Nursing Home Mortality Rate Soared 32 Percent in 2020

The coronavirus pandemic’s “devastating impact” on nursing homes led to a 32% spike in overall mortality rate among Medicare residents during 2020, according to a new report by the Office of Inspector General. The spike means there were 169,291 more deaths in 2020 than would be expected if the mortality rate had remained the same as in 2019. There were 3.1 million Medicare beneficiaries who resided in nursing homes in 2020. 

Each month of 2020 had a higher mortality rate than the corresponding month a year earlier. In April 2020 alone, a total of 81,484 Medicare beneficiaries in nursing homes died — more than twice the number in April 2019.

Federal investigators added that the data shows the pandemic had “far-reaching implications for all nursing home beneficiaries, beyond those who had or likely had COVID-19.” This blog has previously addressed the higher rate of medical mistakes and errors and neglect that occurred amidst the pandemic as well as the horrific impacts from isolation, loneliness, and lack of psychological care and treatment.

The findings also revealed that more than forty percent of Medicare beneficiaries (1.3 million beneficiaries), in nursing homes had or likely had COVID-19 in 2020. The number of infected beneficiaries swelled dramatically during the spring of 2020, with just over 21,000 diagnosed as having or likely having the disease between January and March. By the end of June, the number was close to 419,000. 

Federal researchers also found about half of Black, Hispanic and Asian beneficiaries in nursing homes had or likely had COVID-19 in 2020. Each group was more likely than their white counterparts to contract the disease. 

Harvard health policy expert David Grabowski, Ph.D., said those who work in the field “knew this was going to be bad” but didn’t think “it was going to be this bad.” “This was not individuals who were going to die anyway,” Grabowski told the Associated Press. “We are talking about a really big number of excess deaths.”

“The COVID-19 pandemic has been devastating for Medicare beneficiaries in nursing homes,” the government watchdog agency wrote. “The toll that the COVID pandemic has taken on Medicare beneficiaries in nursing homes demonstrates the need for increased action to mitigate the effects of the ongoing pandemic and to avert such tragedies from occurring in the future.”  

The report is the first in a three-part series focusing on the impact of COVID-19 in nursing homes. Upcoming analyses are expected to focus on strategies nursing homes have used to combat the pandemic. 

Source: D. Brown, "Nursing home death rate soared 32 percent in 2020," McKnight's Longterm Care News (June 23, 2021).

Nursing Home Residents May Have Lower Vaccine Immune Response

A COVID-19 vaccine administered to nursing home residents in northeast Ohio was less effective in creating an antibody response in them than in a control group of health care workers, according to a Case Western Reserve-led study.

Some residents responded "reasonably well," but a portion responded "poorly to very poorly," concluded university researchers. What's not yet clear is why, or what the threshold for protection is when measured in terms of antibodies.

"We urgently need better longitudinal evidence on vaccine effectiveness" to inform best practices for nursing home infection control measures, outbreak prevention and potential indication for a vaccine boost, stated the study. Its co-principal investigators include David Canaday, MD, a professor in the School of Medicine’s Division of Infectious Disease, and Mark Cameron, PhD, an associate professor in the school’s Department of Population and Quantitative Health Sciences.

Once COVID-19 reached the United States, nursing homes became hotspots, with a rapid rise of infections and deaths; when vaccines became available, nursing home residents were among the first to receive them.  The study focused on the antibody immune response in residents by comparing a blood sample taken before the first vaccination, with another taken about two weeks after the second one.  It included 149 residents and a younger control group of 110 health care workers. All participants received the Pfizer vaccine.

Researchers examined three measures of antibodies; in all cases, residents had lower levels. For example, residents had a quarter of the anti-virus antibodies as the control group.

Canaday said the study's results can’t be compared to Pfizer’s vaccine efficacy rate of 95% because the Pfizer clinical trial focused on the number of adults of any age who got COVID-19, not the quantity of antibodies in the blood.

"The vaccine does make an immune response in almost every nursing home resident, although the magnitude is lower than in the younger age," Canaday said.

The study was the first outcome from a $2.3 million National Institutes of Health grant focused on COVID-19's spread in nursing homes awarded to Canaday, Cameron and fellow co-principal investigator Stefan Gravenstein, MD, a geriatrician and professor at Brown University.

They are now exploring varying responses to COVID-19 in nursing home residents and what level of antibodies is protective.

"There are so many questions to be answered surrounding the role of one's immune system in determining whether an infected individual has a mild, moderate or very severe form of COVID-19," Cameron said, "especially in people who are older or have underlying health issues that put them more at risk for poor outcomes."

Recurring Scam Withdrawals Result in Medicaid Application Denial

A New Jersey appeals court has ruled that the Medicaid agency properly denied an application on the basis of the applicant failing to "verify" recurring transactions on the applicant’s bank statement even though the transactions may have been part of a scam.  G.M. v. Division of Medical Assistance and Health Services (N.J. Super. Ct., App. Div., No. A-0433-19, June 16, 2021).

