Nursing Hom

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Death and t

when we took my mother out of the hospital, we haD no iDea that she was facing an even bigger Danger...

d the
by shlomo frieDman

me

eath came unexpectedly for my mother. Only 10 days before her passing, on Thursday evening, October 21, 2010, we had slowly shuffled together down the hallway, she pushing a wheelchair for support, its wheels squeaking, her hands clasping its black, grooved handgrips. After a few dozen feet, she tired quickly and, with the help of a nurses aide, she sank back into the wheelchair. I wheeled her back to her room in the nursing home, where she was rehabbing for a fractured hip. We then made some small talk, discussed her release date only a few days away. At about 11:00 P.M., aware of my exhaustion, she insisted I go home, kissing me good night. It would be the last time. I remember when I was six, a mother of a classmate slipped on a wet floor and banged her head. She then lapsed into a coma and died. That, I think, was the first time I realized that parents are mortal, and the thought gave me a twisting, sinking sensation in my stomach. I had that same nauseous feeling when, on Shabbos morning, my brotherin-law unexpectedly walked into the shul where I was davening, like a strange, out-of-place character in a dream. It being Shabbos, he had walked the four miles from the nursing home to tell me that my mother was taken to Beth Israel Hospital in Brooklyn. Mommy just feels a little uncomfortable. Nothing serious, he had said. Events quickly spun out of control. Motzei Shabbos, she lost consciousness. The diagnosis was a virulent form of sepsis, an infection that had entered the bloodstream through the skin, inflicting damage on her heart and kidneys. During the next week, the family, taking turns, didnt budge from her bedside, catching a few minutes of sleep here and there on a hard vinyl chair. Quickly, we all learned what the fluctuating LED readouts signified on the various monitorspulse, oxygen levels, blood pressure. As I would doze off, the red segmented numbers would be dancing in the blackness of my closed lids. The following week, on a Monday afternoon, November 1, a life that had started in a rural town in Hungary, had survived as a child a harrowing escape through Nazi Germany and France, and had given birth to five children, ended amid beeping and whirring medical monitoring machines in an intensive care unit in Brooklyn. When my mother had first entered the hospital in August 2010, we had not feared the hip surgerythe whole procedure to put in the pins didnt take more than 20 minutesbut rather, the possibility of infection. We had heard of too many horror stories about successful operations on elderly patients followed by deadly pneumonia or other infections. Our whole mindset was to get her out of there as quickly as possible. Get her out of the hospital, my brain kept texting me. When one day I saw her sniffling with a balled-up tissue in her hand, I was terrified that it was the precursor to some deadly infection. So
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the elderly mean

why

money

The modern nursing home concept, a facility devoted mostly to elderly patients, is a relatively recent phenomenon in the American health care system. Until the 1930s, the elderly who didnt have the resources to take care of themselves mostly lived in government-sponsored or not-for-profit facilities. For the most part, though, family members took care of their elderly parents or relatives. A dramatic unintended shift took place with the passage of the Social Security Act in 1935. The Old Age Assistance provision of the legislation granted a guaranteed income to those about the age of 65but there was a catch. Anyone living in a government-sponsored residence was ineligible to receive the funds. The rule produced a high demand for private homes that would not make residents ineligible for the OAA checks. By 1959, nursing homes were overwhelmingly for-profit, with 15,530

for-profits and 1,429 non-profits. Today, forprofits account for an estimated 70 percent of all nursing homes. Government yet again changed the complexion of nursing home ownership with the Medicare and Medicaid Acts of 1965. Medicaid mandated that government provide nursing home care for all those without the means to do so, without any time limit. The legislation made billions available for an industry that had previously operated on low profit margins. The new opportunities to make huge profits transformed the for-profit nursing home sector into a mega-business. Large companies, such as Holiday Inn, began to form nursing home chains and often initiated IPOs and floated bonds, in the same capitalist tradition of any other American corporation that desires fast growth.The push to have unending Medicaid coverage for nursing home care in the late 1950s and 1960s reflected the seismic economic shift taking place in American

