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S.C. Struggles To Monitor Nursing Homes

Lexington County case indicates red tape impedes efforts to protect residents

Feb 16, 2003 | Columbia State Johnnie K. Jackson seemed fine when her daughter, Peggy White, left Manor Care Nursing Home on the evening of Feb. 1, 2001.

An 88-year-old stroke victim who battled dementia and couldn't lift herself out of bed, she lay quietly, eyes open, as White departed just as she had when Jackson's youngest daughter, Nancy Sneyd, left earlier that day.

The next morning, a nurse at Manor Care called Sneyd at Devro Teepak, the sausage casings plant in Calhoun County where she worked, and said her mother had "a suspicious bruise on her left arm," Sneyd recalled.

Sneyd and White raced to their mother's side. They found her with not only a bruised arm, but deep, dark bruises on her leg and chest, plus a busted lip.

"I will never forget the look on Mom's face," White said. "She looked like a frightened child. She had a terrified look on her face, and I could tell that she was in pain. She had such a pleading look about her face as if begging us to help her."

She was taken from the home, since renamed Heartland of Lexington, to the emergency room at Lexington Medical Center. Jackson couldn't say what had happened, her daughters said, and no one from the nursing home on Sunset Drive ever adequately explained the injuries.

Incensed, Sneyd told everyone she could think of that she believed her mother had been abused.

What followed was an adventure in bureaucracy in which the agencies charged with protecting South Carolina's elderly either did nothing or waited so long that learning what happened became impossible.

Sneyd's frustration points to a larger problem, in South Carolina and elsewhere. With more people putting relatives in long-term care, the state's system for ensuring their safety is full of holes.

Up to 5 million elderly Americans are abused each year, according to a 2002 report by the U.S. Senate Committee on Aging. The number reported in nursing homes is unknown because no one tracks all complaints.

Thirty percent of the nation's 17,000 nursing homes are cited each year for conditions that have caused or could lead to death or serious injury, the U.S. General Accounting Office said in a report last year. But with reporting spotty and safeguards "insufficient," the report said, many incidents go undetected.

In South Carolina, four state agencies monitor complaints in some manner, and officials generally agree that abuse and neglect complaints are rising. But the number of incidents is unknown.

Some say that's because the state's priorities are misplaced.

"The whole issue of abuse and neglect is such a low-threshold issue," said Randy Thomas, who teaches elder justice at the S.C. Criminal Justice Academy, "because the public just doesn't care about this age group."

Jackson stopped eating after the incident and died six weeks later. Although her family never alleged any direct connection between the incident and her death, Sneyd sued the home for "gross negligence." Citing her mother's overall treatment as well as the February incident, she said in the lawsuit that her mother was abused and neglected.

The company that owns the home, HCR Manor Care Inc. of Toledo, Ohio, denied Sneyd's charges. It said it provides quality care at the home. The parties agreed to settle the lawsuit in December for an undisclosed amount somewhere between $50,000 and the $225,000 Sneyd originally sought, she said.

Sneyd insisted that the settlement not prevent her from discussing the case because she said telling her mother's story meant more to her than money.

The youngest of Jackson's five children, Sneyd was close to her mother and visited four or five times a week. On the days when Jackson recognized Sneyd, she called her daughter "Nanny," as she always had. They had the same expressive blue-green eyes, and though it was hard to watch her mother recede into the darkness of dementia, Sneyd wanted to be with her.

She also felt her mother deserved better.

"You put them in a nursing home in good faith hoping that they're going to take care of them," she said. "But you see what happened."

According to interviews and notes she took at the time, Sneyd called at least five agencies in the days and weeks after her mother was injured. Her experiences with three in particular help explain her frustration with the system.

THE SHERIFF'S OFFICE

Sneyd called the Lexington County Sheriff's Department on Sunday, Feb. 4, 2001, and Deputy Sam Goodwin came to her home that afternoon.

Goodwin advised her to take photos of her mother but declined to go to the nursing home.

"I don't think he felt like he could walk into the nursing home and do this himself," Sneyd said in a deposition last year.

