From the San Diego Tribune December 14, 2013
At least 80 times in recent years, employees at San Diego County assisted living homes overlooked serious medical issues, gave the wrong medication or otherwise failed to properly care for vulnerable seniors.
The problems arose as a result of the unique position held by the care homes, viewed by many families as health-care facilities even though they lack the required levels of training, supervision and oversight.
The new cases were examined by U-T Watchdog as part of an ongoing partnership with the CHCF Center for Health Reporting at the University of Southern California.
In September, reporters from the two news organizations uncovered 27 deaths from injuries and neglect at homes in San Diego County. Today’s report reveals even farther-reaching problems — those endemic to a system of caregivers who lack medical training:
A client in San Marcos died after caseworkers ignored a serious cough for 10 days. The staff told the family six days before the resident was finally hospitalized that the client did not need to be sent out for medical treatment.
A resident of a La Jolla home landed in the emergency room after being given the wrong medicine by a temporary caseworker who called for the client by first name only. The dose was supposed to go to a neighbor with the same name.
A man living in a San Diego home died after being found naked in a closet with a body temperature of 87 degrees. Later, investigators said staff never treated his sepsis — whole-body inflammation caused by infection — or logged the medication he had been prescribed.
Regulators discovered four separate medication errors during a visit to a home in Oceanside, including one case in which a resident was given four times the prescribed amount. The home was fined $150, the maximum allowed by state law.
Relatives are often not told when caregivers make mistakes. Instead, the findings are tucked into files at the California Department of Social Services office in Mission Valley and largely forgotten.
When Juanita Brashear was found dead at the Angel House Flower in 2011, no one told her sister that the home had been repeatedly cited for violations and deficiencies.
“I was there usually every day, a couple of times,” said her sister, Ida Major. “I got so angry because she went downhill so fast.”
Brashear, 83, died from complications related to an earlier fall. Angel House Flower staff told regulators they were giving her morphine every four hours as prescribed by a doctor.
Major said her sister was ambulatory and conversational when she moved into the home in the Redwood Village neighborhood of eastern San Diego. Even today, she is not sure what went wrong.
“I knew I needed to go back and investigate, but it was so raw for me I kept putting it off,” said Major, 73, who relies on an oxygen tube to breathe. “Then I set to work arranging the funeral.”
According to the California Department of Social Services, Angel House Flower had accumulated a record of violations prior to Nov. 15, 2011, the day Brashear moved in.
There were citations for neglect, unsafe medicine storage, insufficient staffing and residents who needed a higher level of care than the home could provide. Long before Brashear passed away in her rented bed, another woman died after caregivers failed to call 911 following a bad fall.
“Resident #1 had a pattern of fall risk, dementia, diabetes and was unstable and required the use of a walker,” an April 2011 report states. “This resident fell and hit her head on furniture, was placed in bed and later vomited and daughter was called instead of 911.”
Angel House Flower and two other assisted living homes operated by licensees Silvina Torres and Candelaria Espinoza closed last year after regulators took away their permits. Messages left for them at the homes they now rent out for other uses were not returned. Their attorney said he is no longer in contact with them.
The California Department of Social Services, which licenses and regulates about 7,700 assisted living facilities statewide, defends its record of oversight. Officials said inspectors work diligently to catch mistakes and enforce rules to protect senior citizens.
“The facilities’ ability to assist with medication is a primary function in protecting the health and safety of residents,” Deputy Director Michael Weston said. “The department’s enforcement efforts in this area are predicated on ensuring proper training and staff, and that includes retraining some individuals where we see some sort of deficiency.”
The department’s Community Care Licensing division requires licensees to make sure residents are properly assessed when they move in — and re-assessed as needed — so they receive the appropriate level of care.
That means when a client’s condition worsens, caregivers are responsible for alerting medical professionals and seeing that prescribed medication is made available. Meeting that requirement can be tricky because employees can bring medicine to residents but cannot help them take it.
Weston said stricter training requirements were adopted in 2008. Homes now must provide employees 16 hours of training developed by physicians or nurses and workers also must pass an exam written by the licensee.
“This is an area that the department is extremely vigilant about,” Weston said.
When inspectors do issue fines or impose corrective orders, the findings are not publicized — unlike the Department of Public Health and other state agencies, which put out press releases and hold news conferences to bring public accountability to nursing homes and hospitals.
Not medical facilities
Assisted living homes, called residential care facilities for the elderly or RCFEs, are not medical facilities under California law.
They were designed as low-cost alternatives to skilled nursing, providing room and board to seniors who are generally independent and in decent health.
But many operators are granted waivers allowing them to treat clients with dementia and other serious conditions. That means homes can end up serving residents who may be sicker than the staff is trained to treat.
RCFEs, which typically charge $3,000, $4,000 or more per month, can serve as few as six clients in a single-family home. They can also be large campuses serving 200 or more residents.
One smaller facility is Casa Real Residential Care, an assisted living home in San Marcos.
For almost seven months in 2011 workers failed to obtain proper medication even though an unidentified client had twice been ordered into treatment by a visiting physician, state records show.
