Before Casa Real, Lewis was self-sufficient. She took herself grocery shopping, chatted with neighbors outside the apartment complex and only occasionally used a cane to walk.
But at the nursing home, she was confined to a wheelchair. She also became incontinent.
In a letter, dated Aug. 27, 2008, to Lewis’ primary care physician, Begg—who visited Lewis frequently—writes, “The people at Casa Real cannot cover the number of bathroom visits their inmates require so prefer to keep them in diapers.”
Lewis had been referred to Casa Real for rehabilitation. But her experience echoes what others have witnessed for their loved ones.
Dora Vigil, an elderly woman who grew up in Santa Fe, entered Casa Real at approximately the time that Lewis was leaving, in August 2008.
According to her niece, Georgia Kelly, Vigil was happy at first. She ran into friends and acquaintances she’d known in her former life, including a retired doctor’s wife.
“We figured if a retired doctor has his wife there, it’s OK,” Kelly recalls.
After a while, though, Vigil began to complain about how the nursing home staff treated her.
Kelly recalls that, when she visited, Vigil was always thirsty. She finally admitted that she didn’t want to drink too much water, Kelly says, because staff didn’t come frequently enough, and her adult diaper was often wet.
Vigil eventually developed bedsores on her back and buttocks, and Kelly remembers seeing large, yellow bruises from falls her aunt had taken.
Dusti Harvey, Kelly’s attorney in a negligence case against Casa Real, says tales like Lewis’ and Vigil’s are common in New Mexico.
“The poor care—going to the bathroom in your diaper, becoming immobile, not having enough staff—are all things I see very regularly,” Harvey tells SFR.
Steele says staffing issues are often to blame.
“No matter where you look, in any nursing home that has a problem, 95 percent of it can be traced back to low staffing or poor staffing,” Steele says.
According to the most recent report by the American Health Care Association, nursing homes across the country “are facing a serious workforce shortage.”
New Mexico is particularly strapped, ranking near the top of the list for vacancy rates in staff positions.
“There’s just a general staff shortage in New Mexico that doesn’t exist anywhere else in the country,” Michael Evans, a spokesman for Cathedral Rock, the Texas-based nursing home corporation that operates Casa Real and Santa Fe Care Center, tells SFR.
New Mexico state regulations require a minimum staff-to-resident ratio in nursing homes.
“The problem is the numbers do not take into account the severity of the illness,” Sondra Everhart, the state’s long-term care ombudsman says—so state and federal regulations also stipulate that nursing homes employ enough staff to meet residents’ needs.
“People always think that there’s not enough staff,” Gail Trotter, the Long-Term Care Ombudsman Program’s northeast coordinator, says. “‘My loved one’s in a facility’—that’s scary. If there were all the staff in the world, that probably wouldn’t be enough.”
Beyond sheer numbers of staff, though, New Mexico nursing homes are also plagued by frequent turnover.
“It’s a very difficult job,” Everhart tells SFR. “The pay is $9- to $11-an-hour to change diapers, to feed people who can no longer eat.”
The result, she says, is one of the highest nursing home staff turnover rates in the nation. According to AHCA, the average annual turnover rate for Certified Nursing Assistants, or CNAs, in 2007, was 66 percent nationally. Here, it was more than 100 percent—meaning more than the entire staff turns over in a year. New Mexico’s rate is the fourth-highest in the country.
Everhart says frequent turnover, relatively low pay and hard work makes for a potentially taxing situation not just for front-line staff members, most of whom are CNAs, but also for residents.
“If you think about the activities [residents] need help with—eating, bathing, going to the toilet—those are pretty intimate,” Everhart says. “It would be nice if it was the same person, just [for] familiarity. You get sick—who do you want to help you? You don’t want me; you don’t know me. Doesn’t mean I can’t do a good job, but you don’t know me.”
Furthermore, nursing home administrators come and go almost as frequently as CNAs, she says.
“There’s tremendous turnover with administrators and directors of nursing—and those are the key positions,” Everhart says. “You can have the most wonderful facility and have a change in administrator, and it will tank in 60 days. Or the reverse,” she says.
Everhart therefore cautions against judging a facility on its conditions in 2008—or even in 2010, if a change in administration has taken place.
Some cite an ongoing tension between running a for-profit corporation and providing high-quality care as another reason nursing homes sometimes fail their residents.
“There is data available that nonprofit corporations provide better care than profit corporations. Logically, it makes sense,” Everhart says. “If I had my way, I would have nursing homes only owned by not-for-profit corporations.”She adds: “All 50 state ombudsmen in the United States and all their staffs will tell you the same thing.”
According to Everhart, more than half of the state’s 68 nursing homes are run by large, for-profit corporations. (Nationally, it’s approximately 60 percent.)
“It’s a dichotomous moment because they are a business,” Member of the Family founder Steele says. “The biggest problem continues to be staffing. Why would that be? Because staffing is really the first controllable cost.”
At most of Cathedral Rock’s nursing homes, spokesman Evans says, staffing is the single largest expense; at Casa Real, he says, staffing makes up more than 40 percent of the facility’s total annual expenses.
Evans cites New Mexico’s regulatory requirements and a litigious, plaintiff-friendly environment as obstacles to attracting and retaining nursing home staff.
“The litigation environment in New Mexico is more active than a lot of places, and it’s not unusual for a litigator on the plaintiff’s side to name a nurse or an administrator personally,” Evans says. “That probably goes into the presumption of whether or not someone wants to work in a nursing home. We’ve seen a lot of people disillusioned if they get named in a lawsuit. It’s discouraging.”
(Regarding the cases in this story, Evans says Cathedral Rock doesn’t comment about pending lawsuits because “it doesn’t make any sense to do that.”)
Harvey takes issue with the assertion that New Mexico’s legal environment discourages people from working in nursing homes.
“We don’t go after caregivers or CNAs,” Harvey says. “They’re the ones who don’t have enough training, don’t have enough supervision and there’s not enough of them. They’re victims, too.”
Legal action, Harvey says, discourages negligent care—especially when official oversight isn’t enough.
“In our state, it’s up to a jury what someone’s life is worth,” Harvey says of medical malpractice and wrongful death cases involving nursing homes. “In Texas, it’s capped at $250,000. Now, they’re getting horrific care in Texas because [nursing homes] are not being held accountable.”