G.M. suffered from dementia and lived in a nursing home. In 2018, she applied for Medicaid benefits and submitted the required bank statements. The Medicaid agency requested verification of recurring transactions from 2013 in the amount of $300 that were labelled:

"ACH DEPOSIT UNITEDCAPITALCRE UNITED CAP" (UCC)." 

G.M.’s authorized representative stated that her family believed the transactions were part of a scam of which G.M. was a victim.  The representative provided supporting "screenshots" to show that the company UCC was no longer in business.  As a result of the foregoing, the representative declared that she could not provide formal documentation.

The Medicaid agency denied G.M.’s application for failing to provide sufficient verifications. G.M. appealed, but the administrative law judge affirmed the denial, stating that there was a lack of evidence that G.M.’s agent under her power of attorney attempted to determine the nature of the transactions. The Medicaid agency affirmed the denial, and G.M. appealed to court.

The New Jersey Superior Court, Appellate Division, affirmed, holding that the Medicaid agency properly denied G.M.’s Medicaid application for failure to provide verifications. According to the court, the screenshots of UCC’s former website did not provide evidence of the purpose of the transactions, so G.M.’s “proof of eligibility was inconclusive."  The "decision to deny [G.M.’s] application was not arbitrary, capricious, or unreasonable.”

The decision does not address what, in addition to the representative's declaration, would suffice. 

Coordinating Business and Estate Planning Documents: The Not-so-happy Lesson from TV Painter Bob Ross

Celebrity estates often serve as object lessons of how, and how not to, design estate and business plans.  The estate of Bing Crosby is widely hailed as instructive in the use of trusts to avoid probate and protect privacy.  Unfortunately, the estate of TV painter Bob Ross, serves as a cautionary tale regarding the failure to coordinate estate and business planning documents.  

Bob Ross rose to fame in the 1980s as the host and instructor of the wildly popular Joy of Painting TV show. Viewers were drawn to his artistic techniques, mesmerizing voice, and congenial manner. The result of his death was less than congenial as  nasty legal war erupted between his business partners and family. 

Bob Ross Inc. was formed by Ross, his wife Jane, and their friends Walter and Annette Kowalski. Although the four were equal partners, Ross was its widely recognized public face. From 1986 through 1994 the company registered several trademarks using Bob Ross’ name and likeness, with Bob’s written consent, and also signed several licensing agreements with third parties, also with Ross’ consent.

In 1992, Bob’s wife Jane passed away. The business structure required that any shares of a deceased partner were to be distributed equally among the surviving partners. And that is how Ross, despite being the public face of the Bob Ross juggernaut, found himself with only a one-third interest in the company.

Shortly after Jane passed, Ross developed lymphoma. The prognosis was sadly grim. In 1994, while battling the disease that would take his life one year later, the Kowalskis approached Ross. They presented him with a contract giving the Kowalskis all commercial rights to Ross’ name, image, voice, biographical material, and creative works. In return, the Kowalskis would pay Ross or his surviving heirs ten percent (10%) of Bob Ross Inc, profits,  but only for the next ten years.  After ten years the Kowalskis, and not the Ross family, would own and receive all income from Bob Ross, Inc. 

Ross was reportedly infuriated and refused to sign the agreement. Instead, he modified his estate plan in an attempt to keep intellectual rights to everything Bob Ross in his own family. He created the Bob Ross Trust in 1994, assigning 51% of the interest in all intellectual property to his brother, Jimmie Cox, and 49% to his son, Steve Ross.

Ross died July 4, 1995 at age 52, leaving an estate valued at $1.3 million, half of which was his interest in Bob Ross Inc. The Kowalskis, unsuccessful at gaining control of the business while Ross was alive,  sued the estate. In addition to asking for all intellectual rights, the Kowalskis wanted all of Ross’ finished paintings and tools.

Unable to finance a prolonged legal battle, Cox, the estate executor, settled with the Kowalskis. The Estate and the Trust also signed separate Mutual Releases with Bob Ross Inc. stating that the parties and their heirs, assigns, successors in interest, etc., “do, now and forever, absolutely and irrevocably, hereby release each other in and from any and all claims, suits, liabilities, complaints, losses, damages, and charges of every kind and character arising prior to the date of execution hereof.”

Two decades after the lawsuit settled, Steve Ross, the son, realized there was a clause in his father’s trust that bequeathed to him all rights to his father’s name, likeness, and publicity. By then, Bob Ross had become an even bigger and more lucrative business, with the sale of Bob Ross bobbleheads, chia pets, mugs, and even action figures. The streaming services Twitch and Netflix had since picked up The Joy of Painting shows. Calm, the meditation app, even offered a Bob Ross sleep app.  The Kowalskis had deftly managed and grown the Bob Ross business enterprise.

