***Embargoed until 12:01 a.m. Central time
Monday, Feb. 18, 2013**
Mainbar Condensed Version Day 2 (appears below): Wisconsin nursing homes fail to report deaths, injuries. 1,325 words.
Sidebar 1 (appears below): Center’s inquiries prompt state policy changes. 240 words.
Sidebar 2 (appears below): Nursing homes draw lawsuits. 220 words.
About this project
Families’ abilities to hold negligent nursing facilities accountable have been diminished by a recent change in state law that conceals records of abuse and neglect from courts, the Wisconsin Center for Investigative Journalism has found. The Center’s investigation also shows that some long-term care facilities are failing to report deaths and injuries, as required by law.
This project, A Frail System, explores those issues and offers families help in identifying which of the state’s nursing homes have been sued or cited for major problems.
______
A FRAIL SYSTEM
Day 1: State records of abuse, neglect in nursing homes concealed from courts by Wisconsin’s new tort reform law
Today: Nursing homes fail to report deaths, injuries but incur few penalties
______
Wisconsin nursing homes
fail to report deaths, injuries
Investigation finds operators sometimes ignore federal law
Part two of two in a series
By Sarah Karon
Wisconsin Center for Investigative Journalism
Richard Witt thought his wife was lucky.
Over the course of 18 years, Kathy Witt was diagnosed with five types of cancer: ovarian, brain, cervical-spine, spine, breast. In 2008, at the age of 65, she had survived them all. Doctors called her the “miracle lady,” Richard Witt said.
On March 21, 2008, she was admitted to Mayville Nursing and Rehabilitation Center in Mayville, about an hour’s drive northwest of Milwaukee. Among other ailments, she suffered from hypotension, or severe low blood pressure, causing dizziness whenever she sat up or stood.
Four days later, something went terribly wrong.
Witt pressed the call light in her room. No one is sure how long she waited for help; estimates have ranged from five to 20 minutes. Finally she tried to get up unassisted, fell and hit her head on the floor.
Mayville and other nursing homes that receive Medicare and Medicaid are required by federal law to report all instances of alleged mistreatment, neglect or abuse, including injuries of unknown origin, to the state health department’s Division of Quality Assurance within 24 hours.
But an investigation by the Wisconsin Center for Investigative Journalism found that Mayville never reported Witt’s fall to the state, and there are no plans to punish Mayville for that failure.
It is not the only such case.
In response to inquiries from the Center, the Wisconsin Department of Health Services confirmed that KindredHearts, an assisted living facility in Green Bay, failed to report a resident’s death after a 2008 fall that the state determined occurred due to neglect. KindredHearts was cited in that case, according to the state.
Assisted living facilities have seven days to report incidents. The state may then investigate the facility and levy fines or other penalties.
And the state confirmed that Sunrise Care Center, a nursing home in Milwaukee, did not report a January 2010 incident in which a resident fell and fractured her hip, an injury the state later attributed to negligence. The state fined Sunrise for failing to report the incident to the state, failing to develop plans to prevent abuse and neglect, and failing to follow the resident’s care plan.
After having confirmed these three cases, health department spokeswoman Claire Smith declined to do so for more than a dozen additional cases in which the Center sought this information. Smith cited a 2011memo from the federal government that barred the release of records that reveal patient names.
As a result of the Center’s investigation, the Department of Health Services says it has reformed its intake procedures to ensure that complaints against nursing homes are prioritized appropriately and investigated in a timely fashion. (See details in related story.)
‘People should be outraged’
Attorneys for families of residents say that facilities’ failure to report serious injuries or deaths related to abuse or neglect is not uncommon. Far more often, they say, the state health department only learns about a case of alleged neglect or abuse after a family member files a complaint.
“The insidious thing about facilities not reporting incidents is that there’s no way to know what’s not getting reported,” said Ann Jacobs, a Milwaukee personal injury attorney. “People should be outraged.”
Advocates for health care providers stress that incidents of neglect and abuse are extremely rare, and can come to regulators’ attention in a variety of ways.
“Any system will have instances of breakdown,” said Tom Moore, executive director of the Wisconsin Health Care Association, a nonprofit group that represents long-term care providers. “To suggest that this is representative is reprehensible.”
Moore has calculated that Wisconsin long-term care facilities provide 23 million patient days each year — often to people who require around-the-clock care, at reimbursement rates that necessarily limit provider resources. He noted that a 2011study by the American Association of Retired Persons ranked Wisconsin fifth best in the country for affordable high-quality care.
In all, at least 297 civil suits alleging negligence, wrongful death or medical malpractice have been filed against long-term care facilities in Wisconsin since 1986, a Center review found. (See interactive map).
“It’s very important that attorneys are able to take these cases and hold those who neglect and abuse the elderly accountable,” said Dane County Circuit Court Judge William Hanrahan, who prosecuted crimes against the elderly for 19 years as a district attorney and assistant attorney general.
‘She was on the floor’
On March 24, 2008, three days after Kathy Witt was admitted to Mayville, Richard Witt kissed his wife of 44 years goodnight and tucked her in.
“I told her I loved her and waved goodbye,” he said. “The next time I saw her, she was on the floor.”
She died the next day.
Records show that after Kathy pushed her call light, a therapist walked past her room and saw her sitting on the side of the bed. The therapist called a nurse. By the time the nurse arrived, Kathy was on the floor.