households. The postwar American household was fast becoming one where husband and wife both worked full-time. With both spouses out in the workplace it was no longer possible to provide full-time care for elderly parents. Nursing homes became an important component in sustaining the new two wage-earner model. Another change in the face of nursinghome ownership took place after Congress passed the Balanced Budget Act in 1997. The legislation mandated Medicare to lower costs by introducing a system that would cap reimbursement payments to fixed payments per care component. Shortly, after the change, five of the largest publicly-traded nursing home chains went bankrupt, and private equity firms began to buy up facilities. Private equity firms now own four of the top 10 largest nursing home chains. These top 10 chains control 14 percent of all facilities in the U.S. Todays nursing home patients mostly fall into two general categories long-term and short-termeach reflecting the two sources of government-sponsored care. The lions share of nursing home revenue, about 66 percent, comes from Medicaid, but patient eligibility for coverage is limited by state income guidelines. Medicare will pay for patients care after hospitalization without any income restriction, but only up to a maximum of 100 days. Medicare covers most of the short-term patients, accounting for 10 percent of nursing home revenue.

to us, August 27, a cloudless day with a piercing blue sky, was a day of good news. That day, she was judged well enough to leave the hospital to enter rehab. We grinned at each other, my brother and I, about the fact that we had navigated past what we thought was the most treacherous point of recovery. But unknown to us and to many who place their loved one in a nursing home, either for long-term or short-term care, is that these facilities have extremely high rates of infection, and very often harbor virulent infections that are potentially fatal.Our mothers dreadful experience with infection contracted in the facility shocked me, but during shiva, a number of friends and relatives shared similar stories of relatives who had unanticipated tragic experiences in nursing homes, where infections had led to death or serious illness. Their attitudes ranged from indignation to resignation. One woman, who was disgusted with her mothers care in a nursing home, told me she quit her job to be able to care for her parent herself. But if the scope and magnitude of nursing home infections

were mostly unknown to my family and me, neither have they caught the attention of researchers and the federal government until recently. A fresh body of research has uncovered an array of clues as to why nursing home infection rates are so highand will likely get higher. Ever since the mid-19th century, when Ignaz Semmelweiss discovered that hand-washing saved mothers from dying from puerperal fever after childbirth, one of the basics of infection control has been hand-washing. But its that rudimentary procedure which, for a variety of reasons, researchers have found is sorely lacking in nursing homes. One of the researchers of the May Infection Control study was Laura Wagner, a professor at New York Universitys School of Nursing. With a youthful appearance, Wagner could easily be mistaken for one of her students. Photographs of Wagner with some of her nursing home patients hung on her cubicle wall; piles of stapled research studies were stacked neatly on the floor. We are moving soon, she explained to me.

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according to one estimate, 388,000 nursing home patients die annually in the u.s. of infection out of a total of 1.7 million residents. that translates to more than one of out every five residents of a longterm facility who will succumb to an infection.
Wagner developed an interest in nursing home patients while she was a student nurse in Toronto in the late 1990s, taking care of an elderly patient who was kept immobilized in a chair restraint. To the consternation of the administration, Wagner removed the restraint and began to encourage the patient to walk. When I came back a month later, she was walking on her own, Wagner recalled. Restraints in nursing homes became the focus of Wagners research. We used to keep our elderly tied up, she said to me straightforwardly. Her research, and that of others, proved that in many cases restraints were not only unnecessary, but were being used as a convenience for nursing home staff who didnt want to be bothered with walking or checking on patients. When the SARS pandemic swept through Canada in 2003, Wagner saw firsthand the positive effectiveness of extreme infection control procedure. The government imposed strict infection control procedures in nursing homes, mandating that each facility hire a dedicated infectious disease specialist. At Wagners facility, infec-

