SECOND OF THREE PARTS
Seventeen days after Agnes Johnson died in May, state investigators drove out to the White Community Hospital and Nursing Home in Aurora, Minn., to interview the staff.
Johnson, 85, had osteoporosis so severe she couldn't get out of bed by herself, investigators from the Office of Health Facility Complaints (OHFC) noted.
An aide told them she had turned away momentarily while using a mechanical lift to maneuver Johnson from her bed to a wheelchair, and Johnson slipped from the device's sling to the floor, breaking her shoulder and thigh.
The OHFC, which investigates complaints involving the more than 30,800 residents of Minnesota's 397 nursing homes, found that Johnson died from neglect. It concluded that the aide violated the home's guidelines requiring two people to perform lifts, according to a report released in October. It also determined the nursing home had not properly trained the aide to use the lift.
Despite the mistakes and Johnson's death, the OHFC did not cite the nursing home for violating state and federal regulations. The state found neglect in 17 cases statewide since 2004 where residents were seriously injured or died after falling out of lifts. It has issued citations for errors in only three cases.
Minnesota's nursing home investigators issue far fewer citations in complaint investigations of all types compared to five other Midwestern states. Wisconsin, Illinois, Michigan, Indiana and Ohio cite nursing homes at a rate three times higher.When a Minnesota investigation finds that a nursing home made mistakes, in many cases regulators require nothing more of the nursing home if it fired the worker involved or developed a corrective plan before investigators arrived. Minnesota rarely issues fines against nursing homes.
That is why some health care advocates question the OHFC's effectiveness in holding nursing homes accountable for abuse and neglect -- including falls. They question a regulatory approach in which more than 1,000 Minnesota deaths were attributed to falls in nursing homes from 2002 through 2008, but the OHFC fully investigated only about 75 of those.
It found nursing homes or caregivers neglectful in about half of those deaths. Once neglect was determined, citations were issued in 60 percent of those cases.
"Quite frankly from an advocacy standpoint we are quite stymied," said Jennifer Wright, associate professor of law at the University of St. Thomas. "We've had cases that we considered egregious examples of OHFC not doing its job." Wright, who runs the law school's elder law practice, questions whether the OHFC gets better outcomes with a more hands-off approach.
Darcy Miner, who oversees the OHFC as director of the compliance monitoring division at the Health Department, said Minnesota's regulatory approach is different, yet still effective. She said investigators go through a protocol of reviewing nursing home records, following up with requests for more information. If questions remain unresolved or if there is concern about danger to other residents, they may open a full investigation.
"Overall, I think we do a very good job of protecting vulnerable adults in our state," she said.
Federal officials audit the OHFC's process for evaluating reports of all types of incidents -- including falls -- and triaging them for possible investigation. In the past two years, the OHFC has not met federal standards in how it selects cases to investigate. Last year, federal auditors said that in a sample of complaints, OHFC triaged only 60 percent correctly.
In one of the sampled cases, the OHFC declined to do an on-site investigation into whether a nursing home was using mechanical lifts correctly and if the facility was following physician orders for medical checkups after injury. The auditors said the case should have been given the highest possible priority because other residents who were being moved with lifts were at risk.
In the Johnson investigation, state regulators issued no citations because the nursing home took corrective action, including retraining the staff.
In cases where investigators don't issue citations, "if they're back in compliance, that was my goal so I'm pretty happy," Miner said. Issuing a citation would not add "anything to what has already been accomplished." She added that citations are more often issued during routine inspections of nursing homes about once every 18 months.
Miner said Minnesota was one of the first states to post copies of investigative reports on its website, allowing the public to read about all cases investigated, even those that were unsubstantiated.
But Minnesota's practice of not routinely issuing citations has a drawback, she acknowledged. To help consumers shop for nursing homes, the federal government developed a five-star quality rating that uses the number of citations issued against each home as part of the rating. That means that some substantiated cases of neglect are not reflected in the ratings for Minnesota homes.
In 2005, two nurses aides at Viewcrest Health Center in Duluth were using a mechanical lift to move a resident from a wheelchair to bed. Without warning, the sling tore and the elderly woman fell to the floor.
Although the fall left her in great pain, she managed to escape serious injury. But her overall condition deteriorated. Six days later, she died.
OHFC investigators discovered that Viewcrest was using a sling that had been patched to fix a broken strap, despite the manufacturer's recommendation to discard and not repair damaged slings.
"Neglect did occur," a 2005 OHFC report said, noting that Viewcrest lacked a system to ensure slings were safe.
Despite the harm to the resident, the OHFC did not cite Viewcrest for violating government rules. The OHFC's report explained that it did not cite the home because the facility investigated and then took steps to prevent future mistakes.
