Elder advocates raise concerns on assisted living

By Kay Lazar

 | Globe Staff   September 21, 2014

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In Stoughton, an elderly woman walked out of a locked dementia unit at an assisted living residence in May, wandered into another room and fell from a second-story window.
That same month, at a Framingham assisted living facility, two staffers were arrested for allegedly slapping and pinching two elderly residents who have Alzheimer’s, and filming a third who was partly undressed.

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In July, an 88-year-old man with a history of falling, and who had a tube in his chest for dialysis treatment, apparently tripped in the bathroom of his Revere assisted living residence and bled to death before staffers reached him.
Residents in Massachusetts assisted living facilities are in harm’s way too often, and the Executive Office of Elder Affairs, the state agency charged with overseeing the 224 residences, is ill-equipped to protect these increasingly frail residents, elder advocates say.
Even a key staffer at the agency is worried. Peter Antonellis, compliance officer at Elder Affairs who inspects the facilities, said the agency has just two ombudsmen to handle the thousands of complaints that pour in each year involving assisted living residences.
State data show that Elder Affairs has suspended just three assisted living residences for serious infractions since 2008 — an action that merely prevents the facilities from accepting new residents until they fix identified problems.
“I think most elders and their families think this is a regulated industry, but we don’t have the staff to regulate it,” Antonellis said.

‘We don’t want anyone to reside in our community if they are not safe, but often it is the families that want them to stay.’

