Taking Care

Taking Care

Reva Frazier choked on a piece of chicken in July 2004, while living in the Trinity Mission of Char-lottesville nursing home. She was 90 years old and legally blind. She’d entered the home because she couldn’t walk or feed herself anymore. She could barely communicate, and didn’t have the ability to tell anyone she was choking. What’s worse, she should not have been fed a piece of chicken in the first place. The nursing home had been ordered by a doctor to feed Frazier a special puréed diet—no solid food whatsoever.
    When Frazier’s granddaughter, Robin Norford, arrived in Frazier’s room after lunch that day, she found Frazier all alone, covered in vomit, coughing and spitting up foam. Norford alerted the staff, but Frazier was still coughing up foam when her daughter, Gertrude Houchens, arrived to check on her that evening. Houchens says that the staff showed concern for Frazier’s obvious discomfort, and periodically checked on her condition throughout the night. But, apparently, no one caught the dietary mistake, or realized that Frazier was choking, until the next morning, when she was finally rushed to the hospital.
    Houchens says it wasn’t the first time the nursing home had problems delivering basic care to her mother. She says that she would often arrive at the home late in the day and find her mother still in her hospital gown, in bed, not up in her wheelchair where she belonged. It was important, Houchens says, for Frazier to be dressed and helped into her wheelchair, to help maintain what was left of her strength and mobility. Sometimes, Houchens would find a tray of food untouched at the foot of Frazier’s bed (Frazier couldn’t get to the tray or feed herself without assistance). Sometimes the emergency call bell would be hanging over the side of her mother’s bed, not in its typical resting place within her mother’s reach, and the water pitcher would be empty. Upon arriving, on more than one occasion, to find her mother undressed, stuck on her back and hungry, Houchens began spending more and more time at the home, attending to her mother’s needs herself. (This account is according to Houchens, who says she reported it fully to the facility.)
    Houchens complained about these problems of daily care giving to the staff, to the director of nursing, and to the administrator—incessantly. She says she was the very definition of a squeaky wheel. Sometimes her persistence paid off, and the staff responded. Once, after her mother fell while trying to get out of bed, Houchens convinced the staff to install bed railings, and to move Frazier to a room closer to the nurses’ station, where they could monitor her movements.
    But the choking incident landed Frazier in the hospital for several days, where she underwent a risky procedure to clear her esophagus. Medicaid, a medical assistance program for low-income people jointly funded by the State and federal governments, had been covering the nursing home bill, but during the hospital stay Frazier’s family had to pay out-of-pocket to hold her room under Virginia Medicaid regulations. If they hadn’t, Trinity could have filled the room with another resident, which would have forced Frazier’s family to find an empty bed for their mother at another home on short notice.
    The current administrator of Trinity Mission, Edward Mooney (whose tenure began well after these incidents occurred), initially agreed to discuss Frazier’s case with C-VILLE, but later changed his mind, offering “no comment.”
    Ms. Houchens acknowledges, “Mom was 90 years old, and we knew she wouldn’t live forever. We were just trying to hold onto her as long as we could. We just felt like the [choking] incident did cause her to take some back steps.”
Back steps are exactly what nursing homes are supposed to prevent. They are required by law to maintain a standard of care such that a resident’s health and well-being does not decline as a result of entering the facility.
    It’s not that nursing homes in the area lack regulation or oversight. They are licensed by the State and subjected to periodic State inspections without prior notification. And if the homes participate in Medicaid and Medicare (the federal health insurance program for people aged 65 and older), they are regulated by the federal government and subjected to periodic federal compliance surveys.

    But while catastrophic choking incidents like Frazier’s might be rare, problems with basic caregiving are not. Claire Curry, director of the Community Partnership for Improved Long-Term Care (a volunteer organization that advocates for residents in long-term care facilities in Charlottesville, as well as the counties of Albemarle, Fluvanna, Green, Louisa and Nelson) often fields complaints about basic care from local nursing home residents and their families. Many family members tell her they must visit their loved ones every day to ensure that they are being properly fed and hydrated, and changed out of their pajamas. After the choking incident, someone from Frazier’s family was by her side at the home every day and night, seven days a week, to ensure her well-being. So much for the 24/7 nursing care they had signed up for. It was, at least in part, now being provided by them.
    One of the most common complaints Curry hears is lack of assistance with toileting functions. Residents have complained of having to wait hours after ringing their call bells to be assisted to the bathroom or changed out of diapers.
    In at least one nursing home in our region, according to the Virginia Office for Protection and Advocacy (VOPA), the poor quality of care has risen to the level of “abuse” and “neglect,” in violation of the Code of Virginia. In a complaint filed in October 2005 against HP/Stanardsville, Inc.—a Georgia company that owns and operates the Evergreen Nursing Care Center in Stanardsville, Virginia—VOPA charges the staff at Evergreen with 22 incidents of neglect and violations of residents’ rights. These incidents include: falling asleep on the job and failing to perform CPR, resulting in a resident’s death; allowing a patient to be taken to the dining hall while covered in feces; and stealing a resident’s methadone.
    The Evergreen case is undoubtedly an extreme, and uncommon, example of pervasive abuse and neglect. (In fact, Curry knows of no other lawsuits against nursing homes in the area.) But that is of little consolation to Houchens, who had to battle continued problems at Trinity, even after her mother’s choking incident. Houchens continued to find solid chunks of food in the meals given to her mother after her hospitalization until, exasperated, she forced the home’s administrator to inspect each and every meal for proper pureeing before it was brought to Frazier.

