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Old 11-14-2018, 11:03 AM
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Angry Feds find 'blatant disregard' for veteran safety at VA nursing home

https://www.usatoday.com/story/news/...rs/1947406002/

Feds find 'blatant disregard' for veteran safety at VA nursing home, already among the nation's worst

Donovan Slack, USA TODAY, and Andrea Estes, The Boston Globe Published 7:00 a.m. ET

Nov. 14, 2018 | Updated 11:16 a.m. ET Nov. 14, 2018

Don Ruch’s family thought round-the-clock care would help him recuperate, but he ended up in intensive care in septic shock, suffering from “severe” malnutrition, bedsores on his pelvis and back, a burn on his right thigh and a trauma wound. USA TODAY

BOSTON – Staffers at the Department of Veterans Affairs nursing home in Brockton, Massachusetts – rated among the worst VA nursing homes in the country – knew this spring they were under scrutiny and that federal investigators were coming to visit, looking for signs of patient neglect.

Still, when investigators arrived, they didn’t have to look far: They found a nurse and a nurse’s aide fast asleep during their shifts. One dozed in a darkened room, the other was wrapped in a blanket in the locked cafeteria.

The sleeping staffers became a focal point of a new, scathing internal report about patient care at the facility, sparked by a nurse’s complaint that veterans were getting substandard care, according to a letter sent late last month to President Donald Trump and Congress by the agency that protects government whistleblowers.

“We have significant concern about the blatant disregard for veteran safety by the registered nurses and certified nurse assistants,” agency investigators wrote in a report about the 112-bed facility. The Brockton facility is a one-star nursing home, the lowest rating in the agency’s own quality ranking system.

VA spokeswoman Pallas Wahl said officials took “immediate corrective action,” and the employees caught sleeping no longer work there.

The problems at the Brockton nursing home are the latest to surface in a review of VA nursing home care by USA TODAY and The Boston Globe.

In June, the news organizations revealed the VA’s secret quality ratings showed that care at more than 100 VA nursing homes across the country scored worse than private nursing home averages on a majority of key quality indicators last year.

In response to questions from USA TODAY and the Globe, the VA released nursing home ratings that had been kept secret for years, potentially depriving veterans and their families of crucial health care information.

At the time, the VA said it was releasing inspection reports the agency has withheld from the public for nearly a decade. But five months later, none has been released.

VA spokesman Curt Cashour told USA TODAY that the agency is working with an outside contractor to remove patient information from reports. He said the VA expects to release "publicly redacted versions of the most recent reports" around Christmas.

That's not good enough for Leslie Roe, whose husband of 38 years walked out of a supposedly secure unit at the VA nursing home in Tuskegee, Alabama, last year and was never found.

Roe, who had Navy veteran Earl "Jim" Zook declared dead earlier this year, wants the VA to immediately release three years' worth of inspection reports – the standard for private-sector nursing homes whose reports are posted on a federal website, NursingHomeCompare.

"It's just a shame the way the VA is," she said. "It can't help Jim, but maybe it can help just one other person."

The reports can include incidents of poor care and conditions that can be a tip-ff to prospective or current residents and their families about problems with staffing or neglect at a facility.

"What are they hiding? Why wouldn’t you release it?" asked Amy Leise, whose uncle, Vietnam veteran Don Ruch, suffered from malnutrition and bed sores last year at a VA nursing home in Livermore, California.

"It feels like the government is immune from accountability and responsibility, where in other settings that wouldn't be the case," she said.
VA releases new nursing home ratings

In the meantime, the VA has released an updated set of star ratings. They show 45 of its nursing homes received the lowest one out of five stars for quality as of June 30. That’s down from 58 in March. The VA has 133 nursing homes that serve 46,000 infirm veterans each year across the country.

At the nursing home in Brockton, residents were, on average, more likely than residents of other VA nursing homes to deteriorate, feel serious pain or suffer from bedsores, according to agency data. They were nearly three times as likely to have bedsores than residents of private nursing homes.

The Brockton whistleblower, licensed practical nurse Patricia Labossiere, complained to a federal whistleblower agency, the Office of Special Counsel, earlier this year after supervisors ignored her alerts, she said.

“I am a no-nonsense nurse who took a vow to take care of patients,” said Labossiere, who quit in July. “We are there to be kind and treat others as we would want to be treated. I could not believe that this was how we treat the people that fought for our country.”

Labossiere said she saw instance after instance of poor patient care at the facility within days after she started working there last December. She told the federal whistleblower agency that nurses and aides were not emptying the bedside urinals of frail veterans. Nurses failed to provide clean water at night and didn’t check on the veterans regularly, as required, she said. And they often slept when they were supposed to be working.

