Life and death in assisted living-Part 2: “They’re not treating Mom well”

When the ambulance crew arrived, about 8:20pm, Joan Boice was in the TV lounge, face-down on the carpet. Her head had struck the floor with some velocity; bruises were forming on her forehead and both cheeks. It appeared she'd lost her balance and fallen out of a chair

Joan Boice lived in an assisted-living facility. But no one at the facility could say precisely how the accident had occurred. No one knew how long Joan had been splayed out on the floor. She had defecated and urinated on herself.

Worried that Joan might have injured her spine, the emergency medical personnel gently rolled her over and placed her on a back board. They pumped oxygen into her nostrils.

It was Sept. 22, 2008 — just 10 days after Joan had first moved into Emerald Hills.

No Emeritus employees accompanied Joan to the hospital. And even though Joan’s husband, Myron, was living in the facility, the Emeritus workers didn’t immediately alert him that Joan had fallen and hurt herself. Joan, confused, injured, and nearly mute, ended up in the local hospital by herself, surrounded by strangers.

It was supposed to have been a festive night for Joan’s son Eric and his wife, Kathleen, who lived nearby. They were throwing a birthday party for their daughter, then in elementary school. The celebration was interrupted when a doctor called from the hospital with news of Joan’s fall. As Kathleen recalled it, the physician was somewhat baffled — he didn’t understand what Joan was doing in the emergency room without a family member, and he was having trouble deducing the extent of her injuries because she couldn’t communicate.

California law requires assisted living companies to conduct a “pre-admission appraisal” of prospective residents, to ensure they are appropriate candidates for assisted living.

But Emerald Hills took Joan in without performing an appraisal. It wasn’t for lack of time. The Boices had signed the contract to live at Emerald Hills more than two weeks before Joan moved in.

Joan, then, had taken up residence in the memory care unit at Emerald Hills. The unit — referred to as a “neighborhood” by the company — is a collection of about a dozen small apartments on either side of a central hallway. At each end of the hallway are heavy doors equipped with alarms, which sound when anyone enters or leaves. The alarm system is meant to prevent residents from simply walking off.

On the day Joan moved into Room 101 in the unit, a company nurse named Margaret “Peggy” Stevenson briefly looked her over. The nurse realized that Joan needed to be monitored closely to keep her from falling — she wrote it down in her cursory assessment — but facility records show she didn’t craft any kind of detailed plan for her care and supervision.

Stevenson, asked years later about Joan, said she could recall nothing about her or her stay at Emerald Hills.

Kathleen had immediate suspicions about Joan’s fall. The family, she said, had warned the facility not to leave Joan sitting in a chair without supervision because she was liable to try to stand up, lose her balance, and topple to the floor. Joan had fallen several times during an earlier stay in an assisted living facility near Sacramento, but the staff had developed a specific plan to address the issue.

Despite the warning, Kathleen said that when she visited Emerald Hills during Joan’s first days there she often found her mother-in-law sitting in a chair alone.

The recent track record at Emerald Hills featured a host of falls similar to Joan’s, and ambulances were often called to take the injured off to the hospital. Falls are a particular hazard for the elderly, and assisted living facilities like Emerald Hills are required to report them to state regulators.

Internal company records documented 112 falls at Emerald Hills in 2008. Some residents fell repeatedly.

Consider the case of one Emerald Hills resident, 83-year-old Dorothy “Dottie” Bullock.

On April 5, 2008, an Emeritus employee discovered Bullock “on the floor in a semi-seated position” in the memory care unit, according to a state report. She “was unable to tell” the worker what had happened to her. The incident was described as a fall in state records. Emerald Hills sent her to the hospital.

On April 7, Bullock, back at Emerald Hills, fell again, according to the handwritten log of her personal attendant, who was hired by Bullock’s husband to give her extra help.

On April 8, Bullock, complaining of pain, was hauled by ambulance back to the hospital.

Doctors concluded that she’d fractured her pelvis, but soon returned her to Emerald Hills. She fell again on April 12.

Bullock would fall again months later, for the final time.

Emeritus records show Bullock tumbled in front of her apartment and was found on the carpet with her aluminum walker beneath her. Blood spilled from her nose and a “bump” developed on her forehead, according to the company documents. The impact broke a vertebra in Bullock’s neck and crushed her nasal bones and sinus structures, hospital records show. A CT scan revealed possible fractures of both eye-sockets and the base of the skull.

Dottie Bullock died in the emergency room.