Warren Strong, spokesman for Prospect House 

Many elders who once would have moved to nursing homes when their health declined are instead choosing to remain in assisted living, often because the cost is significantly less than nursing homes. As a result, the populations in these loosely regulated, apartment-like facilities have been profoundly transformed, with a growing segment of residents who are increasingly frail.
That shift, combined with limited oversight, is jeopardizing the welfare of the 13,700people who live in these de facto nursing homes, elder advocates and safety specialists say. Assisted living residences were designed as nursing home alternatives for older adults who need help with everyday activities, such as bathing, dressing, and cooking, yet are still capable of living independently.
Among the most glaring shortcomings, advocates say: outdated rules that fail to address the need for adequate staffing levels and training, and guidelines that fall short of ensuring safety during emergencies. Also troubling, they say, are lax rules for monitoring medications, especially among residents with dementia.
Each week, roughly 100 incidents, from fatal falls and suspected abuse, to more mundane accidents, are reported to Elder Affairs.
Antonellis said he has repeatedly alerted his superiors that reports of serious incidents at facilities are languishing for weeks or months at the agency, and that no one seems to be analyzing them for patterns that may point to larger issues. “Unless the facilities know that we are scrutinizing what happens, they don’t have to be too concerned about the system they use to keep residents safe,” Antonellis said.
A spokeswoman at Elder Affairs disputed Antonellis’s assessment, saying the agency converted an antiquated paper-based reporting system to electronic files last year and does not have a backlog.
“The department takes any instance of elder abuse or neglect seriously, whether it comes from an outside party or a member of staff,” spokeswoman Martina Jackson said. “Staff work diligently to process the reports they receive and review the underlying incidents, cooperate with law enforcement on criminal matters, and order corrective action when necessary.”
And the reports keep coming.
David Hoey, a North Reading attorney who specializes in elder abuse cases, said his office used to receive one or two calls a year from people saying a family member had been injured in assisted living.
Now, Hoey said, he receives at least one a month, and he is representing families with a range of complaints, from alleged abuse and deadly falls, to an elderly man who choked to death even though staffers were supposed to be monitoring what and how he ate. Hoey said insufficient training and staffing are at the heart of most of the cases he takes.
Dino Colucci,whose Boston law firm also handles a lot of neglect cases involving assisted residents, said the injuries he sees in those claims are very similar to the ones he has seen in his nursing home cases.
“What I have seen is facilities cut corners, particularly with staff because it’s the most expensive item, so it’s not surprising that some preventable accidents happen.” Colucci said. “People are given the wrong medication, or are overmedicated, or they are not observed and are allowed to get injured.”
State rules do not require minimum staffing levels in assisted living, but do mandate at least seven hours of orientation for new employees and 10 hours of annual training.
Industry leaders say the staffing and training criticisms are unfounded and that relaxed state oversight allows companies to design more homey, less institutional settings that typically cost half of what nursing homes charge.
They acknowledge the conundrum of balancing independence for seniors with rules to ensure their safety, but say industry surveys show consistently high consumer satisfaction and a steady march of customers to their doors.
“This individuality and opportunity for resident choice are two of the most crucial features of Massachusetts assisted living communities, where there is a deep commitment to continuously train staff to respond to residents’ evolving needs and provide the highest quality services,” said Emily Meyer, president of the Massachusetts Assisted Living Facilities Association, which represents most of the state’s facilities.
Massachusetts rules governing assisted living residences have not been updated since 2006. Yet since then, the percentage of residents with dementia has risen from 37 to 44 percent of the assisted living population, according to state data.
At the same time, fewer of these frail residents are being moved each year to facilities where they can receive more skilled care, as intended by the 1994 state law that established state oversight of assisted living facilities. State data show the percentage of residents transferred each year to skilled nursing facilities has fallen from 47 percent to 40 percent since 2006.
The Executive Office of Elder Affairs is preparing updates to its regulations, but Ann Hartstein, state Elder Affairs secretary, declined in an interview to discuss what regulatory changes her office may propose. She said her agency believes some retooling is needed to ensure safety, but that it is not necessary to overhaul the state’s unusual approach to regulating assisted living facilities, treating them much like private residences.
“We are not a medical model,” Hartstein said. “We do not say you are too sick to be here anymore. Nobody would say you can’t stay at home.”
Finances represent one of several ways assisted living facilities differ from nursing homes. Nursing homes are largely federally funded and regulated, and must adhere to a slew of federal, state, and local safety rules and inspections. Assisted living residences are largely paid for by consumers out of their own pockets, with oversight left to states.
Many states regulate assisted living residences as health care facilities, but Massachusetts remains among a handful that still consider the facilities more similar to apartment living, said Karl Polzer, former senior policy director at the National Center for Assisted Living, a trade association.
When the 1994 Massachusetts assisted living law was written, few people envisioned the seismic shift that has occurred, with the facilities evolving into de facto nursing homes.
Paul Raia, vice president of clinical services at the Alzheimer’s Association of Massachusetts and New Hampshire, said he believes it is time for state regulators to “redefine the concept” and rules of assisted living to match the frailty of today’s residents.
“Where is the tipping point between what the person needs and what the facility can provide?” said Raia.
Thomas Cocorochio battled many health problems, with a failing heart and kidney, and instability that led to frequent falls. But the 88-year-old former Everett resident fought the idea of living in a nursing home, so assisted living was a family compromise, said his son, Michael Cocorochio.
When a tube was inserted in July near his neck for kidney dialysis, and he was discharged from the hospital back to Prospect House in Revere, no one told the family that the octogenarian needed to be careful about dislodging the tubing, his son said.
“If I had it to do all over again, I would have been happier if the hospital said this is touchy, you need to put him in a cocoon,” Cocorochio said.
His father apparently fell one evening shortly after a family member visited in late July. He pushed a button to call for help, but bled to death before staffers reached him. It’s not clear how long it took for help to arrive, but Cocorochio said the family received a call from the facility about his father’s death within an hour after the relative’s visit.
Warren Strong, a spokesman for Prospect House, said patient confidentiality laws preclude him from discussing the Cocorochio case, but said staffers routinely analyze serious incidents to determine whether policies or practices need to be updated to prevent a repeat.
“We don’t want anyone to reside in our community if they are not safe, but often it is the families that want them to stay,” Strong said, echoing a dilemma expressed by others in the industry.
Despite staff training, criminal background checks, and dedication, resident injuries occur, but they are isolated incidents, said spokeswomen for the Arbors assisted living in Stoughton, where an elderly woman wandered out of a locked dementia unit and fell out a window earlier this year, and at Framingham’s Emeritus at Farm Pond, where two staffers allegedly abused three Alzheimer’s patients.
“We take the charge of promoting and safeguarding our residents’ health and safety seriously and respond promptly to allegations regarding our residents’ safety and health,” said Emeritus spokeswoman Kristin Puckett.
Massachusetts’ assisted living law prohibits facilities from accepting or retaining residents who require skilled nursing care for more than 90 days in a year. But interviews with industry and government officials suggest that rule has not been widely enforced.
Instead, residents requiring skilled nursing have been allowed to stay in assisted living and hire private nurses, said Robert Larkin, an industry leader and president of Senior Living Residences, a network of 12 assisted living facilities in Massachusetts.
“It’s like as if it were their home,” Larkin said. “That works really well.”
Meanwhile, as the ranks of older adults with dementia continue to swell, so too do the number of assisted living residences with special care units, locked wings that target dementia care. Massachusetts regulations for these units, as with the more traditional assisted living facilities, do not mandate minimum staffing levels, nor oversight to ensure patients are capable of taking their medications.
Instead, the rules allow “self-administered medication management,” with staffers reminding patients to take their medications and documenting whether they took them or refused.
Raia, with the Alzheimer’s Association, worries that too many dementia patients may not be getting their medications under this relaxed approach.
“If you are on a dementia special care unit, if you are at risk of getting lost and hurt, if there are secured doors there, then how can you have the argument that the person is able to take seven different medications in a timely way?” Raia said.
Safety specialists voice similar concerns about vulnerable residents in the event of fires.
Assisted living residences are treated like apartment buildings, meaning local building inspectors are required to conduct fire safety and building code reviews only once every five years, and then just in kitchens, dining halls, and other shared areas
The state’s elder affairs agency also surveys assisted living residences every two years, primarily focusing on operating plans, interviews with staff, residents, and inspections of common areas.
Nursing homes, in contrast, receive annual inspections from state building inspectors, are required to provide annual training of employees by fire departments, and undergo annual state Health Department surveys.
With costs for Massachusetts assisted living residences already among the highest in the country — ranging from $4,800 to $7,000 monthly, according to state data — industry leaders say they are loathe to layer on more regulations that could further raise costs and deplete consumer choices.
Larkin, president of Senior Living Residences, compares the mounting debate about safety versus independence to the relationship between parent and child.
“We all want independence for ourselves, but we are less enthusiastic about it for our children and our aging parents,” he said. “Seniors know what they want.”