Ami Magazine would like to express its condolences to the family of Reb Shlomo Zalman Bleier, zl, for their tragic and sudden loss and specifically to his widow, Mrs. Faigy Bleier ne Kauftheil.
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infections

unleashed

In the May issue of the American Journal of Infection Control, a group of researchers published their findings on the high rate of nursing infections. According to one estimate cited in the study, 388,000 nursing home patients die annually in the United States of infection, out of a total of 1.7 million residents. That translates to more than one of out every five residents of a long-term facility who will succumb to an infection. Infections are the cause of approximately 25 percent of all nursing home patient hospitalization. The estimated cost of treating these infections is anywhere between $673 million to $2 billion annually. Another staggering statistic published in the study: More than three million nursing home residents will be stricken with an infection during their stay, or more than two infections a year per resident. The most prevalent infections in nursing home are pneumonia and urinary tract infections. To be sure, nursing home researchers caution that the high infection rates have to be understood in the context of a population that is much sicker than in years past. Technology and medicine now keep patients alive who, in earlier eras, would have died. Because of advances in medicine, it is common today for a patient to have co-morbiditiesmultiple conditions where each one is life-threatening. Today, a nursing home patient could be stricken simultaneously with diabetes, heart disease, and cancerall creating an immune system that is vulnerable to infection. Because of this, many nursing home patients would die in the best of environments. Nevertheless, the odds are that a resident living in a nursing home facility for one year will have a 36 percent chance of contracting pneumonia. That rate is a shocking 10 times the rate for the same elderly population living outside nursing homes. So many nursing home patients contract pneumonia that they account for almost 20 percent of all pneumonia hospitalizations nationwide.

tions dropped dramatically. We had one winter with no outbreaks. Wagner decided to conduct the study because of her own experience and the federal governments nascent interest in putting more emphasis on nursing home research. We are just not doing things about nursing homes, Wagner said. There is so much emphasis on hospitals, but nobody is looking at nursing homes. Nobody is talking about it seeing that it is an issue. Nursing home infection control has also caught the eye of the federal government because of the recognition that winning the war on hospital infections requires fighting battles on multiple health care fronts, long-term care facilities being only one of them. According to Dr. Vincent Quagliarello, Clinical Chief of Infectious Diseases at the Yale School of Medicine, multiple pathways of infection exist between nursing homes and hospitals, providing free shuttle rides for bacteria to travel between facilities. Elderly patients can pick up an infection in a hospital and bring back a disease to the nursing home, or they bring an infection to the hospital from the nursing home, and then return to the nursing home with an entirely new infection they picked up at the hospital. Whats also of concern to infection control specialists is the lack of data on the vectors between hospitals and nursing homes. A patient who becomes ill in a nursing home and is sent to the hospital and then dies there becomes a hospital statistic. There is no data integration between health-care facilities so that federal, state, or local health departments can holistically view the infection lifecycle. Quagliarello hopes that President Obamas proposal for common electronic medical records for all Americans will build the infrastructure necessary for health professionals to track the sources of infections. If hospitals and nursing homes integrate their data, it would be easier to trace which facilities are epicenters for infections. Better infection control in nursing homes may soon be in their economic interest. The Agency for Healthcare Quality and Research has made fighting healthcare-related infec-

tions a priority because of their extreme costs. The Centers for Medicare and Medicaid Service (CMS) no longer reimburse hospitals for infections that they consider preventable; that same policy might soon be put into place for nursing homes. Another researcher on the May Infection Control study, Nicholas Castle, a professor who teaches infection control at the University of Pittsburgh Medical Center, wanted to apply his infection control knowledge to nursing homes. Castle said to himself, Boy, Im teaching this in hospitals, yet I dont know much about it in nursing homes. Based on research done in hospitals, Wagner and Castle had a hunch that nursing homes with the worst infection rates would also be the ones with the lowest staffing levels. The researchers studied thousand of nursing home records from 2000 to 2007, for homes where the Centers for Medicare and Medicaid Service had given them an F-Tag 441 citation. F-Tag 441 citations are given to nursing homes that do not meet the minimum requirements in infection control, such as proper hand-washing and disinfection techniques. CMS penalizes nursing homes with an excess of citations by withholding Medicaid and Medicare reimbursements. Infection control citations have been on the rise nationwide, indicating a worsening problem. In 2004, CMS found 15 percent of nursing homes to be deficient in infection control. In 2009, the number had jumped to 30 percent. The numbers vary widely from state to state. The worst offending state was Oklahoma, with 59 percent of all its nursing homes failing to provide basic infection control procedures. The state with the lowest percentage, at 2.4 percent, was Rhode Island. New York was above the national average with 35.8 percent. The study proved what the researchers had suspected: Low staffing and high infection rates are highly correlated. The higher the staffing ratio per patient, the better the odds the facility will have a lower infection rate.
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The trajectory of my mothers experi-