While Emeritus recorded the fatality in its internal logs, the company did not report her death to state regulators, a violation of California law. The state requires assisted living facilities to file reports on all deaths, even those believed to be from natural causes, so that it can look into suspicious or troubling incidents.

Emeritus said it lacked information about Bullock’s death and thus could not say why it had occurred.

Bullock’s personal attendant, Julie Covich, says Bullock was not supervised properly.

“I think there was neglect,” said Covich, who usually visited Emerald Hills once or twice a week to help out Bullock. “I would go in there and never see a caregiver.”

“It was hard to find anyone that was running the place,” she said. “It was crazy.”

“Heads on the Beds”

In early 2008, the year Joan Boice entered Emerald Hills, Emeritus rolled out a new business campaign. The company dubbed it the “No Barriers to Sales” effort.

The concept was straightforward: Move as many people as possible into Emeritus facilities.
Wall Street was looking closely at the company’s quarterly occupancy numbers and a few percentage points could propel the stock price upward or send it tumbling down.

With the housing market foundering, Emeritus needed to step up its sales efforts.

In case there was any confusion about just how seriously the company took this new campaign, a company vice president sent a blast email to facility directors across California. In the body of the email, the vice president got right to it: “SALES and your commitment to sales is your highest priority right now.” Facility directors, the message concluded, would be “held responsible for census and occupancy growth.”

Emeritus employees across the country realized they were entering a new era.

“There was a different sense of urgency. The tone was different,” said a former Emeritus manager who ran a facility at the time. “The message from above was put as many people as possible in the beds and make as much money as possible. That’s what they said. Verbatim. Honestly.”

According to Lisa Paglia, a regional executive in California at the time, Budgie Amparo, the company’s top official for quality control, was openly critical when a Northern California facility declined to admit someone who did not have a doctor’s evaluation.

Such evaluations, which are designed to keep out seniors with problems that assisted living facilities aren’t equipped to handle, are required under a California law known as Title 22.

But on a conference call with roughly half a dozen California managers, Paglia said, Amparo declared that the Northern California facility should have admitted the resident.

“Our priority,” Amparo declared, according to Paglia, “is to get the heads on the beds.”

The issue arose again in October 2008 during a training session for approximately 25 facility directors and salespeople held at an Emeritus property in Tracy, Calif. During the seminar, a company vice president reiterated Amparo’s instruction to disregard California law, according to court records and interviews.

The mandate prompted something of a staff revolt.

At least one facility director spoke out at the meeting: His license to operate the facility was at stake, he said.

An employee who worked at the Tracy facility eventually alerted California regulators. The state dispatched an investigator, and state records show that the investigator met with employees who confirmed that a company official had approved the practice of admitting someone without a doctor’s report. The investigator reviewed a random sample of seven resident files, finding that two people had been moved in illegally, documents show.

Amparo, a nurse whose full title is executive vice president of quality and risk management, denies directing employees to violate the regulation. In a written statement, Emeritus said, “Neither Budgie Amparo nor any of our other officers issued a directive to violate Title 22 or any other law. Emeritus does not condone allowing residents to move in without the proper documents.”

Emeritus eventually fired Paglia, and lawyers for the company have since portrayed her as a poor worker who failed to do her job competently. Along with two other former Emeritus employees, Paglia sued the company alleging wrongful termination, and wound up settling on secret terms.

For assisted living chains such as Emeritus, there is a powerful business incentive to boost occupancy rates and to take in sicker residents, who can be charged more.

Emeritus, for its part, rejects any suggestion that a quest for profits has tainted its admission practices. But in interviews, former Emeritus executives described a corporate culture that often emphasized cash flow above all else. The accounts of the executives, who spoke independently but anonymously, were strikingly consistent.

“It was completely focused on numbers and not human lives,” said one executive, who worked for Emeritus for more than three years and oversaw dozens of facilities in Eastern states.

The company’s emphasis on sales and occupancy rates, the executive said, transformed the workforce into “a group of people who were grasping at every single lever they could pull to drive profitability.”

Emeritus operates a sophisticated, data-driven sales machine. There are occupancy goals for each facility, as well as yearly company-wide goals. The company tracks dozens of data points — including every move-in and move-out of residents — in a vast database. It posts a monthly snapshot of each facility’s sales statistics on an internal website, allowing employees to see which strategies are most successful.

Sales specialists are instructed on how to use psychology to persuade potential customers to sign on. One suggestion: Give the customer “a sense of control and choice by offering two possible options.” A 2009 Emeritus sales manual, which runs 181 pages, encourages sales people to generate publicity by hosting seminars on Alzheimer’s or organizing charity efforts in the event of a natural disaster like a “flood or earthquake.”