She offered some specific examples: One patient was having trouble breathing because his oxygen tank was empty. Another fell – his feeding tube got disconnected and the liquid splashed onto the floor – and didn’t appear to have been monitored by staffers for hours.

The VA investigators did not substantiate those specific allegations, saying the patient with the empty oxygen tank suffered no ill effects. Investigators couldn’t confirm that the patient who fell had been neglected because the records had been shredded “in accordance with the local policy.”

'Routinely receiving substandard care'

Wahl, the VA spokeswoman, noted that the investigators “did not find evidence of veteran harm or neglect.” She said the facility’s one-star rating is undeserved and not an “accurate reflection of the quality of care delivered to our patients."

The Office of Special Counsel ordered the VA’s Office of Medical Inspector to investigate Brockton following Labossiere’s complaint. The office turned over its report in September to Special Counsel Henry J. Kerner, who sent the findings to Trump and Congress on Oct. 23.

“Because a brave whistleblower came forward, VA investigators were able to substantiate that patients at the Brockton (nursing home) were routinely receiving substandard care,” Kerner said in an emailed statement.

This is not the first time the Brockton facility has come under fire by the Office of Medical Inspector.

In 2014, a doctor at the nursing home alleged that three veterans with significant mental health issues received “inappropriate medical and mental health care.”

Two of them went years, he alleged, without appropriate treatment. A third allegedly received psychotropic drugs for more than two years against written instructions.

Investigators largely substantiated the allegations, finding that two veterans with significant psychiatric issues did not receive adequate treatment for years. They did not substantiate the allegation that a third received improper medication.
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Old 11-14-2018, 02:05 PM
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Angry Secret VA nursing home ratings hide poor quality care from the public

Secret VA nursing home ratings hide poor quality care from the public
By: Donovan Slack, USA TODAY, and Andrea Estes, The Boston Globe Published 6:00 p.m. ET June 17, 2018 | Updated 8:08 p.m. ET June 17, 2018
RE: https://www.usatoday.com/story/news/...are/674829002/

By early next year, the first foods made from gene-edited plants are expected to begin selling. It’s very different than today’s controversial “genetically modified” foods. But some critics say gene-edited products still need close monitoring. (Nov. 14)AP

World War II veteran Rosario "Russ" Bonanno was facing worsening dementia when his family brought him last year to the Department of Veterans Affairs nursing home in Bedford, Massachusetts. He had been in assisted living, but after six years, some family members thought he needed more specialized care.

Within days after Bonanno arrived, his son Nick said the 93-year-old was “dazed, confused, disheveled" as staff began medicating him. He wasn’t the only resident who looked drugged. "Everyone looks like a zombie," Nick said.

What Nick and his family didn’t know was that the Bedford facility ranked among the worst of 133 VA nursing homes across the country, in part for giving so many residents anti-psychotic drugs.

But the VA knew.

The agency has tracked detailed quality statistics on its nursing homes for years but has kept them from public view, depriving veterans of potentially crucial health care information. Nearly half of VA nursing homes nationwide – 60 – received the agency'slowest ranking of one out of five stars as of Dec. 31, 2017, according to documents obtained by USA TODAY and The Boston Globe.

The VA made some of its ratings public last week after receiving questions from the Globe and USA TODAY about all the secrecy. VA officials said President Donald Trump wanted to release the ratings all along and blamed the Obama administration for not making them public earlier.

Statistics the VA has not released paint a picture of government nursing homes that scored worse on average than their private sector counterparts on nine of 11 key indicators last year, including rates of anti-psychotic drug prescription and residents’ deterioration. In some cases, the internal documents show, the VAratings were only slightly worse. In others, such as the number of residents who are in pain, the VA nursing homes scored dramatically worse.

The worst-performing VA nursing homes were scattered across 32 states, including Pennsylvania, which had five one-star facilities, as well as Texas and California, which had four each. The VA facility in Bedford and another in Brockton, Massachusetts, were the only one-star nursing homes in New England.

Rating chart: https://www.gannett-cdn.com/media/20...mes-Online.png

VA officials argued that the VA nursing home system, overall, “compares closely” with private nursing homes despite caring for typically sicker residents.

VA spokesman Curt Cashour called it “highly misleading” to compare pain levels at the VA with those at private nursing homes because VA residents have “more challenging” medical conditions. The VA's internal quality tracking found that VA nursing home residents were five times more likely to report being in pain than private nursing home residents.

Cashour said 60 VA nursing homes have seen improvements in their rating over the past year, while only one had a “meaningful” decline.

“We are committed to continuous improvement efforts in all of the (VA nursing homes) and demonstrating performance that is as good (as) or better than private sector facilities,” Cashour said.

The VA’s hospitals have drawn intense criticism for repeated scandals involving health care in recent years, including preventable deaths, but the agency largely has operated its nursing homes with scant public scrutiny. VA nursing homes serve 46,000 veterans annually in 46 states, the District of Columbia and Puerto Rico.