“Licensee repeatedly failed to make medical appointments for client 1 that were ordered by mobile doctor staff,” an inspector wrote. “Licensee failure to ensure client 1 obtained treatment for eye condition has caused this client to lose eye.”
Casa Real was fined $150 and told to improve. The licensee was “not available” to provide a correction plan, the report said.
During another visit that year, the same inspector noted a different client had wrongly been given someone else’s medicine for at least the previous six days.
It is unclear from records what happened to the resident due to the error. When the inspector went searching for the operator, the licensee could not be found.
“It appears that the administrator, Fe Joy, is not at the facility a significant number of hours to ensure the proper running and administration of this facility,” the inspector wrote.
Joy did not return numerous calls and messages seeking comment about the state findings. According to research by the U-T and the CHCF Center, medication errors like those at Casa Real are all too common.
At the Silvergate San Marcos Retirement Residence, a caregiver gave one client another resident’s diabetes medication. State records show the staff member realized the mistake but didn’t tell anyone.
Five hours later, another employee was preparing the client for bed and noticed something wrong.
The “resident was very red and this resident was unresponsive,” a state report concluded. “Staff 2 contacted a facility nurse who called 911.”
The employee was fired. State inspectors fined Silvergate $150 and imposed new training orders. Then they cleared the citation the same day.
Most errors leading to injury or death in California assisted living homes are due to poor oversight by staff or lack of training, the U-T and the CHCF Center for Health Reporting found.
The work is difficult, so mistakes may be unavoidable.
Residents require 24-hour supervision and many do not have full control of their faculties. They may wander, they might need bedpans, they often have to be rotated to avoid bed sores.
The workers are often low paid and low skilled. Online job postings call for a high school diploma and the ability to pass a criminal background check.
Many workers are immigrants who do not speak English as their primary language, limiting communication with clients.
Some caregivers live in the same homes they serve, work far more than 40 hours a week and earn a reduced paycheck in lieu of room and board.
According to state records, at least one large senior living company relied on a “culture of fear” among employees to avoid reporting medical mistakes to regulators.
At Brookdale Place of San Marcos, which is licensed for more than 200 beds, employees “feared termination and had been told that they would be terminated if they would report to or talk to Community Care Licensing or to the ombudsman about any violations or during investigations of any issues,” an inspector wrote in 2011.
The report came months after a Brookdale director was found to have falsified records about a resident who was not given a prescribed narcotic.
“In addition, medical attention was not provided in a timely manner when a resident fell, was injured and died shortly after hospitalization,” the document says.
State officials reminded Brookdale managers to maintain open dialog with employees, provide abuse-reporting forms to staff and boost training for caregivers. The home is the only assisted-living license in the county on probationary status from the state.
A Brookdale spokeswoman did not dispute the findings. She said the company took steps to improve conditions in San Marcos and across the company.
“In September of 2013, we instituted 24-hour nursing coverage, seven days a week, to oversee the daily medication administration and records related to medications,” Julie K. Davis, senior director of communications for Brookdale Senior Living Inc. of Brentwood, Tenn., wrote in a statement. “Our focus on a quality medication management program is part of our mission of enriching the lives of those we serve with compassion, respect, excellence, and integrity.”
Davis said survey scores from residents at Brookdale of San Marcos have climbed in recent years.
Untracked medical errors
The Department of Social Services does not track medical errors inside the homes. The U-T obtained 7,000 state records of inspections and searched them for incidents of medication and other medical errors. The results were anecdotal, not statistical.
The state handles violations case by case, meaning its administrators also lack the ability to spot trends or systemic mistakes. Officials say the outdated computer system does not permit analysts to separate violations by type.
San Diego researcher Chris Murphy completed her master’s thesis on irregularities within assisted living homes in San Diego and Imperial counties and found that medical mistakes were the most frequent violations.
Murphy examined 348 case files one by one. Medication errors, lack of medical care and lack of first-aid training were the most common problems — 15.9 percent of recorded violations.
“Medication errors are a significant risk to residents, causing injuries, causing trips to the ER,” said Murphy, who earned a master of science in gerontology from San Diego State University and also co-founded a nonprofit called Consumer Advocates for RCFE Reform.
“Nobody has data to make evidence-based statements; it’s all speculation,” she said. “How can you problem-solve with no data? We have a problem we need to solve.”
Besides assisted living facilities, Social Services’ Community Care Licensing Division oversees 70,000-plus day-care centers, preschools and group homes.
In most states, the people who oversee licensed board and care homes are health-care professionals.
Eric Carlson, directing attorney at the National Senior Citizens Law Center, said the state tries to have it both ways with regard to board and care homes: lower-cost assisted living with professional-level health care supervision.
“California’s RCFEs run on the premise that they are completely non-health care facilities and to the extent that there is any health care they are provided by non-health care providers,” he said. “You’ve got this regulatory system that’s based a little bit on a lie.”
Other states managing the same conundrum have created what are called medication aides or medication technicians — specially trained caregivers licensed to administer prescription drugs to RCFE residents, Carlson said.
“It’s generally considered to be successful,” he said. “That’s where California will end up going. A lot of states in recent years have done that and I don’t see anyone going backward.”