One lunchtime in 2021, a longtime resident at Woodlands Reminiscence Care of Rockland began throwing up. His fingernails turned purple, and his pores and skin turned pink throughout. He was torpid and fidgety, and his respiration grew shallow, in accordance with the ability’s every day care notes.
The resident was well-known at this residential care facility on Maine’s midcoast. Former facility staff advised The Maine Monitor and ProPublica that he was a nationally famend live performance pianist who continued to play a transportable keyboard in his room whilst his Alzheimer’s illness superior.
It wasn’t till a member of the family arrived and requested if the resident had eaten peanuts that staff realized that he was having an allergic response to the peanut butter sandwich that he had been served for lunch, in accordance with the ability care notes. Employees used an EpiPen to deal with his anaphylactic shock and took him to the hospital. He died days later, although no official data have been made out there that present the reason for his demise.
The worker who gave the sandwich to the resident wrote within the facility care notes the day after the incident that they “didn’t know” that the resident “was allergic to peanuts.”
In interviews with the Monitor and ProPublica, nevertheless, 4 former staff mentioned the resident’s extreme peanut allergy had been documented all through the ability: in his resident profile, in his room and posted within the kitchen.
“It mentioned it in all places you seemed round him that he was allergic to peanut butter,” mentioned Stacy Peterson, who served because the human sources coordinator at Woodlands of Rockland from 2018 to 2020.
So it was a thriller to the previous staff how the resident had been served a peanut butter sandwich that day for lunch.
After receiving an nameless grievance, the Maine Division of Well being and Human Providers investigated the incident and cited Woodlands of Rockland for 2 resident rights violations — first by failing to guard the resident from a extreme allergic response and the second time by not reporting the case to the state. (The citations don’t establish the resident.)
Underneath state rules, the well being division had the facility to impose a fantastic of as much as $10,000 or situation a conditional license that may bar Woodlands of Rockland from accepting new residents for as much as 12 months. Nevertheless it did neither. As an alternative, it merely required the ability to submit a report, referred to as a plan of correction, stating the way it meant to deal with the deficiencies.
In that plan, Woodlands of Rockland acknowledged that the resident’s allergy had been documented however disputed the well being division’s characterization that the ability violated the resident’s rights within the incident. Nonetheless, it promised to self-discipline the worker who served the sandwich and to retrain others on the right way to deal with allergy symptoms and to report incidents.
The well being division’s modest response to the peanut allergy incident exemplifies its strategy to oversight, an investigation by the Monitor and ProPublica discovered. The well being division not often imposes fines or points conditional licenses in opposition to the state’s roughly 190 largest residential care amenities, categorised as Degree IV, which offer much less medical care than nursing houses however provide extra homelike assisted residing options for older Mainers.
From 2020 to 2022, the well being division issued “statements of deficiencies” in opposition to these amenities for 59 resident rights violations and about 650 extra violations — involving something from treatment and record-keeping errors to unsanitary circumstances and missed obligatory trainings.
Regardless of these violations, nevertheless, it imposed a fantastic solely as soon as: a $265 penalty in opposition to a facility for failing to adjust to background test guidelines for hiring staff. And it issued 4 conditional licenses: three in response to administrative or technical violations and one in response to a wide range of points, together with a violation of a resident’s privateness rights.
Against this, Massachusetts, which has 269 assisted residing amenities, doesn’t draw back from imposing stiff sanctions. From 2020 to 2022, the state suspended eight amenities’ operations for regulatory violations.
The paucity of sanctions in Maine comes at a time when Degree IV amenities like Woodlands of Rockland — that are much like what are identified typically as assisted residing amenities in different states — are increasing their presence within the state. The share of Maine’s inhabitants that’s 65 or older, 21.7 p.c, is the very best proportion within the nation.
Because the Monitor and ProPublica have reported, the state’s choice within the mid-Nineteen Nineties to tighten the requirement to qualify for nursing dwelling placement helped spur 1000’s of older Mainers, many with vital medical wants, to maneuver to those nonmedical amenities — that are topic solely to state rules that maintain them to a lot decrease minimal staffing, nursing and doctor necessities than nursing houses, which face each state and federal scrutiny.