Armed with this newfound knowledge about his father’s trust, Steve sued Bob Ross Inc. He alleged that all the Bob Ross Inc. business deals and products that used his father’s likeness were unauthorized. He demanded compensation. Unfortunately for Steve, the federal judge didn’t agree. The court ruled that Ross’ trust could not have given away the rights to Steve, because the trust did not own those rights to begin with. The ruling stated: “Plaintiff would not own the intellectual property at issue because the Trust never owned it. Similarly, because Bob Ross gave BRI his right to publicity during his lifetime, it could not have transferred to his son on his death.”

Bob Ross’ trust said Steve was to inherit the intellectual rights, but the trust was never funded with the rights, and could not, therefore, direct them.  The business agreement prevailed. Steve received nothing from the business empire built on his father’s likeness, reputation, or artistic techniques.

Source: "TV Painter Bob Ross’ Son Loses Lawsuit In Battle Between Father’s Trust And Business Agreement," (June 13, 2021) (last accessed 6/17/2021). 

Protecting Seniors From Alzheimer’s Cure Scams

The following is a reprint, for the reader's convenience, of an article published in  Today's Caregiver.  I thought it a timely topic since there is recent discussion of possible approval of a treatment for Alzheimer's disease, which will be addressed in a future blog post:  

Alzheimer’s disease is the health condition that many fear the most. That concern can prompt us to eat well, exercise, get regular health checkups and follow our doctors’ recommendations. However, for some older adults, the fear of the disease leads to wasting money on Alzheimer’s cure scams that at best do nothing and at worst may cause harm.

Alzheimer’s Cure Scams 

Alzheimer’s disease is the health condition that many fear the most. That concern can prompt us to eat well, exercise, get regular health checkups and follow our doctors’ recommendations. However, for some older adults, the fear of the disease leads to wasting money on Alzheimer’s cure scams that at best do nothing and at worst may cause harm.

Alzheimer's and dementia treatment scams are big business. Some manufacturers know that seniors fear Alzheimer’s and have money to spend. Seniors are also uniquely vulnerable to scams. As we age, our brains can change in ways that make us less aware when something important is happening nearby and reduce our ability to read social cues. Researchers say those brain changes can make us more vulnerable to scammers.

The good news is that the FDA is cracking down on companies that prey on people’s desperation for an Alzheimer’s cure. Earlier this year, the agency acted against makers of 58 products that claimed to treat the disease but didn’t have FDA approval or proof that they worked.

The bad news is there are still unproven products out there being sold to seniors and their family members who are desperate for some sense of hope. The FDA says in some cases, they can interact with prescription medications and harm the people who take them.

How to Protect Your Parents From Alzheimer’s Cure Scams

How can you tell if an Alzheimer’s treatment or dementia supplement is worthwhile? Here’s a checklist based on tips from the Alzheimer’s Association and the FDA.

• Does the product appear on the FDA’s Flickr account? The agency has a photo stream of products that have made unproven Alzheimer’s claims. The photos include close-ups of the products’ labels and packaging.
• Does the product claim to cure Alzheimer’s or dementia? Again, the FDA notes that there is no cure for Alzheimer’s.
• Does the product claim to reverse dementia symptoms? The FDA says there’s no product or FDA-approved treatment that can stop or reverse Alzheimer’s symptoms.
• Does the product say it can reduce the risk of Alzheimer’s by a specific amount? The FDA says there’s no proof to back up such claims.
• Some products are marketed with vague language that is misleading, scientists say. Look for these types of statements:
• Does the product claim to be a “scientific breakthrough?” That’s a general term that doesn’t necessarily mean anything.
• Does the product claim to help with lots of illnesses, not only Alzheimer’s? The FDA says you should “steer clear” of products that made broad, vague health claims.
• Does the product mention results in the lab or in animals? Those results don’t prove the treatment will help people.
• Does the product say it “may” help with Alzheimer’s disease or dementia? That means the product may or may not, and your parents may be better off saving their money.

Finally, remember that dietary supplements marketed to Alzheimer’s patients may seem legitimate because they’re available at the drugstore, but the evidence may not support dementia claims. Check the Alzheimer’s Association list of commonly recommended supplements like Omega-3 fatty acids and Ginkgo biloba to learn what they can and can’t do.

If you go through the checklist and you’re still not sure if a product is legitimate, ask their doctor. Your parent’s doctor knows which treatments and over-the-counter supplements may be helpful for your parent’s overall health. They also know which might interfere with their medications and which would be a waste of money.

Other Ways to Combat Alzheimer’s Scams

If you think your parent participated in any Alzheimer’s scams or if you suspect a product is a scam, you can report it to the FDA. Use the online form for reporting unlawful sales of medical products on the internet. You can also file a complaint with the attorney general in the state where your parents live. If your parents have taken a supplement that harmed them, you can report it to the Department of Health and Human Services. Of course, encourage your parent to talk about it with their doctor.