Emeritus motivates its workforce with a broad range of financial incentives. There are bonuses for hitting monthly occupancy goals. Bonuses for hitting yearly occupancy goals.
Bonuses for boosting overall earnings. And the money doesn’t just go to sales people: The company hands out checks to maintenance workers, nurses, facility directors and other workers.

Nurses play a key role in assisted living, providing much of the hands-on care. But nurses at Emeritus facilities are also expected to be deeply involved in increasing revenue by making sales.

During more than a year of reporting, ProPublica and PBS Frontline spoke to 10 facility directors who said nurses were required to participate in weekly conference calls focusing on little but economics. Those accounts are backed by an internal Emeritus document that lays out the agenda for the weekly calls and that shows an overarching concentration on finances.

Doris Marshall was at the forefront of Emeritus’s efforts to have nurses play the dual roles of caregivers and salespeople. After receiving her nursing license in 1984, Marshall had spent many years tending to patients in the emergency department of a Southern California hospital, and she’d later gone on to help run a nursing school.

But Marshall was intrigued by the assisted living business and in March 2008 she signed on to supervise 10 Emeritus properties scattered across Northern California. Amparo, the company’s head nurse, convinced Marshall to take the job, telling her nurses “had a voice” at Emeritus.

Marshall was to oversee the well-being of roughly 800 elderly people. But her job description went well beyond that: She was to help with “marketing” and “attaining financial goals.” Her job, in the end, actually involved very little nursing.

Instead, she said, she was drawn into Emeritus’s evolving strategies aimed at upping its revenues. The company planned to bring in more seniors with Alzheimer’s and dementia because they could be charged more, she said. Her boss gave her a digital tracking tool showing how much more money Emeritus could make by admitting sicker, frailer residents.

By the fall of 2010 Marshall was worn out and disillusioned. She quit.

Emeritus’s extraordinary drive to put heads in beds — perhaps routine in, say, the hotel industry — has distorted the admissions process at some facilities, records and interviews show. Since 2007, state investigators have cited the company’s facilities more than 30 timesfor housing people who should have been prohibited from dwelling in assisted living facilities.

A 2010 episode at an Emeritus facility in Napa highlighted the perils of improperly admitting people. The facility rented a room to a 57-year-old woman with an eating disorder, depression, bipolar disorder and a history of suicide attempts. The woman, who was distraught over the death of her husband, taped a note to her door saying she wasn’t to be disturbed and committed suicide, overdosing on an amalgam of prescription painkillers.

The state’s investigation into the death was scathing: the woman should never have been allowed to move in; the staff had missed or ignored bulimic episodes and her obvious weight loss; no plan of care was ever developed or implemented despite the resident’s profound psychological problems.

Emeritus, asked to respond to the state’s investigation, said only that the woman had overdosed on drugs she had brought into the facility on her own, and that as a result they could not be faulted in her death.

“She Barely Even Talked to Us”

In the aftermath of her fall in September 2008, Joan returned to Emerald Hills. But the staff, inexperienced and often exhausted, worried about her.

“She couldn’t walk, she couldn’t feed herself, she barely even talked to us, and her health wasn’t that good,” recalled Jenny Hitt, a former medication technician at Emerald Hills.

But if concern was abundant at Emerald Hills, expertise was in short supply.

Alicia Parga ran Joan’s memory care unit. On some weekends, she managed the entire building — not only the wing of residents with dementia, but the rest of the three-story assisted living facility, one that could hold a total of more than 100 residents.

After Parga started on the job, it took Emeritus roughly 18 months to give her any training on Alzheimer’s and dementia. The state regulations were hardly substantial: Someone such as Parga was obligated to get six hours of training during her first four weeks on the job. But even that requirement wasn’t met.

Emeritus has insisted that Emerald Hills had properly trained personnel to care for Joan and others, and they described Parga as a woman deeply invested in tending to the residents.

But Parga, who had barely earned a high school degree, wasn’t even familiar with the seven stages of dementia. Though she was responsible for the well-being of 15 or more seriously impaired people, as well as the supervision of employees, Parga was paid less than $30,000 per year.

Catherine Hawes, a health care researcher at Texas A&M University, conducted the first national study of assisted living facilities. In her view, training is absolutely crucial. A well-educated employee can “interpret non-verbal cues” from people like Joan, intercept seniors before they wander away from the building, or keep residents from eating or drinking poisonous substances.

“You can do great care,” she said. “You just — you’ve got to know how.”