Internally, the agency has long monitored care at its nursing facilities through quality indicators and unannounced inspections and, since 2016, through star rankings based on the indicators. Until now, it has kept all of these quality measures from the public.

Under federal regulations, private nursing homes are required to disclose voluminous data on the care they provide. The federal government uses the data to calculate quality measures and posts them on a federal website, along with inspection results and staffing information. The regulations do not apply to the VA.

The VA has “got this whole sort of parallel world out there that’s hidden,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “I still can’t get over that this information is not available to people who are looking for a veteran’s home. That’s just unacceptable.”

VA spokesman Cashour blamed the Obama administration for resisting making quality data public. “But under President Trump’s leadership,” he wrote in a statement June 12, “transparency and accountability have become hallmarks of VA.”

The VA’s decision to release the quality data came after first asking USA TODAY and the Globe for more time to answer questions about the secret ratings. Then the VA released the quality ratings while the reporters waited for answers.

The agency did not release the more detailed information that underlies the star ratings, such as rates of infection and injury.

Alex Howard, a longtime transparency advocate and former deputy director of the Sunlight Foundation, said the VA should release all of the data immediately – and on an ongoing basis. He said the underlying information is critical to understanding what the stars mean.

“There shouldn’t be a gap between the reality of how we’re treating people under the government’s care and public understanding of it,” Howard said. “This is not a situation where we’re concerned about some matter of national security, this is simply being honest about how well things are going.”

'I was told how good it is – by VA, of course'
After 38 years of marriage, Leslie Roe made the gut-wrenching decision to place her husband in a nursing home.

Earl James “Jim” Zook, 72, suffered from dementia and had taken to wandering away from their home in Coosada, Alabama, and she worried she would lose track of him.

Roe moved Zook, a Vietnam-era Navy veteran, into a VA home an hour away in a rural, wooded swath of Tuskegee, Alabama. She said VA staff put a bracelet on his wrist warning he was a flight risk and placed him in a secure ward.

Three months after Roe checked Zook into the Tuskegee facility, staff lost track of him. Zook simply walked out into the woods; Roe said she was told there was a faulty door.

She had no idea that the facility ranked among the worst VA nursing homes in the country last year, scoring only one out of five stars in the agency’s own quality rankings. She had to rely on what the VA said.

“I was told how good it is – by VA, of course,” Roe said.

The VA assigns stars based on 11 indicators that can be tipoffs to larger problems with overall quality. For example, high rates of falls or bed sores may indicate understaffing or neglect.

The Tuskegee nursing home scored worse than private nursing home averages on eight of the 11 criteria as of Dec. 31, 2017, including rates of residents being in pain, receiving anti-psychotic drugs and contracting urinary infections.

This year, the Tuskegee nursing home improved from one star to two stars. That was too late for Zook.

He hasn’t been seen since he walked out of the Tuskegee facility in January 2017. Searches by helicopter and with tracking dogs turned up nothing.

“We finally declared him legally dead,” Roe said this year, “because there was no way he could have lived without his medication.

“Anybody that deals with VA, I feel sorry for them,” she said.

Cashour said that after Zook’s disappearance, which he called an “unanticipated outcome,” the VA implemented more safety measures, including adding GPS to an alarm system that notifies staff if patients leave the facility.

‘They break their spirit’

The VA has relied for more than a decade on an outside company, Wisconsin-based Long Term Care Institute, to conduct inspections of VA nursing homes and report back to the agency.

The VA banned the public release of institute reports after the Pittsburgh Tribune-Review in 2009 published the findings from one report detailing “significant issues” at the VA nursing home in Philadelphia, including poor resident grooming and pest control. In one case, a patient’s leg had to be amputated after an infection in his foot went untreated for so long his toes turned black and attracted maggots.

The VA said the reports are internal quality assurance documents “protected” from disclosure under federal law. However, in their announcement last Tuesday releasing the nursing homes’ star ratings, VA officials said they would also release the long-term care reports. They didn’t say when.

Such reports might have been helpful to Bonanno, the WWII veteran whose family moved him from a private assisted-living facility to the Bedford VA last April as his dementia worsened.

An inspection report obtained by the Globe shows reviewers from the Long Term Care Institute found several instances of neglect at the nursing home in April 2017. They saw a veteran lying in bed covered only by a urine-and-feces-stained sheet. They saw another veteran struggling to eat, using his hands to shove food in his mouth after trying unsuccessfully to maneuver food onto a spoon. Staffers were nearby, the report said.

By then, inattentive patient care in Bedford had already proved fatal to one resident. Vietnam veteran Bill Nutter died in 2016 while an aide who was supposed to check on him hourly allegedly played video games on her computer and didn’t check on him at all. She later resigned, and Nutter’s family sent a letter to the VA seeking $10 million in damages.