But over the next four years, more mistakes were made at Viewcrest that resulted in falls.
Viewcrest was found at fault in 2006, when the OHFC ruled that the nursing home didn't properly care for a resident, a known falls risk, who fell and broke her neck. The OHFC did issue citations in that case.
Two years later, in 2008, the OHFC again cited Viewcrest because it didn't develop a care plan to help a resident who had fallen 11 times.
But in the same year, the OHFC determined Viewcrest was at fault when a resident rolled off a bed and broke her leg while being cared for by a nurses aide. The state regulators said the facility did a poor job training the aide to care for the resident.
However, no citations were issued because Viewcrest took corrective action after the fall.
Then, in 2009, there was another fall-related incident at Viewcrest. The staff left a resident, who was at risk for falls, alone in his wheelchair and did not activate an alarm that would have sounded as he fell and cut his head.
For a third time in four years, the OHFC declined to issue citations for mistakes the home made that resulted in falls.
Viewcrest declined to comment for this story.
Seeking OHFC's assistance
After seeing their mother die unexpectedly with massive bruises and a hip injury, Esther Rannow's 14 children did not want another family to experience what they describe as bad nursing home care.
Rannow, 91, died in October 2007 from a urinary tract infection after she slipped into a coma. The family has lodged one complaint alleging that the infection should have been prevented. But they first asked the OHFC to investigate two incidents where they allege that staff at Benedictine Living Community in St. Peter mishandled their mother while moving her.
"I don't want to see this happen to somebody else. It was so sad," Audrey Glamm said of her mother's injuries.
The OHFC investigated and in an April report said that a nurses aide had moved Rannow by herself when she should have had help. But the OHFC said there was not enough evidence to conclude that the mistake had caused bruising on Rannow's right hip. They said it could have been caused by medications Rannow was taking.
But the family, which includes five daughters who have worked in nursing homes or hospitals, alleged that the staff had mishandled Rannow twice, yet the OHFC report addressed only one of the incidents.
They turned to Minneapolis attorney Kenneth LaBore, who appealed the OHFC's decision to a state panel in June. In a rarely issued finding, the state panel said that since the aide moved Rannow inappropriately in the first incident, the OHFC must "reconsider for neglect."
The panel also said the OHFC should make a finding on the second incident. According to the four daughters who were in the room at the time, the aide dropped Rannow into her wheelchair. She began convulsing and lost consciousness.
In a written response to the panel in August, OHFC director Stella French said family members were mistaken about Rannow being dropped into the wheelchair during the second incident. Rannow had probably fainted from a blood pressure change as she was moved, French said.
But French did not address the allegation that Rannow was being moved with one staff member, when her care plan stated that she required two -- the same thing that happened the first time.
Despite the acknowledged care plan violation in the first incident, French said no citations were issued against the home because it had "corrected this practice prior to OHFC's investigation."
The nursing home has a policy that all transfers of residents be done with two employees, and if that doesn't happen the home retrains or possibly takes disciplinary action, said Linda Nelson, the home's administrator.
How the OHFC investigates
Helen Fellerman, 93, had a rare disease that made her particularly prone to bleeding. She was also unsteady, forgetful and had a history of falls.
So alarms were attached to her bed and wheelchair at Stillwater Good Samaritan Center so staff members would know when she was on the move.
But when Fellerman tumbled from her wheelchair on the night of Aug. 31, 2005, the alarm did not go off, an OHFC report noted. She had been left alone for about 30 minutes.
She died three days later. The fall had caused bleeding inside her skull, made worse by her medical condition.
"It's just like people didn't really care," said Fellerman's daughter, LaVonne Hamilton of Woodbury, who worked for four years as a nurses aide in a nursing home.
Nathan Pearson, administrator at Good Samaritan, would not comment on the case because of privacy laws, but said each incident is investigated thoroughly. The home also has a team that meets weekly to try to reduce falls.
The OHFC investigated after the family's complaint, but reached no conclusion about whether neglect occurred.
Though Fellerman was left alone, the OHFC report said, the home's staff said she was monitored frequently. The chair alarm may not have been turned on, but "it was unable to be determined if that would have prevented her fall." The OHFC report did not address whether appropriate action was taken to keep her safe.
To help select cases to investigate, the OHFC relies on reports by nursing homes, usually containing results of their internal investigations and medical records.
Miner said facility reports are credible sources of information. "I do start out giving them the benefit of the doubt," she said. "Facilities are in the business of trying to provide the right care to residents."
But Hamilton thinks the OHFC should have held the nursing home to a higher standard in caring for her mother.
"I just feel ... you have certain people that are assigned to you and you have certain duties to take care of them," she said. "I don't know how independent [the investigation] is, you know, if you just go by what the nurses are saying."
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