In stark distinction to how not often Degree IV amenities face sanctions, nursing houses in Maine are sometimes hit with appreciable fines for regulatory violations.
Well being division spokesperson Jackie Farwell mentioned that plans of correction are sometimes ample for enhancing circumstances at amenities. She added that as a part of an effort to enhance the long-term care system in Maine, the state has been contemplating guidelines modifications to “set up fines and sanctions as extra significant deterrents.” However she declined to elaborate on the specifics.
Dan Cashman, spokesperson for Woodlands Senior Residing, which runs 14 Maine amenities together with the one in Rockland, mentioned the corporate has “a zero-tolerance coverage” and has taken disciplinary actions in opposition to any staff who have been discovered to have violated residents’ rights.
Cashman added that the corporate is in favor of stronger state motion in opposition to people discovered to have violated residents’ rights to stop them from working in residential care settings once more.
However long-term care advocates say the well being division will not be doing sufficient to crack down on amenities, versus people, and is permitting poor circumstances to persist for susceptible residents.
Richard Mollot, government director of the Lengthy Time period Care Neighborhood Coalition, a nationwide advocacy group targeted on enhancing nursing houses and assisted residing amenities, mentioned stiff sanctions ought to be imposed extra, in order that there’s a “significant ladder of ample penalties to make sure that amenities are correctly motivated to take steps to make sure resident security.”
In any other case, Mollot mentioned, amenities haven’t any incentive to vary their conduct. “To pussyfoot round resident neglect or abuse,” he mentioned, “is actually encouraging. It’s permitting it to occur.”
A overview by the Monitor and ProPublica of state inspection data from 2020 to 2022 exhibits that the well being division employed the bottom intervention potential, even for a number of the most severe abuse and neglect incidents.
In the summertime of 2021, as an example, a resident at Crawford Commons in midcoast Maine was discovered to have sexually abused one other resident a number of instances, in accordance with the state’s investigation. The well being division cited the ability for 2 resident rights violations however solely required it to submit a plan of correction.
A yr later, a resident in Jed Prouty Residential Care House within the Penobscot Bay area was discovered round 6:30 a.m., bare and asleep on the ground, “soaking moist with urine,” after falling someday after 10 p.m. Witnesses mentioned the resident had been crying for assist and complaining of thirst till medics responded. No efforts had been made by workers to maneuver the resident from the ground or present clothes, in accordance with the state’s investigation. Once more, the well being division cited the ability for a resident rights violation however solely required it to submit a plan of correction.
Equally, in 2021 and 2022, the well being division additionally investigated Woodlands of Rockland for 2 different severe incidents. In a single, a licensed nursing assistant on the facility slapped a resident who had spit at and tried to chew her, in accordance with the state’s investigation.
Within the different, a resident wandered out to the ability’s locked courtyard, however staff didn’t discover that she was lacking till they went to provide her drugs almost two hours later, in accordance with the state’s investigation. When the resident was discovered outdoors within the snow at round 8:40 p.m., staff wrapped her in blankets and referred to as for emergency medical care. The resident died in hospice days later, and the state investigation cited the trigger as “issues of hypothermia.”
Ultimately, each incidents additionally led to plans of correction.
Woodlands of Rockland has been disputing the well being division’s characterization that the ability violated the resident’s rights within the courtyard incident. However Cashman declined to elaborate on the specifics.
Edward Sedacca, CEO of Magnolia Assisted Residing, which runs Jed Prouty, mentioned his firm took over the operation of the ability in August 2022, a month earlier than the incident, and has since made it a precedence to boost its staffing and coaching. “The workers we inherited was missing in general common data,“ he mentioned. “Magnolia has constructed an infrastructure effectively past that required underneath regulation to allow us to offer a better stage of care to all of our residents.”
Crawford Commons didn’t reply to requests for remark.
For Maine’s nursing houses, nevertheless, the response to related incidents has been very totally different.
From 2020 to 2022, greater than half of nursing houses in Maine obtained fines — 98 penalties in all, totaling almost $700,000 — in accordance with U.S. Facilities for Medicare and Medicaid Providers experiences. These fines have been imposed in response to a variety of violations, together with not following COVID-19 an infection prevention protocol, making treatment errors, not reporting surprising deaths and failing to guard residents from hurt.