As with all issues concerning a senior for whom you are a caregiver, communication, and reinforcement of the message is important. My wife and I would find alternate ways of communicating a message, such as telling the senior a cautionary tale about another senior.  Being creative makes directed conversations more natural (less "preachy") and reinforces a message without emcouraging resistance.     

 

Home Health Care Worker Shortage Risks Lives- Impacts Aging in Place Planning

Aging in Place Planning should consider and account for all risks, including availability/unavailability of paid health care workers. The Michigan home health care worker shortage is discussed in an article here, and in a newscast video here.  

The reports suggest that Michigan home health care workers are paid only nine dollars per hour, and often call off.  Of course, there is a vast array of choices in health care agencies (public, private, for profit, and non-profit), and every agency deals with worker retention and availability differently.  

Our office is aware of only one private agency that will certify availability of an aide 24 hours a day; their workers agree that they cannot and will not leave until they are relieved, and the company assures availability by always having supervisory staff and periodic staff available to fill needs. 

Regardless, the challenge of caregiver availability is one that must be considered in making aging in place decisions.  Availability of temporary or respite services, workers, or sometimes, charitable hospice services, may provide relief when worker a home care worker shortage exists. Outside custodial care, respite care, or adult day care may relieve risk upon lack of availability, but transport and cost must be considered.       

Nearly 40% of SNF's Reported No 2020 COVID-19 Deaths; SNF Risk of Death Still Ten Times Higher than Independent Living

In rare good news regarding health outcomes in nursing homes, particularly during the pandemic, a recent study found that nearly 40% of nursing homes reported no COVID-19 deaths during 2020.  The new study was conducted by NORC at the University of Chicago.  The analysis, which was funded by the National Investment Center for Seniors Housing & Care, estimated 2020 COVID mortality rates in seniors housing by level of care and compared the rates to seniors who lived in non-congregate settings. Findings were based on data from five states.

Thirty-nine percent of skilled nursing facilities experienced no COVID-related deaths during the year, while about two-thirds of independent living, 64% of assisted living and 61% of memory care prosperities experienced no related deaths.   The analysis also found that COVID-19 deaths across senior housing correlated with how ill the average resident was and the amount of care they needed: 

“The facts include that COVID-19 transmission is more likely with close person-to-person contact and mortality increases with age and comorbidities. This study shows senior housing isn’t homogeneous, and mortality was higher in property types whose residents, on average, are sicker and require higher levels of care,”

Brian Jurutka, NIC’s president and CEO, said in a statement. 

SNFs and memory care had the highest adjusted mortality rates from COVID-19 with 59.6 and 50.4 deaths per 1,000 residents, respectively.

Resident deaths in independent living settings were statistically comparable to the rates of death for older adults living in non-congregate settings in the same geographic area. Independent living had average adjusted mortality rates of 5.9 per 1,000. That’s compared to the 6.7 per 1,000 found for seniors living in the same counties. For Aging in Place Planning purposes, that means that independent and non-congregant settings showed no higher mortality rate. 

The analysis included data from 3,817 senior housing properties across 113 counties in five states: Colorado, Connecticut, Florida, Georgia, and Pennsylvania.

Source: D. Brown, "39 percent of nursing homes had no COVID deaths: report,"  McKnight's Long-term Care News (June 3, 2021) (last accessed 6/3/2021). 

Guardian Lawfully Refused Family's Request to Remove Ward from Nursing Home Amidst Pandemic

COVID-19 may have revealed with horrific and heart-breaking clarity just how deeply is the bias for institutional care in our legal and health care systems.  A recent Maryland case, arising from pandemic decision-making, may provide an object lesson regarding this bias, and is another in a string of cases revealing the dangers of guardianship. 

Mary Boone suffered from dementia and lived in a nursing home. Due to discord between Ms. Boone’s two daughters, the court appointed an independent guardian for Ms. Boone. In April 2020, one of Ms. Boone’s daughters, Sherry Feggins, filed an emergency motion to remove her mother from the nursing home and relocate her to Ms. Feggins’ house due to concerns about COVID-19 in the nursing home.

The guardian opposed the motion, arguing that Maryland’s governor had ordered people to shelter in place. She also noted that Ms. Feggins did not provide a care plan for Ms. Boone at her house. Ms. Boone’s doctor submitted a statement that moving Ms. Boone would worsen her dementia and put her and the facility at risk for COVID-19. Ms. Feggins argued, additionally, that her mother had suffered abuse at the facility. The court denied Ms. Feggins’ motion, and Ms. Feggins appealed.

The Maryland Special Court of Appeals affirmed, holding that it was in Ms. Boone’s best interest to remain at the facility. 

