By James C. Sherlock

One translation of the Hippocratic Oath reads:

“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is (harmful).”

That will prove cold comfort to the thousands of Virginia patients subjected to unnecessary danger, pain, indignities and death at the hands of Virginia’s worst nursing homes.

Virginia hospitals, with a discharge signed by a doctor, transport patients to nursing facilities every day. Government data richly reproduced in this and previous BR series on Virginia’s nursing homes show many of those facilities to be dangerous.

The proper response to anyone enquiring about who could have predicted the twin tragedies charged as crimes at Colonial Heights Rehabilitation and Healthcare Center (Colonial Heights) is: “Anyone charged to oversee nursing homes and the health and safety of patients”.

The most common and most well-correlated cause of danger to patients is long-term understaffing. Staffing also happens to be the most up-to-date government data. It is both readily available on Medicare Compare and auditable against payroll, providing at least some confidence in the numbers.

Yet because staffing data are not used by the government to punish, understaffing is actually a demonstrable feature of the business plans of the private equity firms that control most of Virginia’s worst facilities. They use it to attract like-minded investors with double digit annual returns in an industry in which a 3% return is considered a good year.

Understaffing correlates directly with bad patient outcomes like return to the hospital within 30 days for avoidable reasons, a separately-measured category of nursing-facility-acquired infections, and abuse citations.

So two questions:

1. Why are physicians at hospitals discharging high acuity patients to nursing homes with skeleton staffs?
2. Why are the physician Medical Directors at facilities with major nurse shortages admitting those same patients?

Answer: Nobody stops them.

Let’s look at the proof.

To demonstrate, I have curated from government data a spreadsheet showing what I assess to be the worst nursing homes in Virginia.  The criteria I used to make that judgment are visible in the column headers through column L.

I have led with occupancy rate because it puts to rest any thoughts that physicians are careful to avoid transferring very sick and injured patients to these places.

The exhibit also shows, if you scroll over to affiliated entity name, that Lakewood, New Jersey’s Medical Facilities of America and the recently-shuttered Innovative Healthcare Management, run by the same people, somehow keep these awful facilities full.  The facts behind “somehow” are worthy of their own investigation.  What makes them so attractive?

Eastern Healthcare Group, another New Jersey-based chain, is unable to keep up, but the data suggest that is not for lack of trying.

Because the staffing data are the freshest and the most reliable, and because staffing ratings are the only Medicare Compare star ratings measured against the national set of nursing homes rather than Virginia facilities alone, I always check there first.

Because a 1-star rating requires no minimum staffing, we have seen that Medicare Compare very helpfully breaks down staffing into the rating’s component parts.

As example, look at the Medicare Compare staffing breakdown for Colonial Heights.  Now consider that at least two physicians, one at a hospital and a second at the nursing home, have to sign off on transfers. And those physicians retain their licenses to practice medicine in the Commonwealth.  Except perhaps the Medical Director at Colonial Heights, who faces trial for patient neglect and abuse.  Assuming he returns from a family visit in Pakistan.

Now scroll over and look at the actual average daily and weekend nurse staffing of Parham Health Care and Rehab in Henrico. One star for staffing gives it far too much credit. What hospitals and physicians continue to send patients there? Why?

RNs at Ashland Nursing and Rehabilitation, even if every minute of their time was spent in direct patient care, which is very unlikely, were present on average less than four minutes per patient per day on weekends. And that is on an average weekend day. The federal minimum safe standard is 33 minutes.

Health inspection rating is next.  It is useful if the inspection was recent.  Medicare and Medicaid certification surveys and Virginia licensing inspections are conducted simultaneously by the Virginia Department of Health. Required annually, VDH is years in arrears because of its own staffing problems.

Number of substantiated complaints are the result of investigations of what are largely patient and caregiver complaints. Each substantiates that the nursing facility broke federal law, as does each citation in a standard survey. No Virginia nursing home self-reported an incident in the past year.

Total Weighted Health Survey Score incorporates inspectors’ assessment of the seriousness and scope of each law violation found in standard and complaint investigations over the past three inspection cycles. Points are awarded for each. Higher is worse.

You will see that the facilities with the worst scores are designated as Special Focus Facility Candidates, a special monitoring status that is supposed to mean more frequent inspections.

Abuse icons are warnings to physicians and patients that the facility has been found guilty of that offense in inspections. The warnings are pretty hard to miss. Given the occupancy rates of some of those facilities, they have little effect.

That same link shows how little use is the current quality rating system. CMS knows it, and has very recently completely overhauled that system to make it less subject to manipulation of subjective patient assessments.

The annual total nursing staff and RN turnover figures can be telling. Most of these facilities are beyond chaotic. They explain why a rescue squad member recently told me that too often when they show up at nursing homes they are unable to find anyone who can tell them the patient’s history.

I personally do not consult the overall rating, because it has two defects in Virginia:

• it is dominated by inspection results, which can be years old here; and
• it can be affected by flawed quality measure results discussed above.

Bottom line. Readers can reasonably ask how these facilities, their chain leadership and their private equity owners retain their licenses to operate nursing homes in Virginia.

I have never found a good answer for that.

At some level the term “out of control” assumes they were once in control.  There is no evidence to support such an assumption in Virginia.

But this article is about the hospital and nursing facility physicians who participate in trafficking very sick patients to nursing facilities that the government, and any readers of Medicare Compare, absolutely know do not have the resources to care for them safely and effectively.

The Commonwealth can stop that.

Failure to do so is complicity.