In 2020, as an example, an worker at Pinnacle Well being & Rehab, a nursing dwelling in Canton in western Maine, “misplaced it” when a resident turned combative, in accordance with CMS investigation data. The worker punched the resident, who ended up with a black eye and bruising across the eyebrow. CMS fined the ability $41,650.
A yr later, a resident at Heritage Rehab and Residing Middle, a nursing dwelling in central Maine, wandered off the premises at night time utilizing a walker and was discovered later by police by the facet of a street within the rain. Nobody on the facility had observed that the resident was lacking, in accordance with CMS investigation data. CMS fined the ability $71,243.
Ken Huhn, administrator of Pinnacle, mentioned the worker was fired, and he made it clear that “that sort of conduct wouldn’t be tolerated” at his facility.
Heritage didn’t reply to requests for remark.
Even with out the involvement of CMS, which doesn’t regulate assisted residing amenities across the nation, the well being division has the facility to undertake a harder strategy towards Degree IV amenities. Underneath state rules, as an example, it may impose a fantastic when an incident poses “a considerable chance of significant psychological or bodily hurt to a resident.”
Lengthy-term care advocates advised the Monitor and ProPublica that underneath this normal, a number of the egregious abuse and neglect incidents in recent times at Degree IV amenities ought to have resulted in stiff sanctions.
“As a result of the incidents are so egregious and present such disregard for the well-being of residents, they’d have warranted some vital penalty and never only a professional forma requirement that the ability submit a plan of correction,” mentioned Eric Carlson, director of long-term companies and help advocacy at Justice in Getting older, a nationwide authorized advocacy nonprofit targeted on ending poverty amongst seniors.
Paula Banks, who has served as the chief director of one other Woodlands facility in Cape Elizabeth and as an assistant administrator of a Maine nursing dwelling, mentioned the concern of such sanctions could be efficient. If she have been nonetheless serving to run a residential care facility, she mentioned, it might spur her to take fast motion to deal with any issues.
“What’s the impetus to vary if there’s no consequence?” mentioned Banks, who now runs a geriatric consulting and care administration agency.
However Dr. Jabbar Fazeli, who has served as medical director at a number of residential care amenities and nursing houses in Maine, mentioned that moderately than imposing sanctions, the state ought to require extra medical consideration by rising nursing hours and requiring a medical director to be on the premises.
“If they’d extra medical care, I’d say 50 p.c of those points will self-resolve,” Fazeli mentioned.
The well being division metes out sanctions in solely a small p.c of the incidents it hears about every year. More often than not, it hardly does something.
To higher perceive the well being division’s course of for trying into potential points, the Monitor and ProPublica analyzed a database of incidents reported to the state by Degree IV amenities themselves. Not like the state inspection data, the database of facility-reported incidents provides a window into what occurs earlier within the well being division’s enforcement course of.
Degree IV amenities are required to report an incident to the state when a regulatory violation could have occurred or when a resident’s security was put in danger. We targeted notably on experiences of incidents with the potential for direct hurt: the circumstances of abuse and neglect.
From 2020 to 2022, the state obtained greater than 550 experiences of abuse and neglect incidents from Degree IV amenities, in accordance with the Monitor and ProPublica evaluation. Of these, 342 circumstances concerned residents abusing different residents, 102 circumstances concerned “elopement,” during which residents wandered away unsupervised, and 61 circumstances concerned a workers member abusing a resident.
The evaluation exhibits that in almost 85 p.c of those incidents, state investigators took “no motion” — which, in accordance with Farwell, signifies that the well being division determined to not examine. She mentioned this might have been for a variety of causes, comparable to when a facility has already taken corrective motion, when state investigators don’t anticipate finding a regulatory violation, or when an incident is being investigated as a part of one other case or is anticipated to be reviewed later.
The evaluation additionally exhibits that the well being division didn’t step up its enforcement even when particular person amenities repeatedly reported related points.
From 2020 to 2022, 13 Degree IV amenities, together with Woodlands of Rockland, every had a minimum of 10 abuse and neglect incidents, collectively reporting 348 circumstances to the state. Even after these amenities had reported a number of circumstances, the well being division nonetheless took no motion in 91 p.c of them, the evaluation exhibits.
