuse.
Both the Hollidaysburg home and Gino J. Merli Veterans Center in Scranton show a series of serious deficiencies. The U.S. Department of Health and Human Services rated the facilities below average in meeting inspection requirements, giving them the lowest possible ranking: one star out of five. Other homes in the system, including Pittsburgh's, fared better.
From Erie to Pittsburgh to Hollidaysburg to Scranton and the Philadelphia region, the 1,632-bed state veterans health system dating to the Civil War era costs $165 million a year to operate. It is separate from the federal Veterans Affairs.
The state facilities include nursing home beds, personal care facilities and locked dementia units, where many of the serious violations occurred.
Officials with the state Department of Military and Veterans Affairs, which runs the homes, acknowledged the seriousness of the inspection reports. But they said agency staff resolved outstanding issues.
All six facilities, including Hollidaysburg, are fully licensed.
High approval
"We are humans taking care of humans," said Jeffrey Backer, quality assurance director for the agency.
He said that, overall, the state-run homes compare favorably with other public and private facilities in Pennsylvania, and nationally in many key categories.
Data the state provided show that in one category — bed sores — the state veterans homes' incidence rate among high-risk patients was less than half the state and national average. According to agency data, the state veterans homes exceed national averages in three other categories, including avoiding urinary tract infections.
State officials point to patient satisfaction surveys they conducted, which show a high approval rate.
However, the inspection reports tell another story at Hollidaysburg and Scranton.
A review of reports for the past five years shows the most serious repeat violations occurred at those two facilities.
The Scranton facility was cited for an outbreak of scabies that afflicted patients and staff. Although health facilities sometimes are prone to scabies problems, patients at the Scranton veterans home were hit with a second wave after administrators failed to ensure a staff member was cured before resuming contact with patients, inspectors found.
Backer said the scabies outbreak was not as big a problem as it appeared.
"We revised policies. We haven't had any recurrences," he said.
The Scranton facility was cited for failing to prevent and properly treat potentially life-threatening bed sores, and cited again in November for failing to maintain sanitary conditions and failing to address patient complaints.
'Real problems'
The situation at Hollidaysburg was serious enough to prompt state Sen. John Eichelberger and Rep. Jerry Stern, both Hollidaysburg Republicans, to make two unannounced visits.
Stern said it appeared patients and staff could have been at risk of injury.
"It was pretty serious," said Eichelberger, adding that state health inspectors "uncovered some real problems."
Both legislators said they were advised the situation has improved, but they plan to remain attentive.
"We're not going to let that happen again," Eichelberger said.
At Hollidaysburg, inspectors found the home out of compliance on three occasions in 2009. As a result, the home's license was placed on a provisional or probationary status from February to June.
The violations of state and federal rules included failure to notify physicians and family members about changes in patients' conditions; unsanitary incontinence care; and overuse of side rails, which caused patients to become trapped and suffer injuries.
Medication worries
In one inspection, health surveyors detailed an alarming situation in the 77-bed dementia unit.
According to the report, a nurse's aide "indicated the psychiatrist told her that he was very concerned with the staff working on the East II unit, as the unit had more incidents and requests for medicine in the last year than previously. There was no evidence the facility investigated the additional concerns in this statement."
In a subsequent interview, the unnamed psychiatrist "indicated that staff were not aware of how to manage these behaviors and that the behaviors should be managed with behavioral interventions instead of with medications alone."
According to Lois Lutz of the Alzheimer's Association's Pittsburgh chapter, bathing is "a particularly sensitive issue" for patients with dementia and Alzheimer's disease "because this is such a private situation and patients often do not fully understand what is happening or what is expected of them."
She said the association "does not advocate the use of medications as a first option, but rather trying other avenues such as redirection, interactive activities or communicating on a one-to-one level."
According to the state report, the assistant director of nursing told inspectors "he did not feel he had to investigate statements made by physicians and their personal feelings regarding issues at the facility."
The Feb. 6, 2009, report includes this eyewitness account of an encounter between staff and a patient undergoing incontinence care:
"The resident kicked Registered Nurse #9 and then she held both of his feet to the bed. Nurse Aide #4 held his right hand down to the bed, and Nurse Aide #10 held the resident under his left arm. He yelled, 'I want out of here. Stop hurting me.' "
"Interviews revealed that three to five staff members were routinely used to hold down resident when care was provided," the report states.
In a separate matter, an internal memo the Tribune-Review obtained shows a case of suspected patient abuse by a staff member at Hollidaysburg in December 2007 was reported to police by the victim's wife, not home officials. Under state law, health care officials are required to report suspected cases of elder abuse.
The memo states: "After a consultation with our chief counsel, we made a conscious decision not to contact police until we conducted our investigation because of the circumstantial evidence."
According to the memo, two employees assigned to the patient were suspended and home officials cooperated with the police investigation. No criminal charges resulted.
In other reports, the facility was cited for failure to prevent and treat bed sores; for opening residents' mail without permission; and failure to notify physicians and families of changes in a patient's condition.
Experts say aggressive treatment of bed sores is a key element in the care of bedridden or wheelchair-confined patients.
Backer said the bed-sore issues were addressed, and the state system prides itself on addressing bed sores.
'Gruel-like substance'
At the Gino J. Merli Veterans Home in Scranton, inspectors in August found the facility, once again, out of compliance, citing improper handling of food. The report describes one veteran being served "a gruel-like substance," including a diced hot dog "floating in a large amount of greasy liquid."
Backer said a food delivery system with meals cooked just prior to serving is being developed. Currently, meals are prepared ahead of time and reheated before serving. He said it is difficult in any case to make food look appealing for patients with swallowing difficulties.
The report cited the home for sending patients to daylong dialysis treatments with perishable food but no way to keep the food cool and prevent potential food-borne illnesses.
The Scranton home was cited for failure to prevent and treat bed sores, including monitoring fluid intake of bedridden or wheelchair-bound patients. An inspection report said treatment a physician ordered for an 89-year-old who developed bed sores was delayed for nine days, with no apparent explanation. Inspectors reviewed records and found another resident did not meet his assessed fluid needs on 64 of 74 days. Another patient got only 77 percent of fluid needed to avoid bed sores.
According to a report from the state Auditor General's Office, there were reports of possible abuse by staff and cases of patient abuse by other patients at the Scranton facility. Thirty-eight abuse events were recorded there in three years ending in 2007, the report said.
Some fare better
The state's other veterans facilities have fared better. Inspections at Spring City in Chester County, Pittsburgh and Erie revealed violations ranging from failure to check employee references to failing to document tuberculosis tests for new employees.
Inspectors faulted the Chester County facility in June for a lack of bed-sore prevention measures, failure to maintain patient assessments and failure to monitor the weight loss of a patient who lost 11 pounds in a week.
Backer said the provisional license on the personal care beds at Chester County was lifted when the agency was granted a waiver from staffing requirements.
The Erie home was cited in 2008 for failing to keep residents' records current and for failing to develop a fall prevention program for a patient with a history of falls.
The deficiencies were later corrected.
Walter F. Roche Jr. can be reached at wroche@tribweb.com or 412-320-7894.