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ence during the last few months of her life mirrors those of thousands of others who enter long-term care facilities. She, like many others in nursing homes, had co-morbidities, that is to say, multiple health problems. The hip surgery was only the most recent health issue. She also had a pacemaker, a heart stent, high-blood pressure, and poor kidney function. Looking back, our choices of where my mother could go to recuperate from the surgery were limited. She couldnt remain in the hospital, even if she wanted to, because Medicare wouldnt pay for it. She couldnt return home to be by herself because she couldnt walk, nor would private insurance or Medicare pay for the 24-hour care necessary. In addition, she required physical therapy, using equipment unavailable in a home setting.The nursing home we found met the cultural criteria that my mother needed. It serviced mostly Jewish patients and was fully kosher. It also provided Jewish prayer services on Shabbos and Yom Tov. With Rosh Hashana, Yom Kippur, and Sukkos coming up, she wanted to be able to attend shul. Although a large percentage of the patients in the facility were Jewish, it would admit anyone who was eligible to stay, either through health insurance, Medicare, or Medicaid. Located only a few feet from the river, residents benefited during the summer from the breezes wafting through the open windows. Seagulls soared, glided, and circled the nursing home, landing near where residents sat outside on the ground-level porch. Looking left from the windows in my mothers room, on the 7th floor, we could see the wide panorama of a large section of Brooklyn. Visually, this particular facility didnt have the look and feel of a nursing home: floors were gleaming, and no antiseptic smell assaulted the nostrils. The lobby on the ground floor had several couches and love seats where residents and visitors socialized. The food, my mother always used to marvel, was superb and ample. Tastes homemade, she used to say. With its pastel-colored walls of alternating strips of light and dark beige, the facility had the appearance of an upscale apartment building, defying the image of the

The very best in fine

the

It isnt only understaffing that contributes to improper infection control. It is also the quality of the nursing home staff. The nursing home workers who interact daily with the patients have different levels of expertise. The most trained, the highest salaried (and therefore the fewest per patient) are the registered nurses (RNs). The workers who have the most interactions with the patients moving, changing, feeding, bathing, and medicating themare the certified nursing assistants. CNAs are low paid, earning hourly rates hovering at around minimum wage. They are also poorly trained, receiving certification after only 75 hours of training. Proper infection control is generally given only cursory coverage during training, and there are only three questions in the practice exam on the topic.

weakest links

photography and video

With low pay, too many patients to care for, and a nursing home population that is more challenging than ever before, CNAs burn out quickly. Turnover is high; about 75 percent of CNAs in a facility will quit in any given year. High turnover translates to CNAs who have little experience in infection control, and burdens the RNs with having to continually retrain staff. High turnover among CNAs also leads to a loss in continuity of care. With large segments of the nursing home population suffering from dementia, Alzheimers, or other illnesses that make them unable to communicate, it is often up to caregivers to detect changes in behavior that clue them into the onset of infections. That knowledge requires knowing the patients nuances of behavior, an observation highly unlikely when nursing homes have such low staff retention rates.