Lexington County Sheriff James Metts confirmed that Goodwin did not file an incident report or visit the nursing home. Metts said Goodwin determined that "the case was already under investigation by the state" and that further investigation by the sheriff's office wasn't necessary.

Metts said Goodwin could not recall who or what state agency was investigating.

The sheriff declined to make Goodwin available for an interview. He also declined to check Goodwin's record to determine whether he had received optional "elder abuse" training at the S.C. Criminal Justice Academy, a division of the Department of Public Safety that trains local officers.

Metts said Goodwin and all other Lexington County officers receive elder abuse instruction within the department. Metts also said he was satisfied that Goodwin responded appropriately.

THE OMBUDSMAN

On Monday, Feb. 5, 2001, Sneyd called the S.C. Long Term Care Ombudsman, according to records from that office. The ombudsman, created by the federal government in 1972, monitors care, responds to complaints and makes referrals to law enforcement and state regulators.

How the office handled Sneyd's complaint is in dispute.

She said she reported the case as abuse. But Shirley Thomas of the Columbia ombudsman's office said Sneyd never alleged that her mother had been abused. That would have led to an automatic referral to police, she said.

Records from the ombudsman's office show that Marilyn Comar, Manor Care's director of nursing, called to report an "allegation of physical abuse" Feb. 7. Thomas said she then sought Jackson's hospital records.

Thomas said two messages were left for Sneyd, but Sneyd said no one ever called. "Anything to do with mother, I would've returned the call," she said.

Records provided to Sneyd by the ombudsman's office show that Thomas didn't visit Jackson until Feb. 24, 2001 - 19 days after Sneyd's initial complaint. They also include a memorandum from Comar saying Jackson "is severely cognitively impaired and has little or no memory capabilities, short or long term."

Thomas said she didn't go to Manor Care sooner because the agency's Columbia office has only two investigators to handle more than 1,000 complaints a year in four counties. The office regularly has a backlog of 50 to 60 cases.

When she visited, Thomas said, Jackson "indicated nothing was wrong." After speaking with three other staffers, she said, she stopped investigating.

Despite the delay and Comar's memo about Jackson's memory, Thomas said Jackson remembered what happened. "Just because you get old or sick does not mean that you're not competent to handle your affairs," she said.

According to Thomas' notes from their Feb. 24 meeting, Jackson told her she fell. Thomas then told Jackson a report of physical abuse had been received - specifically, that someone had hit her.

"Ms. Jackson was asked if she would participate in a staff lineup and identify the staff that hit her," Thomas wrote. "She again denied the allegation of being hit. Ms. Jackson was asked if she was fearful of anyone in the facility and she replied that she was not."

Thomas said Jackson told her: "These girls take very good care of me."

Still, Sneyd can't believe Thomas dropped the case based on her mother's memory three weeks later. She said her mother could not have remembered the incident that long after it happened. "Momma did not know what was going on," she said.

One person Thomas did not interview was Barbara Scheriff, a nurse with Hospice Care of Tri-County, which had been hired to help care for Jackson. Scheriff had written a report Feb. 5 based on a visit to Jackson's room. The report contained an allegation that Jackson said she had been hit.

During a visit to help feed Jackson, Scheriff wrote, a nursing assistant at the home entered the room "and Mrs. Jackson immediately withdrew until staff member left." The staffer mentioned Jackson's bruising, and offered that no one knew how it happened.

"Within 5-10 minutes of staff member leaving her room, Mrs. Jackson made eye contact with (Scheriff) and clearly and intelligibly verbalized 'Nurse hit me,'" Scheriff wrote.

Despite Scheriff's account, Sneyd said she doesn't believe a nurse hit her mother. She said Jackson called all of the staffers "nurse," and that she may have said, "Nurse, help me."

Sneyd said Thomas should have talked to Scheriff, the hospice nurse who has since changed jobs and could not be reached for comment.

Because Jackson didn't want the matter pursued, Thomas said it would have violated agency policy to interview Scheriff and the employee who had entered Jackson's room. The interviews also might have risked further harm to Jackson, Thomas said.