The court ruled that “it is the welfare of the ward that is of chief concern -- not the wishes of the relatives nor the convenience of the guardian.” The Court determined that Ms. Feggins did not provide sufficient proof that changing Ms. Boone’s residence would be in her best interest.  In the Matter of Boone (Md. Ct. Spec. App., No. 432, May 13, 2021).

An Aging in Place Plan with a clear appointment of a primary decision-maker,  providing for a succession of decision-makers, and conferring authority to implement aging in place plans and preferences, may have prevented this case and controversy.   

Guilfoyle: "Only a Sick Society Would Tolerate Legalized Abuse of Vulnerable Citizens:" Highlights Need for Guardianship Reform

 

The National Association to STOP Guardian Abuse (NASGA) is an excellent organization, and we often share the organization's blog posts on the firm's Facebook Page.  It is rare that the issue of guardianship abuse receives intense national attention and scrutiny.  Perhaps, such a prominent figure speaking out will invite much needed acknowledgment of a national disgrace. You can read the  NASGA blog post here.    

Family Ties? Estrangement Common; Complicates Aging in Place Planning

Aging in Place Planning demands careful attention to the personal social safety net available to a senior.  This social safety net, meaning family and friends who are willing, available, and able to help a vulnerable senior, is vital in protecting a senior from avoidable and unnecessary institutionalization.

Complicating planning is what appears to be a rising incidence of familial estrangement, and the hesitance on the part of seniors to disclose or acknowledge estrangement where it exists.  Add to these the possible callousness of some family members, whether or not estranged, and a senior has an outrageous prescription for disaster.  This blog has previously discussed familial callousness and abandonment, in  shocking and heart-breaking examples.  See, for example, "Seniors with Dementia Abandoned by Family Caregivers at Hospitals and Homeless Shelters."  This latter article  describes a not-uncommon pre-COVID-19, practice of putting demented family members on planes with one-way tickets to major metropolitan centers, hoping that they will be collected and cared for by authorities.   

The Economist, recently asked, "How many American children have cut contact with their parents?" The subtitle to the article suggests an answer: "A young field of research suggests it is surprisingly common."  A recent study conducted by Cornell University, for example, found that 27% of adult Americans are estranged from a close family member. Karl Pillemer, a professor of sociology who led the research and wrote a book about its findings called “Fault Lines”, says that because people often feel shame, the real figure is likely to be higher. The relationship most commonly severed is that between parent and adult child, and in most cases "it is the child who wields the knife."

Unfortunately, family estrangement has been a subject of research for only the past decade, and as a result, there is no data to show whether it is becoming more common. Many sociologists and psychologists think it is.  Divorce, for example, has long been understood to  heighten the risk of other family fractures. Joshua Coleman, a psychologist and the author of “Rules of Estrangement," found in a recent survey of 1,600 estranged parents that more than 70% had divorced their child’s other parent (children of divorce are more likely to dump their fathers, he notes). In recent years, though  America's divorce rate has actually fallen, other trends are making parent-child estrangements more likely. 

The Economist explains:

A rise in individualism that emphasizes personal happiness is the biggest factor. People are increasingly likely to reject relatives who obstruct feelings of well-being in some way, by holding clashing beliefs or failing to embrace those of others. Personal fulfilment has increasingly come to displace filial duty, says Dr Coleman. Whereas families have always fought and relatives fallen out, he says, the idea of cutting oneself off from a relative as a path to one’s own happiness seems to be new. In some ways it is a positive development: people find it easier to separate from parents who have been abusive. But it can also carry heavy costs.

More individualistic than most rich countries, America also has a higher divorce rate. This suggests adult-child separation is more common in America than it is in other places. “My impression is that this isn’t considered much of a problem in many European countries,” says Dr Pillemer. Geography also plays a part. Though people move from state to state less than they used to, America remains one of the most geographically mobile countries in the world. The vast distances often involved allow people who want to leave their families behind to do so.

.     .     .

Those who decide to break off contact with their parents find support in a growing body of books (often with the word “toxic” in the title), as well as online. Threads on internet forums for people who want to break ties with their parents reveal strangers labelling people they have never met as narcissistic or toxic and advising an immediate cessation of contact. This may make it easier to shelve feelings of guilt.

Therapy has played a role too, says Dr Coleman. A lot of therapy in America emphasizes the role family dysfunction plays in personal unhappiness. Though it is often a factor, it is also often not, he says. “As therapists we need to do due diligence on what our patients say. Just as I wouldn’t take at face value a parent’s depiction of their parenting as flawless, I wouldn’t assume an adult child’s claim that a parent is ‘toxic’ should be accepted without further inquiry,” he says. He is launching an online programme with a British researcher that helps therapists and others develop techniques for working with those who have become estranged from close relatives.

Raising awareness about the issue in this way is likely to be important, and not only because some broken bonds may be fixable. Parent-child estrangement has negative effects beyond the heartbreak it causes. Research suggests that the habit of cutting off relatives is likely to spread in families. But most immediately, it is likely to exacerbate loneliness in old age.