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hospitals have mostly jettisoned their role as facilities for recuperation, focusing primarily on acute care. patients leave hospitals sick, but not sick enough to stay. recuperation, rehab, and other sub-acute care have been offloaded to nursing homes.
depersonalized setting so associated with nursing homes. Moreover, the home was convenient, within several miles of where three of her children lived. My mother wound up in a nursing facility only because of the new structure of our healthcare system. Until the 1990s, homes would have residents who were relatively healthy, with some as young as in their 60s. Today, long-term care facilities house a wide range of demographics with a host of illnesses: middle-aged or otherwise healthy seniors undergoing rehab; Alzheimers and dementia patients; patients in need of complex intervention protocols like IV and dialysis; and those who are terminally ill. The mix has created an infection-control nightmare. Whereas hospitals inherently have a setting where patients, mostly confined to their rooms or beds, do not mingle with other patients, nursing homes have more of a communal atmosphere. Patients

eat together, socialize together, and rehab together, creating an environment ripe for the spread of infection. It also exposes mostly healthy patients to infections that have colonized in much sicker residents. The primary reason behind the changing makeup of the nursing home population is exploding healthcare costs of hospitalization. Private insurance companies, Medicaid, and Medicare are all anxious for patients to leave the expensive confines of hospital care, where a bed can cost thousands of dollars a day. Paying for a patient in a bed in a nursing home is far cheaper than in a hospital. Hospitals have mostly jettisoned their role as facilities for recuperation, focusing primarily on acute care. Patients leave hospitals sick, but not sick enough to stay. Recuperation, rehab, and other sub-acute care have been offloaded to nursing homes. Sharing the experience of many nursing home patients, my mother contracted pneumonia during the second week of September. We didnt want to scare her, so we told her she had bronchitis. Although her lungs were officially clear two weeks later, she was still coughing the last time I saw her at the home, a month and a half later.
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Could my mothers death have been prevented with better

month period in 2008, and found that in 41 percent of the cases in which antibiotics were prescribed, they were unnecessary. In the cases where they were prescribed according to medical guidelines, 72 percent were given either the wrong dosage or told to take it for the incorrect amount of time. Urinary tracts infections, or UTIs, are a scourge to nursing home patients. Often a UTI will be the start of an elderly patients slippery slope to sepsis and then death. Dr. Seth Lapin, a gastroenterologist in Brooklyn for the past 15 years, has treated hundreds of nursing home patients. He blames many nursing-home UTIs on unnecessary bladder catheterization, where a tube is inserted into the bladder and then a bag collects the urine. I find that a lot of patients have them, even though they dont need them, he said. Its easier for the staff to leave the catheter in than to change the patient. Lapin estimates that a majority of catheterizations are not medically justified.

Deadly
The revolving door of nursing home staff also contributes to the widespread overuse of antibiotics in nursing homes. Dr. David Dosa, health services researcher and professor at Brown University, said the following scenario is common: Mrs. Smith has dementia; she gets confused very easily. A new nurse comes on, doesnt know Mrs. Smith, and thinks Mrs. Smith is more confused than she should be. The nurse suspects the confusion is due to a urinary tract infection. She tells the doctor that she would like to send out a urine sample to the lab. Once that decision is made, often what happens is a knee-jerk reach for the antibiotics.

antibiotics
Although antibiotics kill harmful bacteria, their rampant use in nursing homes actually creates the opportunity for more infections to thrive, particularly C difficile, a bacterium that can lead to diarrhea and sometimes fatal sepsis. To illustrate the harmfulness of unnecessary antibiotics, Dosa made this analogy: Imagine you walk into a field and you poison all the grass, and only the weeds are left. Bacteria are like weeds; they wont do anything because they cant crowd out the grass, but now you kill out all the grass. Whats left? Dosa studied antibiotics dosage in two nursing home in Rhode Island during a six-

