8-9-15 Iowa:Karen Wininger keeps raising a fear to the staff at her new nursing home. Several times a day, she asks if she's going to be taken somewhere else.
The 75-year-old woman expresses her anxiety in a voice so soft it's barely audible. Davis Center staff members lean down to her wheelchair, sometimes putting their ears inches from her mouth when she speaks.
They reassure her, time and again, that she can stay.
The patient, who decades ago was a nurse, gives a wan smile to the staff. But her anxiety will bubble back up, and she'll ask again: Am I going to be taken away?
Until this spring, Wininger was one of 18 residents at a state program for elderly people with serious mental illnesses, such as schizophrenia. The program was housed at the Iowa Mental Health Institute at Clarinda, which Gov. Terry Branstad ordered closed earlier this year, saying it was outdated and inefficient. More than half the residents were sent to private nursing homes.
Supporters of the Clarinda program said it cared for some of the frailest and most complicated psychiatric patients in the state. Wininger was one of two residents who wound up at the Davis Center, a well-rated nursing home that specializes in handling elderly people with mental illness.
But eight others were transferred to four traditional nursing homes, all of which are rated "below average" or "much below average" on a federal registry. The four facilities are in the bottom 29 percent of Iowa nursing homes for overall quality, according to the Medicare registry. Two of those eight patients died shortly after their transfers.
Wininger said she spent eight years at the Clarinda institution before transferring to the Davis Center near Bloomfield in June. When asked if she is satisfied with the new place, she nodded. "I like all the people," she said.
State human services officials say they went to great lengths to find suitable placements for the former Clarinda patients, and that relatives were often involved in choosing the new facilities. The officials also say they are closely monitoring how the former Clarinda patients are faring.
But relatives of some of the patients have told the Register they're displeased with their loved ones' care, especially at the Perry Health Care Center in Perry.
After move, decline in health seen
The Perry nursing home's quality is rated "below average" by Medicare, earning two stars on a five-star system. It also has been repeatedly fined by state inspectors.
Janice Scalise, the sister of one of five longtime Clarinda patients sent to the Perry facility, said state officials assured her it was a good place. But she is now working to have her sister, Carole, transferred to the specialized and more highly rated Bloomfield facility.
Scalise said her sister, who has schizophrenia and serious diabetes, has declined dramatically since being taken out of the Clarinda institution. Carole Scalise, 63, uses a wheelchair, and she has fallen several times while trying to get up in the middle of the night, her sister said.
"I think the staff is not equipped to take care of the people from Clarinda," Janice Scalise said. "I don't think they have the experience. They don't have the knowledge. I'm not saying they're bad people — they're just not qualified."
Since transferring to the Perry facility, Carole Scalise has become increasingly delusional, her sister said. She used to talk to imaginary friends, including cats that she called her babies. Now, she's talking to imaginary people who say angry, frightening things, her sister said.
"They agitate her, and she's screaming at the top of her lungs — and it goes on for hours," Janice Scalise said. At times, Carole has even taken to speaking in imaginary people's voices, including a man's, her sister said.
Janice Scalise's concerns about the Perry facility spiked when she heard last month that another former Clarinda resident, Jim Hanson, died shortly after being transferred there. Hanson's family has said he became so dehydrated that he was taken to a Des Moines hospital eight days after he was moved to the Perry nursing home. He never recovered, his family has said.
Jim Hanson's brother, Tim, said he did well at Clarinda for many years but immediately deteriorated after his transfer. He would not have become dehydrated if the nursing home had been capable of handling his complex needs, which stemmed from diabetes and a brain injury, Tim Hanson said.
Hanson said state social workers assured him the Perry nursing home would be a suitable place, but he now regrets agreeing to the transfer there. He complained about the incident to the state Department of Inspections and Appeals, which began investigating a few weeks ago. Hanson said he looks forward to the investigators' report, and he is considering legal action.
The family of a third former Clarinda hospital patient transferred to the Perry nursing home also told the Register about concerns for that person's well-being. The problems have included significant weight loss, relatives said. But the family did not want to be identified, for fear of retaliation against the patient.
Company remains confident in its care
The Perry Health Care Center is a one-story, red-brick building built in 1962. It has 46 beds, half of which were empty when the state put out a call early this year for nursing homes willing to take the elderly psychiatric patients from Clarinda, state documents show.
"We had some bed availability. We reviewed the residents, and we identified several who might be appropriate for our facility," said Bruce Mehlhop, manager of the company that owns the Perry Health Care Center and five other Iowa nursing homes. He said members of his staff visited the state hospital twice and carefully went over the patients' needs.
The nursing home declined to take several people who seemed too complicated, he said. But the facility's staff felt confident it could take care of the five it accepted, since it has some experience dealing with elderly psychiatric patients.
"I guess the biggest thing from our perspective is we believe we have the capability to provide the care that they need," he said.
Mehlhop acknowledged that the Perry facility is ranked as "below average" in overall quality on the Medicare website. He said that's partly because of recent changes in how nursing homes are rated for their use of anti-psychotic drugs. The Perry nursing home has used those medications, because it accepts people with mental illness, he said.
But he said the low rating might also be partly due to record-keeping issues involving how the anti-psychotic drugs are used. He expressed confidence that the rating would rebound.
Mehlhop also acknowledged that the facility has been fined by state investigators, including for a 2013 incident in which staff allegedly didn't promptly seek hospitalization for a resident who suffered a stroke. But he noted that there have been no fines for the Perry home since then.