The agency must respect the wishes of a resident who doesn't want an investigation, Thomas said, unless he or she has been declared incompetent legally.

Thomas cited an ombudsman's office policy that says "if the resident does not consent, tell facility that the resident has no complaint and leave." She said she interviewed other staffers because of Sneyd's concerns.

Sneyd believed her mother was dropped, and alleged that in the lawsuit. She said the bruises on her mother's inner thigh measured 10 by six inches, which she said was exactly the same as the band on a hoist used by the nursing home to lift patients. She thinks her mother was dropped and then lifted by a single staffer "dangling there like some puppet" trying to put her in bed.

Sneyd doesn't believe the ombudsman's report and Thomas' claims about what Jackson said.

THE REGULATORS

Sneyd also called the state Department of Health and Environmental Control on Monday and Tuesday, Feb. 5 and 6, according to agency records. DHEC had been notified by the nursing home on Feb. 2, the day the injuries were discovered.

Nursing homes must report an incident within 24 hours, which Manor Care did. But DHEC didn't send a surveyor until March 20, four days after Jackson died.

Experts say timing is crucial in nursing home investigations because witnesses die or forget, and evidence disappears.

"I want to get people in early," said Bill Gambrell, who runs the S.C. Medicaid Fraud Control Unit, a federally funded agency set up to prosecute allegations of abuse and neglect in nursing homes. "Because time is the death knell of these cases."

Two divisions of DHEC opened investigations.

The agency's licensing division referred the matter to the S.C. Long Term Care Ombudsman, records show. The ombudsman never reported back, and the licensing division's investigative file remains open, according to its records.

A separate inquiry was made by DHEC's bureau of certification, the division charged with inspecting nursing homes to ensure quality care. The certification division is required to investigate the most serious charges within two working days.

The certification division first learned of the incident Feb. 2, when the nursing home called the agency's abusehot line.

The nursing home reported finding Jackson with a large bruise on her left wrist and hand on Feb. 2, which appeared to be a recent injury, according to a DHEC memorandum. An examination revealed other bruising, including "the right chest, right inner thigh, both extremities, left elbow and a contusion of the lip." The injuries, the report said, were "in various stages of healing, as indicated by color."

Karen Price, director of DHEC's certification bureau, initially said inspectors didn't go to the home before March 20 because a family member "requested that we not investigate until the facility had completed their report." But Sneyd said no one in the family ever asked DHEC to wait.

Asked in an e-mail to document that request, Price said through a DHEC spokeswoman that she "misspoke."

Price said DHEC decided the incident wasn't severe enough to warrant an immediate visit.

Federal policy regarding nursing home care requires DHEC to visit the home within two days after receiving complaints involving "immediate jeopardy" to residents. Immediate jeopardy occurs when a care facility, by not following regulations, "has caused, or is likely to cause, serious injury, harm, impairment or death to a resident."

Price said Jackson's injuries didn't meet that standard, which she said "is defined as a crisis situation."

"The information received revealed that the resident had bruises," Price said in an e-mail. "These in and of itself would not constitute a crisis situation."

Arthur Starnes, who supervises the certification division under Price, said DHEC didn't interview Scheriff, the hospice worker, because "we had no trigger" to do so.

According to DHEC records, Sneyd called again on March 26 to ask about the February incident. A DHEC surveyor then visited the home and, in a report dated March 29, cited Manor Care for 26 violations, including three related to Jackson's care. The inspector found that:

• Her care plan did not address potential problems or side effects related to the children's aspirin she was taking, which left her susceptible to bruising;

• No documents were provided showing that all staff were trained in transferring and turning over residents;

• The home failed to ensure that nursing staff were monitored "to ensure the resident was assisted in attaining or maintaining the highest level of functioning practicable."

Manor Care was not fined for the deficiencies but was given a "followup packet" and told to correct the problems, which it did to DHEC's satisfaction.

In the correction related to Jackson's care plan, nursing home officials noted that she "no longer resides in the facility."