Farwell mentioned state investigators do take note of repeated incidents. “If patterns are noticed, particular points could also be flagged for follow-up on the subsequent scheduled survey,” she mentioned.
However such follow-ups won’t occur for a lot of months, relying on the timing of the following inspection required for license renewal, which takes place solely as soon as each two years.
Dionne Mills, who served as this system coordinator at Woodlands of Rockland from 2019 to 2021 and in addition labored at two different Degree IV amenities, mentioned she turned conscious of the shortage of state oversight throughout her time on the Rockland facility. She mentioned she reported a number of incidents to the state till finally a state investigator advised her that they have been too overwhelmed with complaints and that she would have extra success taking her issues to the media.
“The state is so tremendous busy that they solely have time to look into absolutely the worst-case situation,” Mills mentioned.
Farwell disputed Mills’ account, noting that state investigators made seven visits to Woodlands of Rockland from 2020 to 2022, the time interval when the ability was underneath investigation for the courtyard, peanut allergy and slapping incidents. Mills’ account “is inconsistent with the variety of onsite visits that have been carried out at this facility,” she mentioned.
In response to Farwell, the well being division has 13 investigators — and is within the means of hiring two extra — to examine greater than 1,100 assisted housing amenities within the state for license renewals and to analyze any incidents.
Mollot, of the Lengthy Time period Care Neighborhood Coalition, mentioned the well being division must do extra in opposition to amenities with a historical past of repeated incidents, comparable to requiring impartial monitoring and, presumably, revoking licenses.
“Confronted with the truth that these amenities have reported time and again and over and again and again incidents of abuse and neglect, why have there been a paucity of enforcement acts?” Mollot mentioned.
A number of former staff advised the Monitor and ProPublica that the historical past of repeated incidents at Woodlands of Rockland illustrates what can occur to a facility’s requirements when the well being division takes little enforcement motion.
From 2020 to 2022, Woodlands of Rockland had the very best variety of abuse incidents reported by a Degree IV facility — 48 circumstances in all, together with 38 during which a resident abused one other resident, in accordance with the well being division database.
However the well being division investigated solely 5 of the incidents that Woodlands of Rockland reported, took no motion on the remainder and imposed no sanctions apart from requiring the ability to submit one plan of correction.
With little stress from the well being division, efforts to deal with recurring issues “have been nonexistent once I labored there,” mentioned Mills, the previous program coordinator.
Joshua Benner, who served as a residential care aide at Woodlands of Rockland from 2018 to 2020, mentioned he discovered it regarding that when the ability was cited by the well being division, not one of the managers on the facility shared with staff what issues had been discovered.
“Each different well being care place that I’ve ever labored, you have got interventions, normally after the state is available in, to go over what you’re dinged on and what could be improved,” mentioned Benner, who has labored at a nursing dwelling and two different residential care amenities.
Cashman, the Woodlands spokesperson, denied that Woodlands of Rockland had “an ongoing or systemic downside” with abuse incidents, noting that the majority of the circumstances concerned a small variety of residents “whose progressively worsening dementia-related behaviors turned increasingly more difficult.”
In response to those residents’ behaviors, Cashman mentioned Woodlands of Rockland has been proactive and brought “a number of interventions,” together with resident care plan updates, treatment modifications, referrals for hospital remedy and discharge planning.
Cashman mentioned Woodlands of Rockland and its staff have been doing “their greatest to handle what could be extraordinarily tough behaviors by people residing with vital cognitive impairments.”
However Banks mentioned one thing is amiss if any facility has repeated incidents, noting that she would have been alarmed to see a couple of or two incidents of abuse in three years, not to mention 30 or extra as Woodlands of Rockland did.
“When you have got individuals in your constructing and also you took them in and also you advised their households you’ll maintain them and also you took their cash,” Banks mentioned, “I don’t care what’s occurring. I don’t care when you have a workers of three. You’ve acquired to maintain your individuals.”
This story was initially revealed by The Maine Monitor, a nonprofit and nonpartisan information group. To get common protection from the Monitor, join a free Monitor publication right here.