Dr. Pillemer, who is also a professor of gerontology in medicine at Weill Cornell Medicine, says the idea for the research was sparked by a one-to-one survey he did of elderly people. “I discovered that dozens had been cut off by their children,” he says. Often, they did not want to admit it. People who work with the elderly should consider the possibility, he says, that an old person is not receiving the support and solace that might be assumed about someone who has adult children. “Mrs Smith may say she has two daughters,” he says. “She is quite likely not to add that she never sees them.”

Heartbreaking. 

See: How many American children have cut contact with their parents?, The Economist, May 22, 2021 (last accessed June 3, 2021).  

Deaths from Nursing Home Neglect Surged Amid the Pandemic

As more than 180,000 of the nation’s long-term care residents and staff died of COVID-19 in a pandemic that has pushed staffs to the limit, advocates for the elderly say a tandem wave of death separate from the virus has quietly claimed untold tens of thousands more.  The most common causes included neglect occasioned by overburdened workers unable to provide necessary care.

Matt Sedensky and Bernard Condon, writing for the Associated Press (AP), told the soul wrenching story of David Wallace: 

"When COVID-19 tore through Donald Wallace’s nursing home, he was one of the lucky few to avoid infection. He died a horrible death anyway."

Hale, hearty, and reportedly happy before the pandemic, the 75-year-old retired Alabama truck driver became so malnourished and dehydrated that he dropped to 98 pounds.  His son reported that he looked like he’d "been in a concentration camp."  No wonder: septic shock suggested an untreated urinary infection, E. coli in his body from his own feces hinted at poor hygiene, and aspiration pneumonia suggested that  Wallace, who required assistance with meals, had  choked on his own food.  All of these conditions developed while Wallace was under the control, custody, and care of a nursing home.  

Kevin Amerson, Walace's son indicted the institution:

“He couldn’t even hold his head up straight because he had gotten so weak. They stopped taking care of him. They abandoned him.”

According to the AP, as nursing homes were opening up to family visitations nursing home watchdogs were being flooded with reports of residents kept in soiled diapers so long their skin peeled off, left with bedsores that cut to the bone, and allowed to wither away in starvation or thirst.

Beyond that, AP interviews with dozens of people across the country reveal swelling numbers of less clear-cut deaths that doctors believe have been fueled not by neglect but by isolation.  The AP described a common mental state plunged residents into despair as a result of prolonged isolation.  The AP noted that many residents cause of death as reported on death certificates was simply “failure to thrive.”

A nursing home expert who analyzed data from the country’s 15,000 facilities for the APs investigation reportedly estimated that for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes. Those “excess deaths” beyond the normal rate of fatalities in nursing homes could total more than 40,000 just since between last March and November.

The industry's record was not stellar prior to the pandemic; studies have indicated that one 

These extra deaths are roughly 15% more than you’d expect at nursing homes already facing tens of thousands of deaths each month in a normal year.

“The healthcare system operates kind of on the edge, just on the margin, so that if there’s a crisis, we can’t cope,” Stephen Kaye, a professor at the Institute on Health and Aging at the University of California, San Francisco, who conducted the analysis, told the AP. “There are not enough people to look after the nursing home residents,” he admitted.

Comparing mortality rates at homes struck by COVID-19 with ones that were spared, Kaye also found that the more the virus spread through a home, the greater the number of deaths recorded for other reasons. In homes where at least 3 in 10 residents had the virus, for example, the rate of death for reasons besides the virus was double what would be expected without a pandemic.

That suggests the care of those who didn’t contract the virus  suffered, possibly  as healthcare workers were consumed attending to residents ill from COVID-19 or were left short-handed as the pandemic infected employees themselves.

Chronic understaffing at nursing homes has been one of the hallmarks of the pandemic, with a few homes even forced to evacuate because so many workers either tested positive or called in sick. In 20 states where virus cases are now surging, federal data shows nearly 1 in 4 nursing homes reported staff shortages.

The nursing home trade group American Health Care Association disputed that there has been a widespread inability of staff to care for residents and dismissed estimates of tens-of-thousands of non-COVID-19 deaths as “speculation.”

Dr. David Gifford, the group’s chief medical officer, said the pandemic created “challenges” in staffing, particularly in states like New York and New Jersey hit hard by COVID-19, but added that, if anything, staffing levels have improved because of a drop in new admissions that has lightened the patient load.

“There have been some really sad and disturbing stories that have come out,” Gifford said, “but we’ve not seen that widespread.”

Another industry group, LeadingAge, which represents not-for-profit long-term care facilities, said staffing challenges are real, and that care homes are struggling in the face of federal inaction to provide additional stimulus money to help pay for more workers.