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infection control at a different facility? Its difficult to say, but if we had known how prevalent these deadly infections are, and the variables that may make a facility less likely to spread them, we might have made a different choice. One important source of information to which we were oblivious was the nursing-home comparison website, which makes some nursing home infection data more transparent. All facilities that receive Medicaid or Medicare reimbursements are searchable. According to the site, my mothers facility had the highest overall rating a nursing home can have, five stars, a distinction given to it because of its outstanding record of inspections. But a stellar record of inspections doesnt guarantee positive outcomes for patients. A deeper dig into the data reveals that despite the high overall rating, my mothers facility had the potential to be a dangerous place for its residents. In 2009, 14 percent of its residents developed urinary tract infections; one out of every three long-term patients developed bedsores, more than triple the national average; and 70 percent lost bladder or bowel control. In these quality measures, the facility only received a two-star rating. The site also indicates whether an institution is non-profit or for-profit. The facility in question is a forprofit institution. Its a privately owned partnership, so its finances are not open to the public. Although research keeps indicating that non-profits are superior when it comes to infection control, structural changes in how we care for our elderly are unlikely to take place anytime soon. As Professor Charlene Harrington said when she presented her research findings before Congress (see sidebar), They are just not interested in doing anything about it because they say, These are private companies. We cant tell them how to run the company. Harrington maintains that at the heart of the high nursing home infection rate is a cultural attitude of, We dont like to think about people getting old. We dont like to talk about it. When they go in there, we just like to write them off.

numberskill
Why does understaffing lead to more infections? Professor Nicholas Castle thinks the answer is simple: the fewer health care workers there are the more hurried you are, the less likely you are to follow infection control procedures, he explained. The most basic procedure to prevent infections is hand-washing, and its there that nursing homes commonly fail: In general, handwashing compliance is dismal. Mark Loeb, a professor of Public Health at McMasters University in Toronto, studied several nursing homes in 1999, monitoring hundreds of instances where hand disinfection should have been done but wasnt. The staff in the nursing homes that Loeb studied washed their hands only 15 percent of the time after performing tasks like moving or dressing a patient. Loeb doesnt believe much has changed since his original study. I dont think compliance is more than 20 percent, he said. Understaffing at long-term care facilitiesand how it contributes to poor carehas been on the radar screen of nursing home researchers for at least a decade. Its what many researchers see as the smoking gun of nursing home infections. Charlene Harrington, a professor at the University of Southern California, said, We have done tons of studies, and every single one shows that nursing homes are understaffed. Nursing homes infections are worse than hospitals because they have half the staff that hospitals have. Nursing homes are grossly understaffed. We know from federal studies that the minimum staffing should be 4.1 hours per resident per day, but the average staffing level is much lower. The biggest single problem is inadequate staffing. Harrington thinks that the problem of poor infection control is so intractable because of the difficult balance for institutions that, on the one hand, have to provide profits to shareholders and owners and, on the other, are expected to provide the best care possible to their residents. In Harringtons view, too often poor infection control is a symptom of the pursuit of large profits. Most nursing homes are businesses; more staff slices into their profit margin. That profit margin can be significant. In 2008, two of the top 10 nursing homes had profit margins of 15 to 18 percent, profitability comparable to such corporate behemoths as General Electric or Alcoa in a good year. Thats somewhat startling when most nursing home income is derived from federal and state governments. Nursing homes generally dont make money on Medicaid patients. In fact, with a maximum reimbursement rate of about $270 a day, nursing homes often lose money on Medicaid patients. Where nursing homes earn a profit is on Medicare patients, where reimbursements can reach $700 to $800 a day. Medicare patients have larger reimbursements because the patients are supposed to be sicker, and therefore require more staff per patient. But the problem, according to Harrington, is that nursing homes take the Medicare reimbursements, but dont provide the care. They get paid more by Medicare, but then they dont put the staffing in. Medicare hasnt set any accountability requirements for the nursing homes. They are getting away with this because the federal government has no minimum staffing standards. Overall, the most understaffed facilities are the for-profits. The non-profits do hire more people; the for-profits cut staffing to the bone, Harrington said. Harrington and other researchers published a study that looked at state inspections of thousands of nursing homes, finding that for-profit facilities averaged 47 percent more unsatisfactory citations than non-profits. A 2007 study of the most-cited nursing homes by the Government Accounting Office bolsters Harringtons contentions. The worst performing facilities in the nation, the GAO concluded, were more likely to be for-profit and part of a chain and have more beds and residents. In addition, they had an average of almost 24 percent fewer registered nurse hours per resident, per day.
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