Dangers cited at Tennessee's nursing homes

Sanctions being issued at unprecedented rate

NASHVILLE - State inspections have uncovered an unprecedented number of dangerous living conditions at nursing homes during the past year.

The crackdown comes after a May report from the Government Accountability Office found that Tennessee is one of nine states that most commonly failed to identify serious violations in a sampling of surveys from fiscal years 2002 to 2007.

State inspectors in Tennessee missed deficiencies - deemed serious enough to cause "actual harm" or put patients in "immediate jeopardy" - 26.3 percent of the time, the report says.

The most frequently missed violations involved poor quality of care, as with regard to ensuring proper nutrition and hydration and preventing pressure sores.

A record 22 nursing homes in Tennessee had their admissions temporarily suspended in 2007 after unsafe conditions were found. That's compared with 10 in 2006 and six in 2005.

The trend has continued. Five months into this year, admissions have been suspended at 13 nursing homes.

Despite the unprecedented number of sanctions, industry officials have said the vacancy rate at Tennessee nursing homes hovers at around 10 percent, or 3,000 available beds.

Christy Allen, who started as assistant commissioner of the Tennessee Department of Health's Bureau of Health Licensure and Regulation in April 2007, said the public should be assured that surveyors have undergone extensive training to remedy the problems cited in the report.

"I believe that we are doing things right," Allen said.

Patrick Willard, AARP Tennessee's advocacy director, is troubled by the report's findings.

"I think it points out the reason why Tennesseans are so concerned about nursing homes," he said. "We rely on state surveyors to find deficiencies and point those out. So when we find out they've been missing them, that's cause for concern."

'Tele-nurses' offer alternative to tying up ambulances

Should you call an ambulance for a sprained wrist or child's fever? A spider bite?

The medical consensus is no, but every year thousands of people in the Houston area dial 911 for non-emergencies.

Hoping to cut back on the number of ambulances responding to non-emergency calls, the City Council voted Wednesday to hire round-the-clock "tele-nurses" to work with 911 dispatchers.

For callers who do not have a true emergency, a nurse will offer first-aid advice over the phone, or help them find a clinic or doctor.

The Houston Fire Department responds to about 750 emergency medical calls a day.

"In a large percentage of cases, when we get there, the patient didn't even want to go to the hospital," said Dr. David Persse, the city's director of Emergency Medical Services. "Maybe they just wanted some advice, get their blood pressure taken."

Some people call 911 because they have no health insurance or no transportation to the hospital. Others have insurance but do not know how to get after-hours care or cannot judge how serious a problem may be.

Until now, the default solution has been to send an ambulance. That costs taxpayers and also can cost the patient: An ambulance ride to the ER costs $415, plus $7.50 per mile. That's before the hospital bill.

"That's a waste of resources, and it also could endanger somebody who really does need an emergency response," Mayor Bill White said.

The city will spend $6.8 million over five years on a contract with the Harris County Healthcare Alliance. The nonprofit group has subcontracted with San Antonio-based CareNet, which will provide at least two nurses around the clock.

If primary care is needed, the nurses can refer callers to health-access "navigators" at the nonprofit Gateway to Care. The navigators will help 911 callers make an appointment at clinics in Houston and can help arrange transportation.

Treated like a cab ride

Houston is among the first cities to try tele-nurses for 911 calls. Richmond, Va., has a similar program, Persse said.

Capt. Alan Nollkamper, who worked for more than 12 years as a Houston paramedic, said flu season is the worst for unnecessary runs.

"It comes in as a 'breathing difficulty' call," Nollkamper said. "We get there and realize the patient has a low-grade fever or congestion. Maybe they need antibiotics, but they don't need our services."

Nollkamper said people call ambulances for minor cuts, sunburns or even because they need prescriptions refilled.

"It's a 911 ambulance, but it's treated like a taxicab," said Sebastian Chavez, a paramedic in the Sunnyside and South Park neighborhoods. "You'll get told many times on the street, 'just do your job and take me to the hospital.'

"They're taking away a paramedic unit from somebody who may need a paramedic unit."

City officials did not provide an estimate but said they were certain the program will save money in the long run.

At first, the nurses will handle about 20 calls a day, but that could grow to 75 or 100 calls a day.

More than half of emergency-room visits by Harris County residents in 2006 were for problems that could have been treated in a doctor's office, according to a study by UT's School of Public Health. The estimated cost was $50 million, the study said.

Only 32 percent of those ER visitors had no health insurance. The rest had private or federal coverage but may not have known how to use it efficiently, said Karen Love, executive director of the Harris County Health Care Alliance.

"The whole idea is to educate people, help them get self-care when appropriate," Love said. "It's just about getting these folks to connect to what we call a 'medical home,' a regular source of care where someone has your medical records there."

There is little danger that a true emergency will get diverted to a phone nurse, officials said.

"If, at any time during the call, the nurse feels the call has shifted and is of an emergency nature, then the call is immediately directed back to (Houston Emergency Center) and an ambulance is dispatched," said HFD Capt. Karen Dupont.

She added that working with the nurse will be voluntary. If at any time a caller wants an ambulance, it will be dispatched, she said.

Fully insured

The alliance is purchasing additional liability insurance, and CareNet, the company providing the nurses, also carries insurance of $3 million per claim, Love said.

More than 30 percent of Harris County residents are uninsured, compared with 24 percent in Texas and 15 percent nationwide.

The reasons are manifold, Love said. Texas has strict income limits for Medicaid eligibility. A high proportion of Texans work for small businesses, which are less likely to offer insurance. Undocumented residents also contribute to the uninsured rates.