“These incidents, stemming from the challenges being faced by too many committed and caring nursing home providers during this pandemic, are horrific and heartbreaking,” said Katie Smith Sloan, LeadingAge’s president. “I hope that these tragedies will wake up politicians and the public.”

When facilities sealed off across the country in March, advocates and inspectors were routinely kept out too, all while concerning reports trickled in, not only of serious injuries from falls or major medical declines, but of seemingly banal problems that posed serious health issues for the vulnerable.

Mairead Painter, Connecticut’s long-term care ombudsman, said with dentists shut out, ill-fitting dentures went unfixed, a factor in mounting accounts of malnutrition, and with podiatrists gone, toenails went untrimmed, posing the possibility of painful conditions in diabetes patients.

Even more widespread, as loved ones lost access to homes, was critical help with residents’ feeding, bathing, dressing and other tasks. The burden fell on aides already working tough shifts for little pay.

“I don’t think anyone really understood how much time friends and family, volunteers and other people spent in the nursing home and supplemented that hands-on care,” Painter said.

Strict rules barring in-person visitation persisted in many homes, but as families and advocates have inched back inside, they’ve frequently been stunned by what they found.

The AP shared the  story of June Linnertz, who, when she returned to her father’s room at Cherrywood Pointe in Plymouth, Minnesota, for the first time in three months, she was struck by a blast of heat and a wall thermometer that hit 85 degrees. His sheets were soaked in sweat, his hair was plastered to his head and he was covered in bruises.  Linnertz would learn these bruises came from at least a half-dozen falls. His nails had been uncut so long, they curled over his fingertips and his eyes crusted over so badly he couldn’t get them open.  

Linnertz father, 78-year-old James Gill, was found screaming, thinking he had gone blind, and Linnertz grabbed an aide in a panic. She snipped off his diaper, revealing genitals that were deep red with skin sloughing off.

Two days later, Gill died from Lewy Body Dementia, according to a copy of the death certificate provided the AP. Linnertz told the AP that she always expected her father to die of the condition, which causes progressive memory and movement loss, but she never thought he would end his days in so much needless and avoidable pain and suffering.

“What the pandemic did was uncover what was really going on in these facilities. It was bad before, but it got exponentially worse because you had the squeeze of the pandemic,” Linnertz said. “If we weren’t in a pandemic, I would have been in there... This wouldn’t have happened.”

The assisted living facility’s parent company, Ebenezer, told the AP: “We strongly deny the allegations made about the care of this resident,” adding that it follows “strict regulatory staffing levels” required by law.

Cheryl Hennen, Minnesota’s long-term care ombudsman, said dozens of complaints have poured in of bedsores, dehydration and weight loss, and other examples of neglect at various facilities, including a report of a man who choked to death while he went unsupervised during mealtime. She fears many more stories of abuse and neglect will emerge as her staff and families are able to return to homes.

“If we can’t get in there, how do we know what’s really happening?” she said. “We don’t know what we can’t see.”

The nagging guilt of unnecessary death is one Barbara Leak-Watkins understands. It was just in February that her 87-year-old father, Alex Leak, went for a check-up and got lab work that made Leak-Watkins think the Army veteran, contractor and farmer would be with her for a long time to come.

You’re going to outlive all of us,” Leak-Watkins remembered the doctor saying.

As nursing home outbreaks of COVID-19 proliferated, Leak-Watkins prayed that he be spared. The prayer was answered, but Leak was nonetheless found unresponsive on the floor at Brookdale Northwest in Greensboro, North Carolina, his eyes rolled back and his tongue sticking out.

After he arrived at the hospital, a doctor there called Leak-Watkins with word: Her father had gone so long without water his potassium levels rocketed and his kidneys were failing. He died two weeks later of lactic acidosis, according to his death certificate, a fatal buildup of acid in the body when the kidneys stop working. For a man whose military service so drilled the need for hydration into him that he always had a bottle of water at hand, his daughter had never considered he could go thirsty.

“The facility is short-staffed...underpaid and overworked,” Leak-Watkins said. If they “can’t provide you with liquids and fluids to hydrate yourself, there’s something wrong.”

The daughter is considering filing a lawsuit but a North Carolina law granting long-term care facilities broad immunity from suits claiming negligence in injuries or death during the pandemic could stymie her efforts. Similar laws and executive orders have been enacted in more than two dozen states.  Critics say the laws are a free pass for neglect.

The owner of the father’s facility, Brookdale Senior Living, said it couldn’t comment on individual cases but that “the health, happiness and wellbeing of each of our residents will always be our priority.”

Around the country, the heartache repeats, not only among families who have already buried a member, but also those who feel they are watching a slow-moving disaster.