Other than the Emeritus employees working in the memory care unit at Emerald Hills, only one person saw Joan enough to know what kind of daily care she was getting: Her husband, Myron.

He was worried. And he did his best to sum up his concerns to his son Eric:

“They’re not treating Mom well.”


PREVIOUS PART: The Emerald City                            NEXT PART: A Sinking Ship




Telangana: CWC proposes creation of the new state by dividing Andhra Pradesh

The decisions by the CWC and the UPA came after hectic consultations for the last over a week on creation of the 29th state of the country that will have a geographical area of 10 of the 23 districts of undivided Andhra Pradesh

Brushing aside opposition after dithering for nearly four years, the Congress and the UPA coalition on Tuesday unanimously endorsed creation of a separate Telangana state from out of Andhra Pradesh.


“It is resolved to request the Central government to make steps in accordance with the Constitution to form a separate state of Telangana ...within a definite timeframe,” said a resolution of the Congress Working Committee (CWC), the highest policy-making body of the party, after over an hour-long meeting.


The Congress also decided to recommend to the government that Hyderabad be made the joint capital of the newly-proposed state and the other regions—Rayalaseema and Coastal Andhra—for a period of 10 years.


The momentous decisions by the CWC and the UPA came after hectic consultations for the last over a week on creation of the 29th state of the country that will have a geographical area of 10 of the 23 districts of undivided Andhra Pradesh.


Tuesday’s decision also brings to fruition the announcement made by the then home minister P Chidambaram on 9 December 2009 for creation of Telangana.


Contrary to speculation that the new state could be named Rayala Telangana, including a couple of districts of Rayalaseema, the districts that will be part of the new state will be Adilabad, Karimnagar, Khammam, Mahaboobnagar, Medak, Nalgonda, Nizamabad, Rangareddy and Warangal besides Hyderabad.


At the moment the idea is to have 10 districts in Telangana but it will be for the Group of Ministers to consider demands for inclusion of more areas, AICC General Secretary Digvijay Singh, in charge of Andhra Pradesh affairs in Congress, told a press conference after the CWC meeting.


Out of 42 Lok Sabha seats and 294 Assembly seats in Andhra Pradesh, Telangana is likely to have 17 Lok Sabha seats and 119 Assembly seats.


At the CWC meeting, the prime minister said the decision to create a separate Telangana would help entire Andhra region.


Gandhi, who is also the UPA chairperson, gave a historical perspective on the issue to the CWC meeting in which Digvijay Singh moved the resolution. It was adopted unanimously.


Like last weekend, when indications emerged that the Congress was veering towards formation of Telangana, ministers and MPs belonging to the non-Telangana regions made last ditch efforts to convince Congress president Sonia Gandhi and Prime Minister Manmohan Singh to have a rethink on the issue.


Andhra state, the first entity formed on linguistic basis, was created in 1953 from out of the erstwhile Madras Presidency with Kurnool as the capital. With the passing of the States Reorganisation Act, 1956, there was a merger of Hyderabad state and Andhra state to be called Andhra Pradesh from 1 November 1956. Andhra Pradesh now has a population of over 8.5 crore.


The 2009 announcement, taken at the height of an indefinite fast by TRS leader K Chandrashekhar Rao, had ignited street protests in the non-Telangana regions and opposition from ministers, MLAs and leaders from within the party that forced the central government and the Congress leadership to put the issue on hold.


The Centre held rounds of meetings with all parties from the state and set up a Commission under the chairmanship for Supreme Court Judge Justice Srikrishna, which had given a report suggesting various solutions.


Chief minister Kiran Kumar Reddy, who was opposed to the division of Andhra Pradesh and was said to be thinking in terms of resigning, was called for consultations. He attended the UPA meeting.


However, he dismissed reports of resignation as ‘rumours’. Similarly, Congress ministers in the Union government and the MPs gave enough indications that they would follow the party line.


Sensex, Nifty in a strong downtrend: Tuesday Closing Report

Only a close above 5,820 on the Nifty tomorrow will be the first sign of a reversal in downtrend

Indian benchmarks closed with losses of over 1.2% as the RBI cut the GDP growth forecast for the current fiscal to 5.5% and decided not to change its monetary policy. The National Stock Exchange reported a turnover of 58.95 crore shares and advance-decline ratio of 311:1023.


The market opened flat on a mixed note as investors remained cautious ahead of the Reserve Bank of India’s (RBI) quarterly review of the monetary policy. Hinting at status quo on policy rates, the RBI on Monday said its focus is to stabilise rupee and made a case for calibrated action to contain the current account deficit, which is a major reason for the steep fall in currency.


