Secret VA nursing home ratings hide poor quality care from the public

Donovan Slack, USA TODAY, and Andrea Estes, The Boston Globe | USA TODAY

Show Caption Hide Caption Life in a VA nursing home: One veteran’s story Don Ruch’s family thought round-the-clock care would help him recuperate, but he ended up in intensive care in septic shock, suffering from “severe” malnutrition, bedsores on his pelvis and back, a burn on his right thigh and a trauma wound.

World War II veteran Rosario "Russ" Bonanno was facing worsening dementia when his family brought him last year to the Department of Veterans Affairs nursing home in Bedford, Massachusetts. He had been in assisted living, but after six years, some family members thought he needed more specialized care.

Within days after Bonanno arrived, his son Nick said the 93-year-old was “dazed, confused, disheveled" as staff began medicating him. He wasn’t the only resident who looked drugged. "Everyone looks like a zombie," Nick said.

What Nick and his family didn’t know was that the Bedford facility ranked among the worst of 133 VA nursing homes across the country, in part for giving so many residents anti-psychotic drugs.

But the VA knew.

The agency has tracked detailed quality statistics on its nursing homes for years but has kept them from public view, depriving veterans of potentially crucial health care information. Nearly half of VA nursing homes nationwide – 60 – received the agency's lowest ranking of one out of five stars as of Dec. 31, 2017, according to documents obtained by USA TODAY and The Boston Globe.

The VA made some of its ratings public last week after receiving questions from the Globe and USA TODAY about all the secrecy. VA officials said President Donald Trump wanted to release the ratings all along and blamed the Obama administration for not making them public earlier.

Statistics the VA has not released paint a picture of government nursing homes that scored worse on average than their private sector counterparts on nine of 11 key indicators last year, including rates of anti-psychotic drug prescription and residents’ deterioration. In some cases, the internal documents show, the VA ratings were only slightly worse. In others, such as the number of residents who are in pain, the VA nursing homes scored dramatically worse.

The worst-performing VA nursing homes were scattered across 32 states, including Pennsylvania, which had five one-star facilities, as well as Texas and California, which had four each. The VA facility in Bedford and another in Brockton, Massachusetts, were the only one-star nursing homes in New England.

VA officials argued that the VA nursing home system, overall, “compares closely” with private nursing homes despite caring for typically sicker residents.

VA spokesman Curt Cashour called it “highly misleading” to compare pain levels at the VA with those at private nursing homes because VA residents have “more challenging” medical conditions. The VA's internal quality tracking found that VA nursing home residents were five times more likely to report being in pain than private nursing home residents.

Cashour said 60 VA nursing homes have seen improvements in their rating over the past year, while only one had a “meaningful” decline.

“We are committed to continuous improvement efforts in all of the (VA nursing homes) and demonstrating performance that is as good (as) or better than private sector facilities,” Cashour said.

The VA’s hospitals have drawn intense criticism for repeated scandals involving health care in recent years, including preventable deaths, but the agency largely has operated its nursing homes with scant public scrutiny. VA nursing homes serve 46,000 veterans annually in 46 states, the District of Columbia and Puerto Rico.

Internally, the agency has long monitored care at its nursing facilities through quality indicators and unannounced inspections and, since 2016, through star rankings based on the indicators. Until now, it has kept all of these quality measures from the public.

Under federal regulations, private nursing homes are required to disclose voluminous data on the care they provide. The federal government uses the data to calculate quality measures and posts them on a federal website, along with inspection results and staffing information. The regulations do not apply to the VA.

The VA has “got this whole sort of parallel world out there that’s hidden,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “I still can’t get over that this information is not available to people who are looking for a veteran’s home. That’s just unacceptable.”

VA spokesman Cashour blamed the Obama administration for resisting making quality data public. “But under President Trump’s leadership,” he wrote in a statement June 12, “transparency and accountability have become hallmarks of VA.”

The VA’s decision to release the quality data came after first asking USA TODAY and the Globe for more time to answer questions about the secret ratings. Then the VA released the quality ratings while the reporters waited for answers.

The agency did not release the more detailed information that underlies the star ratings, such as rates of infection and injury.

Alex Howard, a longtime transparency advocate and former deputy director of the Sunlight Foundation, said the VA should release all of the data immediately – and on an ongoing basis. He said the underlying information is critical to understanding what the stars mean.

“There shouldn’t be a gap between the reality of how we’re treating people under the government’s care and public understanding of it,” Howard said. “This is not a situation where we’re concerned about some matter of national security, this is simply being honest about how well things are going.”

'I was told how good it is – by VA, of course'

After 38 years of marriage, Leslie Roe made the gut-wrenching decision to place her husband in a nursing home.

Earl James “Jim” Zook, 72, suffered from dementia and had taken to wandering away from their home in Coosada, Alabama, and she worried she would lose track of him.

Roe moved Zook, a Vietnam-era Navy veteran, into a VA home an hour away in a rural, wooded swath of Tuskegee, Alabama. She said VA staff put a bracelet on his wrist warning he was a flight risk and placed him in a secure ward.

Three months after Roe checked Zook into the Tuskegee facility, staff lost track of him. Zook simply walked out into the woods; Roe said she was told there was a faulty door.

She had no idea that the facility ranked among the worst VA nursing homes in the country last year, scoring only one out of five stars in the agency’s own quality rankings. She had to rely on what the VA said.

“I was told how good it is – by VA, of course,” Roe said.

The VA assigns stars based on 11 indicators that can be tipoffs to larger problems with overall quality. For example, high rates of falls or bed sores may indicate understaffing or neglect.

The Tuskegee nursing home scored worse than private nursing home averages on eight of the 11 criteria as of Dec. 31, 2017, including rates of residents being in pain, receiving anti-psychotic drugs and contracting urinary infections.

