Trickledown Health Care

Hospitals and nursing homes call it "subacute care," but for some patients, it's just a death sentence

Her name is "Patient A," at least that's how she's memorialized in a Hillhaven Skilled Nursing Facility citation file at the California Department of Health Services. She was 80 years old, and had landed in Hillhaven following a heart attack.

On June 8, 1995, at 3 p.m., Patient A told a physical therapist at Hillhaven, "Feels like my heart is beating in my throat." She was afraid she was having another heart attack. The physical therapist noted that her heart rate was 126 beats per minute. A nurse took her vital signs and noted that her pulse was 104; blood pressure was 162/94; and she had a slight temperature.

By 9:40 the following morning, Patient A's vital signs included a pulse of 126 beats per minute and blood pressure of 132/81. Patient A's records also note that her right upper lung had crackling sounds and right lower lung had rales.

A nurse notified Patient A's family and her doctor. At 11:15 a.m., Patient A's family called Hillhaven and requested that she be taken to the hospital. She wasn't. Instead, a nurse called her physician again, who gave the following order over the phone: "Continue monitoring condition and notify [doctor] per any change."

According to the citation report that fined Hillhaven $8,000, no documentation shows that the Hillhaven staff ever reassessed Patient A's condition. She was found dead in her room at 4 p.m., with no one there to say goodbye.

Patient A may have died alone, but her case has plenty of company. She is among the more than 300 people who die or are placed in danger of death because of errors in California nursing homes every year. That's not to mention the countless others harmed or neglected because of understaffing.

These are not just elderly folks on their last legs. Increasingly, they come in all ages, with all kinds of medical problems. And most of them come from the hospital.

They are people like the cancer patient at Crestwood Convalescent Hospital in Vallejo who died in November after being given 200 milligrams of morphine -- 10 times the prescribed dosage -- by mistake.

Some of them are like the 44-year-old woman whose lifetime of boundless achievement came to a halt when she was diagnosed with multiple sclerosis and her body started deteriorating. She is nearly blind, dependent upon a wheelchair, and living in an East Bay nursing home because, despite several attempts, her family cannot find any other place for her. Since her admission to the nursing home, this woman has been in the hospital three times with severe infections and high fever, and battled bedsores and depression. "I'm scared that if I actually complain to the authorities," says her sister, "she will be out and no one will take her. She's complicated. She's in a place where people die in the next bed."

Ever-evolving health care reform has turned nursing homes into way stations for those patients who are caught in the middle -- too expensive to stay in the hospital and too sick to go home. At the same time, California nursing homes are well above the national average in "deficiencies" issued for patient care, which is bureaucratese for saying that they failed in some way to meet certain standards.

The worst case histories read like a Stephen King novel.
In July 1994, a patient was transferred from a hospital to Vale Care Center in San Pablo. She had a brain tumor and had had portions of her skull removed. Two months later, her husband brought a serious problem to the attention of the staff. Paramedics called to the scene found the woman's wound "raw, oozing and with an enormous amount of maggots crawling over the tumor. Flies were seen flying around the room." Tests indicated that the maggots had been there as long as 11 days prior to the patient's transfer back to the hospital (Vale had received a deficiency by state inspectors the previous month for flying insects).

In fact, throughout the state, licensing officials have issued at least 10 citations (penalties) to nursing homes during the past three years for violations involving maggots found in and on patients -- maggots in bedsores, sinuses, gangrenous toes, and feeding tubes.

Other problems are more subtle, the accident waiting to happen.
In April, state inspectors found that 13 of 25 patient records sampled at Hillhaven's Alameda facility were inaccurate, incomplete, or fundamentally disorganized. In one case, the medical record of a 56-year-old man indicated that he had had a mammogram (examination of breast tissue), when in fact, the patient had had a myelogram (examination of the spinal cord and surrounding features).

At Bayside Nursing and Rehabilitation Center in Kentfield, state licensing inspectors in October found a 16 percent error rate in administering medication to patients -- wrong medications, omission of medications, or wrong time of administration.

The pressure to cut costs from both managed care and government reimbursement programs is sending an increasing number of patients from the hospital into its cheaper, lower-staffed cousin, the skilled nursing facility. The assumption is that nursing homes, absent the baggage of overhead and high-end medicine that comes with acute-care hospitals, can provide care for at least half the price. But a closer look reveals that this care may not be such a bargain after all. Without some of the very same overhead held responsible for driving up the bill -- the labs, X-ray departments, physicians, and specialists -- patients go right back to the hospital when the going gets serious.

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