Health department spokeswoman Smith confirmed that Mayville never reported Kathy Witt’s fall to the state, and that the agency never knew she fell. Smith said the state will not investigate Mayville, explaining that the health department does not investigate a facility if no one files a complaint within 12 months of an incident.
Smith added that a facility’s failure to report incidents to the state does not typically warrant a monetary penalty. But she said the state health department is taking steps, from memos to training opportunities, to “help providers prevent abuse and neglect from occurring in their facilities and to understand the reporting requirements.”
Richard Witt filed a wrongful death lawsuit against Extendicare, the Ontario-based company that owns Mayville, on Jan. 20, 2011. The case was dismissed in March 2012 after a settlement was reached, the presiding judge’s office confirmed, but terms were not available.
Extendicare declined to comment, citing resident and employee privacy concerns. Spokeswoman Holly Gould would not discuss why the facility failed to report Witt’s fall.
“We are very proud of the care provided by our caregivers,” she said in a statement, saying that Mayville is “in compliance with all state and federal regulations.”
Complaints up, inspectors down
Moore, of the Wisconsin Health Care Association, argued that long-term care facilities are subject to intensive scrutiny and record keeping. “What goes on in a nursing home is more transparent than what goes on in any other health care setting, because of the regulatory systems in place,” he said.
In fact, the Wisconsin health department has cut its staff of full-time nursing home surveyors from 100 in 2002 to 64 in 2012. Smith said staff was reduced because the number and capacity of nursing homes in Wisconsin have decreased. She provided data showing that, during this same period, the number of facilities fell from 412 to 398, and that resident capacity declined from 43,268 to 35,183.
The number of complaints the state received about Wisconsin nursing homes and assisted living facilities rose from 1,684 in 2000 to 2,562 last year, an increase of more than 50 percent.
Since 2009, state inspectors have found serious deficiencies — problems that pose immediate jeopardy to a resident’s health or safety — in about a quarter of Wisconsin’s federally certified nursing homes, a review of federal records showed.
And with an aging baby-boomer population, some say keeping a close watch on long-term care facilities will only grow more important. A state report found that Wisconsin will have 1.3 million residents over 65 by 2030, compared to about 777,000 residents in 2010.
“You have a huge wave of baby boomers, and this has got to be an issue that’s on the front burner of policy makers,” Hanrahan said. “I can’t see this problem getting any better on its own.”
Witt agrees, saying that when injuries occur because duties were neglected, “that’s a serious fault, and it’s got to be dealt with. You have to try to stop it from happening again and again.”
The nonprofit Wisconsin Center for Investigative Journalism () collaborates with Wisconsin Public Radio, Wisconsin Public Television, other news media and the UW-Madison School of Journalism and Mass Communication.
All works created, published, posted or disseminated by the Center do not necessarily reflect the views or opinions of UW-Madison or any of its affiliates.
Sidebar #1
Center’s inquiries prompt state policy changes
In response to the Wisconsin Center for Investigative Journalism’s inquiries into an accident involving a 88-year-old woman at a Milwaukee nursing home, the state Department of Health Services launched an internal review, which concluded that state officials did not properly respond.
As a result, the department says it has reviewed its intake procedures and made changes to ensure that complaints against nursing homes are triaged appropriately and investigated in a timely fashion.
“Complaint and triage assignments are now completed by our management staff,” said health department spokeswoman Claire Smith, adding that these officials are trained in obtaining detailed information from the person filing the complaint.
The accident involved Mary Pietrowski, who fell and broke her hip at Sunrise Care Center in January 2010. The facility did not report the incident to state officials, and the state did not launch an investigation for more than seven months, even though Pietrowski’s son said he filed a complaint within a month of her fall.
The health department review found that the complaint against Sunrise was “inappropriately triaged by intake staff,” causing a delay in the state investigation, Smith said.
She said the department’s goal is to investigate serious complaints filed against nursing homes within 10 days of receipt, and non-serious allegations within 60 days of receipt. Similar timelines are set for assisted care facilities.
Extendicare, the Ontario-based company that owns Sunrise Care Center, declined to comment on Pietrowski’s fall, citing patient and staff privacy concerns.
-- Sarah Karon
Sidebar #2:
Nursing homes draw lawsuits
Since 1986, at least 297 personal injury, wrongful death and medical malpractice lawsuits have been filed against Wisconsin nursing homes and other long-term care facilities, according to an analysis by the Wisconsin Center for Investigative Journalism.
The Center commissioned Court Data Technologies, a Madison company that specializes in researching Wisconsin’s publicly available court records, to find civil cases that met defined parameters. The Center then analyzed the data.
Among the findings:
●The largest number of cases, 16, were filed against Mount Carmel Health and Rehabilitation Center, now named Kindred Transitional Care and Rehabilitation-Milwaukee. Woodland Health Care Center, now named Brookfield Rehabilitation and Specialty Care, ranked second; it was sued 11 times.
●At least 167 of the cases (56 percent) were settled before trial. Other cases were dismissed, with no indication of whether a settlement was reached. Only seven cases are listed as going to trial.
●Of the cases that went to trial, the largest judgment awarded was $1.5 million. Of the cases that settled for a known amount, the largest was $2.75 million. That concerned a resident at Lakeside Nursing and Rehabilitation in Chippewa Falls who sustained numerous life-threatening bedsores and lost 30 percent of his body weight, according to his attorney.
For an interactive map of the lawsuits, see this article at WisconsinWatch.org.