This year, the Tuskegee nursing home improved from one star to two stars. That was too late for Zook.

He hasn’t been seen since he walked out of the Tuskegee facility in January 2017. Searches by helicopter and with tracking dogs turned up nothing.

“We finally declared him legally dead,” Roe said this year, “because there was no way he could have lived without his medication.

“Anybody that deals with VA, I feel sorry for them,” she said.

Cashour said that after Zook’s disappearance, which he called an “unanticipated outcome,” the VA implemented more safety measures, including adding GPS to an alarm system that notifies staff if patients leave the facility.

‘They break their spirit’

The VA has relied for more than a decade on an outside company, Wisconsin-based Long Term Care Institute, to conduct inspections of VA nursing homes and report back to the agency.

The VA banned the public release of institute reports after the Pittsburgh Tribune-Review in 2009 published the findings from one report detailing “significant issues” at the VA nursing home in Philadelphia, including poor resident grooming and pest control. In one case, a patient’s leg had to be amputated after an infection in his foot went untreated for so long his toes turned black and attracted maggots.

The VA said the reports are internal quality assurance documents “protected” from disclosure under federal law. However, in their announcement last Tuesday releasing the nursing homes’ star ratings, VA officials said they would also release the long-term care reports. They didn’t say when.

Such reports might have been helpful to Bonanno, the WWII veteran whose family moved him from a private assisted-living facility to the Bedford VA last April as his dementia worsened.

An inspection report obtained by the Globe shows reviewers from the Long Term Care Institute found several instances of neglect at the nursing home in April 2017. They saw a veteran lying in bed covered only by a urine-and-feces-stained sheet. They saw another veteran struggling to eat, using his hands to shove food in his mouth after trying unsuccessfully to maneuver food onto a spoon. Staffers were nearby, the report said.

By then, inattentive patient care in Bedford had already proved fatal to one resident. Vietnam veteran Bill Nutter died in 2016 while an aide who was supposed to check on him hourly allegedly played video games on her computer and didn’t check on him at all. She later resigned, and Nutter’s family sent a letter to the VA seeking $10 million in damages.

Bonanno’s family would learn about the conditions the hard way.

His son said Bonanno, a happy-go-lucky retired mechanic, would always wake up early for breakfast. But for the first few months in the Bedford facility, he was fast asleep when his son arrived after 11 a.m. for a visit. According to Nick, the staff woke him up at 6 a.m. to put him back to sleep. They gave him an anti-psychotic drug and a sedative, Nick said.

“They medicate them until they break their spirit and make them passive. I guess it’s easier for the staff to deal with them,” Nick said. “In six years in assisted living, he’d never been medicated during the day.”

Staff told Nick that his father was “agitated” and needed the medication — a contention Nick disputes.

Cashour said many of the veterans at Bedford live with “chronic mental illness” related to their military service and require psychotropic medication “to reduce distress and manage behavior.” After the veteran is stabilized, he said, the VA works to reduce the use of these drugs.

Nick’s brother, Russ, who lives in Indiana, said he and his sister, who also lives outside of Massachusetts, believe their father’s overall health has improved and he is properly medicated.

“My sister and I both agree he’s getting care that’s high quality and appropriate for his needs,” he said.

Nick said that as their father became more and more groggy, he participated in fewer activities; he went from walking with help to sitting in a chair for hours, doing nothing.

“There are ways to care for people with dignity and allow them to be themselves,” said Nick, who visits his father several times a week. “I was lucky to have Dad in a place that was pretty good for six years. It was a huge drop-off in the way they provide care at the VA versus a private facility.”

‘I thought my heart was going to stop’

Even higher-ranking VA nursing homes scored below private nursing homes on individual quality measures last year, the internal documents show.

The VA assigned three stars to its nursing home in Livermore, California, even though the facility scored worse on average than private facilities on six of 11 criteria. Residents reported being in pain at dramatically higher rates and experienced general declines and developed sores at slightly higher rates.

As a paraplegic, Livermore VA resident Don Ruch couldn’t feel the gaping wound festering on his leg. When the 71-year-old saw a picture of the hole, he went from trusting to terrified.

His family had moved him into the VA nursing home last year, hoping the round-the-clock care and rehabilitation services would help him recuperate from the aneurysm that caused his paralysis.

Within months, the onetime Army infantry radio operator ended up in the intensive care unit at a nearby private hospital, Stanford ValleyCare. Doctors found him in septic shock from a “significant” urinary tract infection, medical records show. He was suffering from “severe” malnutrition, bedsores on his pelvis and back, a burn on his right thigh and a trauma wound on the back of his right calf.

Ruch couldn’t lift his leg to see the wound, so he asked a caregiver to take a picture and show it to him.

“I saw a hole in my leg that I think I can stick a golf ball into,” he said. “I thought my heart was going to stop.”

Ruch, who said he was so depressed he didn’t realize he wasn’t eating enough, felt betrayed — by the nurses who had repeatedly changed his bandages without saying anything about how bad the wound had become and by the doctor who told his family it was nothing to worry about and from a “small bruise.” The same doctor told his niece he was malnourished because “we can’t make a veteran eat.”

Cashour, the VA spokesman, said Ruch has a complex medical history and a review of his medical records “does not suggest that there was a delay in diagnosis, treatment or triage to the hospital in this case.”

The episode triggered Ruch’s post-traumatic stress disorder and his niece managed to get him transferred to a private nursing home — paid for by the VA — near her home in Omaha, Nebraska. It took three months to recover, but he’s better, his family said.

“Can you imagine the thousands and thousands and thousands of veterans who sit in these places and act compliant because they don’t have a choice,” his niece, Amy Leise, said. “This makes me want to cry.”