The Nifty resumed trade at 5,836, up four points from its previous close and the Sensex started the day, down 15 points. The benchmarks inched higher on buying in select blue-chip shares amid volatile trade in the initial session.  But selling in realty, fast moving consumer goods (FMCG) and power stocks led the indices to their lows a short while later.


The market perked up as the RBI, in its policy review, kept key rates unchanged and reiterated that the recent measures to tighten liquidity would be rolled back “in a calibrated manner as stability is restored in the forex market”. The benchmarks hit their highs shortly after the central bank assured investors that liquidity curbs would be eased. The Nifty rose to 5,861 and the Sensex climbed to 19,673 at their respective highs.


However, the gains were short-lived as the indices soon began a downward journey weighed down by selling in PSU, realty, power and FMCG sectors. The market expanded its losses in noon trade as selling continued unabated.


The benchmarks continued their southward journey in late trade as the rupee breached the 60 per dollar mark in noon trade. The rupee was quoting at Rs60.07 a dollar compared with previous close of Rs59.41 per dollar around 2.00pm.


The indices touched their lows at the fag-end of the trading session with the Nifty falling to 5,748 and the Sensex going down to 19,329. The Nifty settled 77 points (1.31%) down at 5,755 and the Sensex finished at 19,348, a decline of 245 points (1.25%).


The broader indices too settled lower. The BSE Mid-cap index fell 1.96% and the BSE Small-cap index fell 1.98%.


BSE IT (up 0.91%) was the sole sectoral gainer. The major losers were BSE Oil & Gas (down 3.89%); BSE Realty (down 3.60%); BSE Power (down 3.35%); BSE PSU (down 3.11%) and BSE Auto (down 2.06%).


Out of the 30 stocks on the Sensex, eight stocks settled higher. The main gainers were Wipro (up 2.75%); Jindal Steel (up 1.45%); Infosys (up 1.20%);

Larsen & Toubro (up 0.97%) and Sun Pharma (up 0.92%). The main losers were ONGC (down 5.64%); Hindalco Inds (down 4.64%); Tata Motors (down 3.94%); Bharti Airtel (down 3.76%) and Bajaj Auto (down 3.40%).


The top two A Group gainers on the BSE were— Neyveli Lignite (up 6.33%) and Mahindra & Mahindra Financial Services (up 4.42%).


The top two A Group losers on the BSE were— Jaiprakash Power (down 15.77%) and Havells India (down 12.60%).


The top two B Group gainers on the BSE were— Panasonic Appliances (up 19.93%) and GEI Industrial Systems (up 19.88%).


The top two B Group losers on the BSE were— Vakrangee Softwares (down 19.98%) and Geometric (down 19.96%).


Of the 50 stocks on the Nifty, nine ended in the in the green. The major gainers were IDFC (up 2.53%); Jindal Steel (up 1.95%); HCL Technologies (up 1.58%); Sun Pharma (up 1.36%) and Larsen & Toubro (up 1.05%). The main losers were BPCL (down 8.90%); Reliance Infrastructure (down 7.09%); DLF (down 7.09%); Ranbaxy (down 6.44%) and ONGC (down 5.91%).


Markets in Asia closed mostly higher on China’s fund infusion measures to boost liquidity and a weaker yen which improved the prospects for Japanese exporters.


The Shanghai Composite advanced 0.70%; the Hang Seng rose 0.48%; the Jakarta Composite gained 0.61%; the Nikkei 225 surged 1.53%; the Straits Times rose 0.26%; the Seoul Composite climbed 0.90% and the Taiwan Weighted settled 0.98% higher. On the other hand, the KLSE Composite fell 0.21%.


At the time of writing, the key European markets were trading with minor gains and the US stock futures were in the positive.


Back home, institutional investors, foreign and domestic, were net sellers in the equities segment on Monday. While FIIs sold stocks totalling Rs231.77 crore, domestic investors offloaded shares amounting to Rs101.25 crore.


Pratibha Industries has bagged a Rs 205 crore contract for a water supply project from Public Health Engineering Department, Jaipur. The contract has been awarded for water supply scheme to 161 villages of Phagi Tehsil in Jaipur under Bisalpur Dudu Phagi Water Supply Project. The contract is scheduled to be completed in 30 months from date of commencement. It includes one year defect liability and 10 years operation and maintenance of the system. The stock rose 3.06% to close at Rs23.60 on the NSE.


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