Bonanno’s family would learn about the conditions the hard way.

His son said Bonanno, a happy-go-lucky retired mechanic, would always wake up early for breakfast. But for the first few months in the Bedford facility, he was fast asleep when his son arrived after 11 a.m. for a visit. According to Nick, the staff woke him up at 6 a.m. to put him back to sleep. They gave him an anti-psychotic drug and a sedative, Nick said.

“They medicate them until they break their spirit and make them passive. I guess it’s easier for the staff to deal with them,” Nick said. “In six years in assisted living, he’d never been medicated during the day.”

Staff told Nick that his father was “agitated” and needed the medication — a contention Nick disputes.

Cashour said many of the veterans at Bedford live with “chronic mental illness” related to their military service and require psychotropic medication “to reduce distress and manage behavior.” After the veteran is stabilized, he said, the VA works to reduce the use of these drugs.

Nick’s brother, Russ, who lives in Indiana, said he and his sister, who also lives outside of Massachusetts, believe their father’s overall health has improved and he is properly medicated.

“My sister and I both agree he’s getting care that’s high quality and appropriate for his needs,” he said.

Nick said that as their father became more and more groggy, he participated in fewer activities; he went from walking with help to sitting in a chair for hours, doing nothing.

“There are ways to care for people with dignity and allow them to be themselves,” said Nick, who visits his father several times a week. “I was lucky to have Dad in a place that was pretty good for six years. It was a huge drop-off in the way they provide care at the VA versus a private facility.”

‘I thought my heart was going to stop’

Photo link: https://www.gannett-cdn.com/-mm-/67d...t=405&fit=crop
As a paraplegic, Don Ruch couldn't feel the gaping wound festering on his leg. But when the 71-year-old saw a picture of the hole, he went from trusting to terrified. His family had checked him into a VA nursing home last year with hopes the round-the-clock care and rehabilitation services there would help him recuperate from the aneurysm that caused his paralysis. But within months, the one-time Army infantry radio operator ended up in the intensive care unit at a nearby private sector hospital. (Photo: Ryan Henriksen for USA TODAY)

The VA assigned three stars to its nursing home in Livermore, California, even though the facility scored worse on average than private facilities on six of 11 criteria. Residents reported being in pain at dramatically higher rates and experienced general declines and developed sores at slightly higher rates.

As a paraplegic, Livermore VA resident Don Ruch couldn’t feel the gaping wound festering on his leg. When the 71-year-old saw a picture of the hole, he went from trusting to terrified.

His family had moved him into the VA nursing home last year, hoping the round-the-clock care and rehabilitation services would help him recuperate from the aneurysm that caused his paralysis.

Within months, the onetime Army infantry radio operator ended up in the intensive care unit at a nearby private hospital, Stanford ValleyCare. Doctors found him in septic shock from a “significant” urinary tract infection, medical records show. He was suffering from “severe” malnutrition, bedsores on his pelvis and back, a burn on his right thigh and a trauma wound on the back of his right calf.

Photo link: https://www.gannett-cdn.com/-mm-/0fe...t=240&fit=crop
A trauma wound on Vietnam veteran Don Ruch's right calf. (Photo: Handout)

Ruch couldn’t lift his leg to see the wound, so he asked a caregiver to take a picture and show it to him.

“I saw a hole in my leg that I think I can stick a golf ball into,” he said. “I thought my heart was going to stop.”

Ruch, who said he was so depressed he didn’t realize he wasn’t eating enough, felt betrayed — by the nurses who had repeatedly changed his bandages without saying anything about how bad the wound had become and by the doctor who told his family it was nothing to worry about and from a “small bruise.” The same doctor told his niece he was malnourished because “we can’t make a veteran eat.”

Cashour, the VA spokesman, said Ruch has a complex medical history and a review of his medical records “does not suggest that there was a delay in diagnosis, treatment or triage to the hospital in this case.”

The episode triggered Ruch’s post-traumatic stress disorder and his niece managed to get him transferred to a private nursing home — paid for by the VA — near her home in Omaha, Nebraska. It took three months to recover, but he’s better, his family said.

“Can you imagine the thousands and thousands and thousands of veterans who sit in these places and act compliant because they don’t have a choice,” his niece, Amy Leise, said. “This makes me want to cry.”
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O Almighty Lord God, who neither slumberest nor sleepest; Protect and assist, we beseech thee, all those who at home or abroad, by land, by sea, or in the air, are serving this country, that they, being armed with thy defence, may be preserved evermore in all perils; and being filled with wisdom and girded with strength, may do their duty to thy honour and glory; through Jesus Christ our Lord. Amen.

"IN GOD WE TRUST"
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