Hope I Die Before I Get Old

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Zarembski died on October 4, 2003, from pneumonia. She was 94. Malnutrition, pressure ulcers and orthopedic trauma were contributing factors, according to an autopsy report. In a lawsuit filed in September, Zarembski's niece says the nursing home and the physician who ordered the leg brace are responsible for her aunt's death.

Zarembski wasn't the only one who suffered at Plaza Del Rio. While investigating her case, a state inspector found that three other residents had suffered harm because their pressure sores weren't properly treated. One woman hadn't had the bandage over her sore changed for two weeks; her daughter told the inspector that the staffers never repositioned her mother to help the sore heal. The staffers certainly seemed busy: In full view of the inspector, a nurse's assistant summoned via a call light to help change the woman's soiled undergarments bellowed, "I told them don't put me down for no lights 'cause there's no time for lights here."

Because of "lack of sufficient evidence," inspectors couldn't substantiate an allegation that Plaza Del Rio hadn't given Zarembski enough food. The complaint report shows the state relied on the home's records, which showed Zarembski gained two pounds during her three weeks at Plaza Del Rio and weighed 91 pounds when she was sent to California. There's no evidence the state checked with the Modesto home that admitted her the same day she left Plaza Del Rio.

According to the Modesto home, Zarembski weighed 75 pounds when she arrived, 16 pounds less than claimed by Plaza Del Rio.

Plaza Del Rio wasn't fined or otherwise punished. In the world of nursing home enforcement, a bedsore here and there doesn't count. Eugenia Zarembski and these other folks were gimmes in a system built on second chances.

The Department of Health Services says no fines were levied in any of these cases because violations were considered isolated incidents. "That has changed," says Catherine Corbin, program manager in the department's enforcement section. The department now considers fines when just one resident is injured or killed, she says. But punishment still isn't certain, even in homes with histories of not meeting standards.

Life Care Centers of Scottsdale, for instance, had 20 violations between July 2003 and September 2004, twice as many as the statewide average. The home had 18 violations in each of the two previous inspection periods, which can last as long as 15 months. Since July 2001, inspectors have cited Highland Manor for 50 violations.

Yet neither of these homes has been punished, even after the state documented real harm to residents.

Nursing homes are big business in Arizona. All told, the state has 16,104 beds in 134 nursing homes that collect more than $30,000 a year for each Medicaid resident. If every bed was filled, with Medicaid paying the bills, that works out to a conservative $483 million a year.

Until last year, Arizona relied on someone else to punish nursing homes, referring the worst violations found by state inspectors to the federal government for sanction. It was a haphazard way to hold homes accountable.

The federal system has long been criticized for going light on bad nursing homes. For one thing, the federal government doesn't always follow state recommendations for sanctions. For another, the feds give grace periods: If violations get fixed within 30 to 60 days, no punishments are levied. And homes that pay fines without appealing receive a 35 percent discount.

Furthermore, the federal system is reactive rather than preventive. In most cases, someone has to be killed or hurt before the federal government takes action. Even then, the feds don't require states to refer cases for sanction if only one person dies or is injured. Homes on the brink are rarely punished at all for violations that have the potential to injure or even kill.

Besides issuing fines as large as $10,000, the federal government can terminate a home from the Medicaid program or temporarily stop a home from accepting new Medicaid or Medicare patients. A ban on new residents is a huge hammer, given that the government pays about 60 percent of nursing home costs in the United States.

Since 2000, the federal government has banned new admissions to homes within Maricopa County on just eight occasions, and for periods as short as two days, even when poor care has led to death. During the same period, the feds have levied $180,600 in fines against 14 nursing homes in the county. Three homes still haven't paid fines totaling more than $76,000 that were levied as long as two years ago.

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Bruce Rushton