And that can mean the difference between life and death.
Simple neglect can be as fatal as more elaborate medical screw-ups (see sidebar). In nursing homes, it comes in the form of severe bedsores, malnutrition, dehydration, and even death.
It's the domino theory. Just as patients are increasingly moved from hospital to nursing home, traditional nursing home patients are monitored less.
"Patients don't get one-to-one attention," says San Francisco Patient Ombudsman Benson Nadell. "They don't get fed, they get a tube. It's like an assembly line."
These are people who need assistance to eat their meals and to move around without falling. They are patients who are incontinent, and must be kept clean and dry to prevent infection. Medical protocol calls for bed-bound patients to be turned every two hours to prevent bedsores.
It's one thing to have 15 patients when most of them are able to feed themselves, maybe half are incontinent, and a couple are on oxygen. But when those 15 patients include five people whose fluids need monitoring, 10 who are bed-bound, a few with intravenous therapy, and a couple of Alzheimer's patients who tend to wander, it's quite a different scene.
"We're always short of staff," says a nurse's assistant in a San Francisco facility, who refused to be named for fear of administrative retaliation. "These residents who came from the hospital need more care. They need more time. They are in pain. You are supposed to take care of them.
"There's only one CNA [certified nurse assistant] for 14 patients," she says. "There's a lot of [call] lights on our floor, and we cannot answer them right away. You don't know which light is the urgent one."
Despite the human cost, drastic change is not likely to occur anytime soon inside nursing homes. The situation typifies America's health care crisis -- a great need to contain runaway health care costs but without a better plan.
Fact is, were it not for nursing homes, nearly 8 million sick people would have nowhere else to turn. And a handful of attempts at more tightly regulating these facilities have met with a faster death than some of the patients. Efforts to match reimbursement payments to actual costs have met with equally dismal results.
Way back in the mid-1980s, activists pursued an acuity-based payment system for Medi-Cal patients. At about the same time, however, the federal government made a major change of its own, the Omnibus Budget Reconciliation Act, which essentially created most of the category-based system for government-paid medical care.
Last year, the Legislature passed a law that created a new Medi-Cal reimbursement category known as "Transitional Inpatient Care," which pays a higher reimbursement for short-term patients whom hospitals designate as having rehabilitation potential. According to the CAHF, the state has so far issued 31 contracts to providers, only five of which were to skilled nursing facilities. Most of the remainder were issued to hospitals. And, it doesn't even apply to patients covered under private insurance.
A more recent attempt at broader regulation occurred earlier this year when Assemblyman Burton introduced a bill that would have required nursing homes offering subacute care to obtain a separate license from the Department of Health. The bill also would have required that patients be clinically stable for 24 hours prior to transferring from the hospital and would have restricted the level of patient that nursing homes could admit; staffing would have been kicked way up, too.
But opposition proved powerful, with the CAHF and the HMOs weighing in. In an Assembly Health Committee with 12 Republicans to seven Democrats, the bill didn't stand a chance.
Neither did the bill proposed by state Assemblyman Martin Gallegos (D-San Gabriel Valley) that would have amended current laws regarding nursing home inspections. Among other things, the bill would have raised the fines imposed for citations and shifted the burden of proof in finding negligence from the state to the nursing home.
"We think additional regulation is not necessary," says CAHF spokesperson Daigle. "We have to meet the needs of the patient. If you don't staff appropriately for that patient and there is a problem, they [the nursing homes] are going to have a deficiency or citation for it.
"When you get the survey, that's about 200 hours, it's pretty thorough. And there's a complaint process, there's an ombudsman ... boy, you pretty much have it all."
In fact, the state can't seem to handle enforcing the regulations it has now. California Advocates for Nursing Home Reform reports that only 19 percent of the $3.8 million in fines assessed against nursing homes in 1995 was actually collected.
What's especially tragic is that, although California led the nation in managed care, it continues to pay for medicine through an antiquated, overwhelmed system. And as the rest of the country looks longer and harder for cheaper medical care, the problems here snowball.
Simply put, the system itself is ill. The payment doesn't match the cost of health care. The care doesn't match the needs of the patients. The result is that people are dying -- people like Patient
