No evidence of neglect.
Sheila Van Pelt couldn’t believe it when she received the letter from state health investigators in 2011. Her mother had suffered a stroke at an assisted-living facility and later died, and now she wondered: Did they even bother to seriously review the case?
Investigators never formally interviewed her, Van Pelt says, even though she found her mother, with her legs twitching as she suffered convulsions from a severe stroke. No one was ever held accountable for the incident and, she says, investigators didn’t seem interested when she tried to bring information forward.
The Plymouth woman has been on a mission since then to change a state investigative agency that she says is too friendly toward health care facilities and fails to give equal weight to the public.
“I do not believe they see us as respectable sources of reliable information,” Van Pelt said. “They view the facilities as the only source of that information. Until that changes, truthful accounting of what happened will not be known.”
The target of Van Pelt’s concerns is the state Health Department and its Office of Health Facility Complaints, which regulates more than 2,000 licensed health care businesses, including nursing homes, assisted-living facilities and home care agencies. It receives 12,000 complaints and self-reported incidents each year; about 1,000 are investigated and about one in four result in findings of maltreatment or other violations.
Van Pelt scored a victory last month when state health officials acknowledged through a policy change that they need to ensure that families play a role in the agency’s investigations.
Yet some families and attorneys representing patients still think the agency holds information too closely, and are asking if the Health Department is sufficiently accountable to the public. Attorney Mark Kosieradzki, who represents patients in nursing home cases, said in the past year or two, investigations seem more cursory and the resulting reports provide less information.
The agency’s new policy requires investigators to interview a relative of a vulnerable adult in complaints involving nursing homes or other health facilities. The protocol also stresses the importance of communicating with families, returning phone calls and helping ensure that relatives get copies of completed investigative reports.
OHFC director Stella French says the policy is designed to help family members participate when her agency investigates a complaint regarding a loved one. She said there were a couple of cases in the past year that left families feeling they weren’t involved, but that the office’s goal is to ensure they are included.
“Did it happen a hundred percent? I wouldn’t say that,” French said. “That is our goal. We feel this will enhance the quality of the investigations.”
Sometimes ‘fall short’
Deb Holtz, the state ombudsman for long-term care, applauded the new policy because, she said, investigators do sometimes “fall short” of ensuring that they have collected all relevant information. She said it’s a matter of staff resources, not a bias in favor of the care industry.
“I don’t know that they are slanted to the industry,” Holtz said. “I know they listen to the industry. I would hope families and complainants are given the same overall time.”
Those in the care industry don’t see the office as favoring their interests, said Patti Cullen, CEO of Care Providers of Minnesota, a trade group.
“If they were too friendly we wouldn’t see the large number of investigations that we currently have,” Cullen said, adding that her members sometimes find the investigations too harsh.
Yet even when investigators find wrongdoing, they have been providing less and less information to the public.
Core information omitted
One policy change a few years ago led to streamlined and shortened public reports. French said it was designed to limit the amount of time investigators spend on paperwork, make reports easier to read and protect witness identities. Some believe it has also had the effect of reducing outside scrutiny of incidents and the ensuing investigations.
Then, in recent months, the office has begun omitting the dates that incidents occurred in an effort to keep that information from reporters and prevent them from contacting relatives of people who have been victimized in licensed-care settings.
“The purpose is to provide a public summary of the investigation,” French said. “It isn’t supposed to be we are recreating everything that happened.”
Yet omitting core facts often matters to families and their advocates, Kosieradzki, the attorney, said.
“I think it’s very troublesome if a report is not listed to a date, listed to documents, listed with witnesses interviewed, listed with facts,” he said. “I’m very troubled by it. It raises a question of the validity of the finding either way.”
Kosieradzki said one client who felt she had received neglectful care at a nursing home had no idea the state had conducted an inquiry and has no memory of being interviewed by investigators.
Investigators concluded there was no neglect, but now Kosieradzki and his client are fighting the Health Department in court to release basic information about the investigation.
“The investigator’s conclusion contradicts the sworn testimony and the evidence,” he said.
When Sandi Lubrant’s mother experienced persistent medication errors at an assisted-living facility, the family filed a complaint and Lubrant dealt firsthand with the OHFC. She said the agency did not seem consumer-friendly and didn’t take the data she provided seriously.
The experience undercut her confidence in the state’s ability to protect vulnerable adults.
“If I had another friend in a situation, I might say file a complaint,” she said. But, she added, “If you’re looking for an immediate action or to protect your loved one, it’s not what I would recommend.”