Six years after the state Department of Health declared “War on the Sore,” residents in New York City nursing homes experience painful and preventable bedsores at a rate almost 50 percent higher than the national average. In New York City, 16 percent of high-risk residents have one or more of the painful wounds, compared with 11 percent nationwide.
Statewide, victory remains just as elusive. In 2011, according to an AARP analysis of the data reported to the federal Centers for Medicare & Medicaid Services, New York ranked 44th among states in preventing the development of sores among high-risk residents.
The wounds, clinically known as pressure sores or pressure ulcers, can set in when an immobilized patient is not moved regularly. Bones push through areas of soft skin, and openings in the flesh can deepen down to muscle and bone. The National Quality Forum, a patient safety organization, puts advanced pressure sores acquired in a facility on its inventory of preventable “serious reportable events,” a list that also includes wrong-site surgery and injury resulting from contaminated drugs.
At the 538-bed Rutland Nursing Home, in East Flatbush, Brooklyn, 84-year-old Mary Lee developed multiple sores, included a severe ulcer on her lower back, according to a lawsuit filed against the facility. Bryant Lee had put his mother in the home reluctantly in December 2007, after she was released from its affiliated Kingsbrook Jewish Medical Center.
In the six months following her arrival at the home, his mother’s condition worsened. In addition to bedsores she suffered sepsis, malnourishment and dehydration. By the following July, she had died.
“I didn’t realize that it’s such a big facility and handles so many people, but they aren’t responsible,” said Lee. “They put me through a whole lot of grief.”
Lee sued the home for negligence, in a case still pending in State Supreme Court. Rutland Nursing Home has denied all allegations.
Lee’s is not the only such complaint. Last year, Rutland paid $275,000 to settle a 2007 negligence suit that alleged the home allowed an 81-year-old woman to develop three acute pressure sores under its care. She died soon after.
In late 2007, Rutland was one of three New York City nursing homes among 16 statewide that received a total of $800,000 in federal grants to reduce the incidence of pressure sores among residents through careful, daily documentation of patients’ condition.
At all three of the city nursing homes that received the grants, their own statistics reported to the federal Center for Medicare and Medicaid Services show the rate of sores for high-risk residents has increased the years since.
At Rutland, 23 percent of high-risk residents have pressure sores, up from 18 percent in the final quarter of 2007. At St. Barnabas Rehabilitation and Continuing Care Center, in the Bronx, the rate is 25 percent, up 7 points from late 2007. And Silvercrest Center for Nursing and Rehabilitation, in Queens, is at 22 percent, up 1 point. All of these facilities have rates near or more than double the state average.
Rutland Nursing Home did not respond to emails, phone calls, faxes or office visits requesting comment. A spokesperson for St. Barnabas said the facility could not release information on the grant program’s effects without clearance from the sponsor. Silvercrest has not responded to requests for comment.
Researchers who have studied pressure sores say that nursing homes frequently receive patients who already had sores before they arrived. “Those measures do not separate pressure ulcers that were on people who come into the facility from ones formed in the facility,” said William Spector Ph.D, a senior social scientist for the federal Agency for Healthcare Research and Quality, which funded a pressure ulcer prevention program for New York nursing homes identified by the state health department as having high rates of the condition.
His agency found that as a result of improved monitoring and care following the grant, St. Barnabas saw a 56 percent decrease in the development of new pressure sores among patients already residing in the home. Before the program, 4.2 percent of residents developed new sores during the period of time studied, while afterward 1.8 percent did.
Confidentiality protections limit further disclosure of research data, says Spector. What matters in the end, he says, is that fewer patients suffered.
St. Barnabas assistant nursing home administrator Zaldy Mateo said that the program achieved its goals. “We saw a substantial decrease in pressure ulcers,” said Mateo. “We are not getting the pressure ulcers here. I mean, yes we get some here, but most of them come from outside.”
So what accounts for the New York City facilities’ alarmingly high rates of pressure sores among nursing home residents? Federal data collected from nursing homes risks-adjusts for health conditions residents may have that can make development of pressure sores more likely, such as diabetes. But Spector contends that this risk adjustment fails to adequately account for factors that lead to higher rates at some nursing homes than others, like age and gender. Facilities willing to take in gravely ill patients can unfairly be penalized with a poor rating. Research on nearly 60,000 residents in New York State nursing homes also shows that even adjusting for other risk factors, black residents are more likely than white residents to develop pressure sores.
Patient advocates say that ultimately, the facilities themselves need to be held accountable no matter what conditions their residents arrive with — and that state regulators are not pressing nursing homes strongly enough to give them an incentive to improve care.
A 2011 state inspection at Rutland shows failures to prevent or properly treat pressure sores. A 69-year-old patient developed a new sore even after a doctor had flagged a knee brace as a risk factor that should be monitored at every nursing shift. Yet for almost a month, nurses’ progress notes did not document any evidence of care. The report also noted that one out of eight observed residents with pressure sores at the facility also lacked proper follow-up observations. Another patient who had a painful sore did not receive required pain medication.
Based on these and other alleged violations of state law protecting the well being of nursing home residents, Rutland and the state reached a settlement in March, in which the facility agreed to pay $22,000. The home’s revenue was $71 million that year.
It’s not unusual for nursing homes to settle with the state health department. But even if the facilitydid receive fines, they would not be large ones: state law caps fines for most violations at $2,000 — too low, some patient advocates say, to deter homes from taking significant steps to lower the incidence of pressure sores.
“That’s absolutely nothing,” said Cynthia Rudder, director of special projects at the patient-care advocacy group Long Term Care Community Coalition. “That’s the cost of doing business.”
Officials at the state health department say they are looking to improve the facilities, not beat up on them. “Our goal isn’t to be punitive or to collect fines, but to make sure that the quality of care is being met,” said Jeffrey Hammond, a spokesman for the New York State Department of Health. He added that the department uses enforcement actions mainly in the event of repeat violations. “We don’t use fines to treat pressure sores.”
David Bruso, acting director at New York State Department of Health’s Bureau of Quality Assurance, the agency that oversees enforcement of penalties for nursing home violations, acknowledged that for these multi-million dollar facilities, fines capped at $2,000 are less a financial deterrent than simply a threat to a home’s public image.
“A loss of reputation is really the biggest threat to these places,” he said.
Federal sanctions are somewhat stronger. Following last year’s inspection, Rutland was denied Medicaid payment for accepting new admissions and fined an additional $6,500, reduced 35 percent because the home did not contest the charge. Medicaid admissions resumed a few weeks later after the facility submitted a plan of corrective action.
But while homes and oversight agencies haggle over punishments, scores of New York City residents continue to suffer.
“It’s hard to pin all of your assessment of quality on a single indicator, but [pressure sores] are a good indicator if you had to pick one,” said Dr. Mary Jane Koren, Vice President for the Picker-Commonwealth Fund Long-Term Quality Improvement, a health care quality think tank. Nursing homes tend to serve very fragile residents whom are often completely immobile, which makes preventing ulcers more difficult. But that rate, she said, “should be as close to zero as you can get.”
Additional reporting by Alexander Hotz