Mehlhop's company also owns the Primghar Rehab and Care Center, which accepted one former patient of the Clarinda institution. The Primghar nursing home also is rated "below average" by Medicare, but Mehlhop defended its capabilities to care for elderly people with mental illness. He said the patient's relatives helped choose it, and they have been satisfied.
Administrators of the three other nursing homes that accepted former Clarinda patients declined to comment or did not respond to requests for comment.
Families weigh factors other than ratings
Amy McCoy, a spokeswoman for the Iowa Department of Human Services, stressed that her agency's employees made great efforts to find proper placements for the former Clarinda patients. McCoy added that the Medicare rating system is a helpful tool, but that it isn't the only way to judge a nursing home.
"Many families wanted facilities that are close to their residence, some preferred it feel more like a home, not a hospital. Others take into account things like what churches offer Sunday services there or if specific activities their loved one enjoys are part of the activities program," McCoy wrote in an email. "Some find word-of-mouth and pop-in visits much more useful than an online rating."
She also said her department's case managers referred families to the state Department of Inspections and Appeals website, which posts inspection reports and documentation of problems and fines.
McCoy added that other agencies, including two patient-advocacy groups, have been in contact with the patients and their families to monitor how the transition is going.
McCoy said the state is not paying extra to nursing homes that accepted the patients, even though the Clarinda hospital's supporters described them as having unusually complex needs. In general, McCoy said, the state Medicaid program pays $127.50 per day for nursing home care. For people in the specialized Bloomfield facility, Medicaid pays $243.14 per day. The daily cost at the Clarinda institution was $742, she said.
Dean Lerner, who used to be Iowa's top nursing home regulator, said he isn't surprised that two of the 18 patients died shortly after transferring out of the Clarinda institution.
"That decision was made with great haste, and little to no regard for the health, safety and welfare of the people being transferred," said Lerner, who was director of Inspections and Appeals under Branstad's Democratic predecessor and remains a fierce critic of the current governor. "Transfer trauma is a well-studied consequence of moving frail elders, and anybody with even the slightest research and knowledge would know that and would make sure they accounted for it."
Lerner said the Medicare nursing home quality rating system is imperfect but is improving. He said that families should be wary of moving a loved one into a nursing home that is rated poorly on the Medicare website — and that the state should have hesitated before sending former Clarinda patients to such facilities.
Just 3 Iowa facilities offer specialty
The Davis Center near Bloomfield has a special license, designating it as a care facility for people with mental illness. The only two others like it in the state are in Keokuk and Waterloo.
The facility, which once was the area's "county home," is now run by a statewide agency called Optimae Life Services. It has more staff hours per resident than a standard nursing home, administrator Dawn McCarty said. It has a psychiatrist who visits at least monthly from Fairfield and also can interact with patients via a video linkup. A mental health therapist visits twice a month, McCarty said, and staff is accustomed to the quirks and special needs of seniors with mental illness.
"You're kind. You're respectful. Sometimes you have to be very patient," said McCarty, who has overseen the facility for 17 years. "You have to understand that what you're seeing a lot of times is part of the symptoms of their disease."
For example, McCarty and other staff members said, their residents can have delusions, including that imaginary people are talking to them. Some delusions could be harmful, such as a voice telling them that family members have died or are locked in the basement. The staff tries to gently bring residents back to reality. But not always.
"If the delusion is not upsetting the resident — because not all delusions are bad — that's OK. That's part of their life, and some of them are very happy with those delusions," McCarty said.
For example, a longtime resident was convinced she would soon be married. She planned for her wedding, talking ecstatically about how she wanted her hair done and whom she would invite to the reception. She packed her suitcase for her honeymoon. The staff went along with it.
The atmosphere inside the Davis Center isn't always placid. After lunch on a recent day, an elderly resident in a wheelchair suddenly began to weep and wail in the hallway. Staff members kneeled down to talk to her and comfort her, as other residents walked or wheeled past the scene, seemingly unperturbed by the commotion.
Staff members said one of the benefits of having a specialized center is that the residents and their families are familiar with mental illnesses, so they are less likely to be distressed by other residents' symptoms.
McCarty said that in the past, her nursing home sent a few particularly difficult patients to the geriatric psychiatry program at the Clarinda state hospital.
Since that option has been closed, she said, she would have to seek a psychiatric bed in another hospital. That can be a daunting task, since Iowa has seen a dwindling number of such programs, and beds are nearly always full.
McCarty has seen a rising need for such facilities, as more people with serious mental illnesses are living longer due to improved medication and care methods.
Nursing homes where Clarinda patients went:
The Iowa Department of Human Services says a total of 10 former patients of the geriatric psychiatry program at the Clarinda Mental Health Institute were transferred to five private nursing homes after the state decided in January to close the institution and a sister hospital in Mount Pleasant. (The program's eight other patients went to the remaining two state mental institutions.) Here is information about the nursing homes that accepted former Clarinda patients, including whether they've been fined by state inspectors since 2013. Overall, fewer than half of Iowa nursing homes have been assessed such fines in that time period, state records show.
Perry Health Care Center, Perry
Overall rating on Medicare's "Nursing Home Compare" website: Two out of five stars, or "below average." Score means facility is rated in the bottom 29 percent of Iowa nursing homes.
Fines paid due to government inspections since 2013: $8,000. The fine stemmed from an incident in which nursing home staff did not promptly send a resident to a hospital for treatment of an apparent stroke. The person wound up losing function on the right side of the body. A physician told inspectors the person's body function likely could have been recovered if there hadn't been an 11-hour delay in obtaining treatment. ..Continued.. by Tony Leys
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