MANOR CARE

The most detailed explanation Manor Care offered about what happened came in a report dated Feb. 22, 2001, sent to both the ombudsman and to DHEC. The report noted that Jackson "has a history of bruising easily," a statement supported by Jackson's medical records.

The Manor Care report said that after reviewing Jackson's medical record, interviewing staff, the resident's roommate and her family, "the facility has concluded that the most reasonable explanation for the incident is that the resident was cleaned and positioned toward the end of the 11 p.m. to 7 a.m. shift and struck her hand against the side rail as she was turned to her side, causing the injury to the left wrist, which was not apparent until later in the morning when it was discovered."

"There is no evidence to support any harmful intent or abuse of the resident by our staff or any others," the report concluded.

Although it settled the lawsuit, HCR Manor Care Inc. denied all of Sneyd's allegations about Jackson's care. John Elliott, administrator of the Heartland of Lexington facility, referred questions about her treatment to the parent company, HCR Manor Care Inc., of Toledo, Ohio.

In a statement, HCR Manor Care spokeswoman Julie Beckert said: "We are very sympathetic to Mrs. Jackson's health problems and feel our staff acted appropriately in providing good care to her. Heartland has high standards for our employees and the level of care they deliver."

Beckert declined to discuss specifics about Jackson's care because she said it would violate confidentiality requirements. She said the West Columbia facility has made management changes in the last two years and noted it was cited for only four minor deficiencies in its most recent annual inspection.

"Unfortunately, today's society is very litigious and the health care industry is no exception," Beckert said in the statement. "Financially stable companies have become a target for lawsuits in this environment. We pride ourselves in doing our best to provide the programming, staffing and resources to care for the frail and elderly."

In retrospect, Sneyd said she wishes she had moved her mother. But the homes that offered better care had long waiting lists, she said.

"If I had known what mother was going through or what she had to go through, I would have quit my job and we would have sold the house," Sneyd said. "Whatever it would have taken."

The warning signs were obvious enough, she says, and went beyond the February incident.

Jackson moved to Manor Care in March 1998, but Sneyd said, "I don't think her care was bad up until months after she got there."

Sneyd's lawsuit said she complained to Manor Care in the last year of Jackson's life that her mother's medication was mismanaged, that the home didn't ensure "appropriate hygiene," and that Jackson wasn't given proper food and water.

Sneyd said in the deposition and in an interview that the sheets on Jackson's bed and her adult diaper were changed infrequently, and that the nursing home staff didn't always make sure she had food and water.

"Peggy and I got to where we changed the sheets ourselves," Sneyd said in the interview.

Because of her strokes, Jackson couldn't feed herself or use the bathroom without help. She had to wear adult diapers, but Sneyd and White said they were soiled so often that Jackson developed blisters on her behind.

THE NEED TO VISIT

Despite the settlement, Jackson's daughters say they still wonder what really happened.

Sneyd and White visited often, but Sneyd said many residents at Manor Care never had visitors. "Who I felt sorry for were the ones who had no family come see them," she said.

Sneyd said she hopes regulators, law enforcement officers, and others who handle complaints about abuse and neglect in nursing homes never forget that the patients have real life stories and - often, but not always families who love them.

Johnnie K. Jackson had both.

Long before she moved to Manor Care, she was a seamstress. In 1984, her employer of 20 years, the Swansea Manufacturing Co., nominated her for Oldest Industrial Worker in South Carolina. After she retired, Jackson continued to sew as a member of the Hen House, a group of ladies who made quilts for the needy.

She also raised five children, mostly on her own, according to her daughters.

"She was a very special lady," Sneyd said.

In an essay written after Jackson died, White recalled the day of her mother's passing:

"On the morning that she died, we were all gathered around her. She would get this haunted look in her eyes as if she would be deserting us if she left us, but we let her know that it was OK. It was almost as if she was asking us if we would be OK after she had left us. We assured her that everything was OK and that she would be too. She slowly left us and part of our hearts went with her. At last, she had found peace and at last she is safe."

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