Are the nursing homes of Charlottes-ville, and its surrounding counties, worse than most? Dr. Jonathan M. Evans, chief of geriatric and palliative medicine at the UVA Medical Center and medical director at two area nursing homes—Trinity Mission and The Laurels of Charlottesville—says no.
    “I can say, quite honestly, that I don’t have any special or unique concerns about the quality of care in long-term care [facilities] in this town, or in this community, compared to other communities around the country,” says Evans. “The quality of long-term care in Charlottesville and the surrounding areas is not by any means worse than the quality of care throughout the state, or in other states.”
    The statistics tend to back him up. The official Medicare website, medicare.gov, provides a comparison of all nursing homes throughout the country that participate in Medicare and Medicaid (as most in the Jefferson Planning District do). The results of each home’s federal survey is publicly available on the site, and gives helpful, quantifiable details, such as the percentage of residents with bed sores, the percentage of residents whose mobility decreased over a certain period, and the number of other “deficiencies” in quality of care. Based on that data, the nursing homes in the Jefferson Planning District generally aren’t any worse in most categories than homes in the rest of Virginia, and throughout the country.
    But that’s cold comfort for many residents and their families, as Dr. Evans readily admits. “No one wants to get average health care,” he says. “No one wants to live in an average place, eat average food, live an average life.”
    And no one wants her loved one to sit in urine for hours, or be fed a potentially fatal piece of chicken—especially in a place like Charlottesville, a city rated by Where to Retire magazine as one of the 100 best places in the country to spend your golden years.

So why, in a community known for its retirement amenities and world-renowned research hospital, are these apparent breaches of basic care occurring?
    Both Evans and Curry have a single reply: staffing, staffing, staffing.
    Under federal standards (and to be licensed in Virginia) a nursing facility generally must provide one licensed nurse at all times. In addition, a registered nurse must be on duty for one eight-hour shift every day. Other than that, the applicable regulations require enough staff to meet the needs of residents. That’s a standard wide enough for an ocean liner to fit through. And at many facilities, according to Curry, “there just simply aren’t enough hands on deck to the get the job done.”
    The biggest problem is that there is no regulation specifying the exact number of certified nurse aids (CNAs) required to be on duty—and these are the people tasked with providing most of the basic and direct care to residents. (CNAs aren’t licensed nurses, but must complete a 120-hour training program and pass a competency test in Virginia.)
    Unfortunately, area nursing homes are already struggling to keep the staff they do have. When Houchens complained about the quality of care her mother received on a particular day—such as when she once waited 20 minutes for an emergency call bell to be answered—she would often receive the same response: “We’re short of staff today. We’ll get to it as quick as we can.”
    It’s little wonder that nursing homes have difficulty attracting people, and keeping them committed, to the decidedly unglamorous profession of CNAs. These are, after all, the folks charged with feeding, bathing, and changing the diapers of residents, who are often, at best, too mentally frail to communicate their appreciation and, at worst, are verbally and physically abusive due to Alzheimer’s disease and other ailments. Making recruitment even harder is the fact that, for all of the CNA’s physically and emotionally draining work, their average starting pay begins at $8-10 an hour.
    “The system is broken for the people who live there and for the people who work there,” says Curry. As Dr. Evans puts it, “the direct care [is] being provided by the people with the least amount of training, the least amount of supervision and support and salary. In some respects, it’s as if the economy, at least, is saying those things just aren’t as important. When, to me, those are the things that most symbolize not only how well we care, but whether we care at all.”
    Perhaps Virginia doesn’t care. The State consistently ranks near the bottom compared to the rest of the country in its nursing home Medicaid reimbursement rates. And that has a direct effect on staff salaries and retention. The CNA turnover rate in Virginia is about 73 percent, according to a 2002 study of the American Healthcare Association. Registered nurses, those with advanced nursing degrees who generally don’t have to do as much menial labor in the care-giving field, had a turnover rate of about 56 percent in Virginia during the same period.

Reva Frazier remained at Trinity Mission for several more months, until her death at the age of 91 on Christmas Day, 2004. She died peacefully in her sleep, with her family by her side. She’d had a stroke and been comatose for about three days. Houchens believes her mother held on until 6pm on the 25th so her family could get through Christmas. She wonders if anybody could have ordered his or her death to be any better. “As sad as it was,” Houchens says, “it was perfect… She just took a deep breath and went to sleep.”
    Is it too much to expect such a peaceful passing for all our loved ones and neighbors? To expect for them not only the right to die peacefully, but to live comfortably in their later years and to have their basic needs provided for? Houchens doesn’t think so. Despite her mother’s recent passing, Houchens is still active with the Community Partnership for Improved Long-Term Care, and continues to work with the family council at Trinity Mission, trying to make a difference in the lives of the residents and staff she grew to know and love during her mother’s time there.
    People like Houchens prompt Curry’s guarded optimism: “If any area can solve these problems, it’s this one,” she says. Dr. Evans agrees: “One of the things I love about this community is that it’s a very caring community. There’s a strong sense of community here, and strong interest in community-wide issues and in improving the quality of life for everybody, not just in building more gated communities.”