In Hendersonville, Tennessee, Tara Thompson was able to see her mother for the first time in more than six months when she was hospitalized in October. The 79-year-old had dropped about 20 pounds, her eyes sunken and her legs looking more like forearms. Doctors at the hospital said she was malnourished and wasting muscle. There were bedsores on her backside and a gash on her forehead from a fall at the home. Her vocabulary had shrunk to nearly nothing and she’d taken to pulling the blankets over her head.

The facility Thompson’s mother lived in had been engulfed in virus outbreaks, with more than half its residents testing positive and dozens of employees infected, too. She never caught it, but shaken by the lack of care, Thompson transferred her mother to a new home.

“It has nothing to do with the virus. She’s declined because she’s had absolutely no contact with anybody who cares about her,” she said. “The only thing they have to live for are their families and, at the end of their life, you’re taking away the only thing that matters to them.”

“Failure to thrive” was among the causes listed for Maxine Schwartz, a 92-year-old former cake decorator whose family had been encouraged prior to the lockdown by how well she’d adjusted to her nursing home, Absolut Care of Aurora Park, in upstate New York. Her daughter, Dorothy Ann Carlone, would coax her to eat in the dining room each day and they’d sing songs and have brownies back in her room. Several times a week, Schwartz walked the length of the hallway for exercise.

When the lockdown began March 13, Carlone feared what would happen without her there. She pleaded to staff: “If you don’t let me in to feed her, she won’t eat, she will starve.”

On March 25, when a staffer at the home sent a photo of Schwartz, Carlone was shocked how thin she was. Carlone was told her mother hadn’t been eating, even passing up her favorite brownies.

Two days later, Carlone got an urgent call and when she arrived at the home, her mother’s skin was mottled, she was gasping for breath and her face was so drawn she was nearly unrecognizable. An hour later, she died.

Dawn Harsch, a spokeswoman for the company that owns Absolut Care, noted a state investigation found no wrongdoing and that “the natural progression of a patient like Mrs. Schwartz experiencing advanced dementia is a refusal to eat.”

Carlone is unconvinced.

“She was doing so good before they locked us out,” Carlone said. “What did she think when I wasn’t showing up? That I didn’t love her anymore? That I abandoned her? That I was dead?”

Before the lockdown, Carlone’s mother would wait by an elevator for her to arrive each day. She thinks of her mother waiting there when her visits stopped and knows the pain of the isolation must have played a role in her death.

“I think she gave up,” she said.

You should never give up.  Plan to age in place.  Learn what aging in place planning entails, develop a plan, and then implement the plan. If you won't for yourself, do it for those whom you love, who may be ravaged by the consequence of there being no plan when it is needed.    

Source: Sedenski and Condon, "Not just COVID: Nursing home neglect deaths surge in shadows," AP NEWS (November 19, 2020) (last accessed 4/15/2021). 

Medicaid Denied Due to Land the Applicant Cannot Sell - Considering Asset Illiquidity

 

An Ohio appeals court has ruled that a Medicaid applicant’s land is a countable resource even though the applicant  is unable to sell the land. Cowan v. Ohio Dept. Jobs & Family Servs. (Ohio Ct. App., 1st Dist., No. C-200025, May 26, 2021).

Mary Cowan entered a nursing home, applied for Medicaid, and named the nursing home as her authorized representative. Ms. Cowan owned two parcels of land that she listed for sale, but she was unable to find any buyers. The county auditor, however, valued the parcels at $3,000 each. 

Unless an exclusion applies, Ohio’s Medicaid guidelines provide that individuals are not eligible for benefits if the value of their personal and real property exceeds $2,000. The $6,000 value assessed by the county auditor exceeded the regulatory threshold, so the state denied her Medicaid benefits for excess resources due to the property.

Ms. Cowan appealed, through the state administrative process, arguing that because she couldn’t sell her land, she did not have the legal ability to access the resource. She argued that Federal SSI regulations explicitly state that a property that cannot be liquidated is not a resource. The state denied the appeal, and Ms. Cowan appealed to court. The trial court ruled that Ms. Cowan had excess resources. Ms. Cowan appealed.

The Ohio Court of Appeals, First District, held that the state properly denied Ms. Cowan’s Medicaid application for excess resources.  The Court held that the federal SSI regulation does not apply to the state Medicaid case. According to the court, under state Medicaid law, “if the applicant has the legal authority to sell the property, the plain language of the Code renders it a countable resource.”  Ms. Cowan had the legal authority to sell the property, evidenced by the fact that she tried to sell the property.  The court noted that Ohio clearly concerns itself neither with practical value, or the ability of the seller to find a buyer: “[w]hether [the applicant] was able to find a purchaser is a wholly different consideration from what the regulation contemplated, namely whether [the applicant] had the legal authority to sell the properties in the first place.” In other words, even if the asset is illiquid (cannot be readily converted to cash) the asset is, nonetheless, countable and potentially disqualifying.  

The case illustrates the importance of considering the illiquid assets comprising the estate, and dealing with these assets before they create challenges or liabilities.