Budget downsizes (closes) Fircrest

Write to your Washington State Legislators and the leaders of both chambers:
Senator Sharon Nelson, Senator Mark Schoesler, Representative Dan Kristiansen and Speaker Frank Chopp – remind them of the need for a continuum of care and remove these sections from the budget.

 

Dear Speaker Chopp,

I am a constituent and am writing to you with some concerns regarding ESSB 5048 – particularly Section 205 – Part 1 (K), Part 2 (C) and Section 206 Part 18.   I am also a registered nurse specializing in the care of adults with intellectual and developmental disabilities and a parent of a young man who recently transitioned from Fircrest to supported living in the community.

These sections state that appropriated funds will be  “provided solely for transitioning clients from Fircrest school residential habilitation center into community settings.” The clients from both the nursing facility and the intermediate care facility would be forced to move and it appears that this is a step towards closing Fircrest.

There are many concerns raised regarding attempts to close or downsize Fircrest through a budget proviso.  It is written in law (Olmstead v L.C. 1999)  and supported by CMS regulations that a person has a choice to live in an intermediate care facility.  In addressing the issue of changing care from an institutional placement to a community placement, there is a three part test to determine if community placement is appropriate:

  1. The State’s treatment professionals have determined that community placement is appropriate
  2. The transfer is not opposed by the affected individual and/or guardian
  3. The placement can be reasonable accommodated by the resources available to the State

If the above points are satisfied, then it is appropriate to have people move but I know that they are not met for the majority of the residents who live at Fircrest or other RHCs in our state.

It is important to address the crisis we have with community care before taking steps which would only increase the risk of harm to some of our most vulnerable citizens.

It is critical to keep our RHC communities open to best serve the diverse population of people with intellectual and developmental disabilities.

Save Fircrest – Essential Supports

A bill has been passed to the Senate Floor to vote on closure of Fircrest School – one of our states Residential Habilitation Centers (RHCs).  The RHC houses two critical communities of care – a Skilled Nursing Facility (SNF) and an Intermediate Care Facility (ICF).

It is a fact that there does need to be some capital improvement to the facilities to provide a safe environment for the residents and this is why we support the Fircrest Master Plan Fircrest Master Plan A-2

The campus has been neglected in the capital budgets for years and this is one reason why there is a large dollar sign to this project.  When buildings are neglected, they deteriorate and become unsafe for residents.  This is the situation we face now.

This does not mean that the land should be sold and the residents forced from their homes and community.  It does provide opportunity to change and to make needed improvements and to re-access the needs.

These are the opportunities that we support:

Fircrest Master Plan Alternative A-2

Federally Qualified Healthcare Center with oversight provided by the Department of Health for Fircrest residents and adult residents in the state who live with intellectual and developmental disabilities.

Collaboration with the University of Washington, Center on Human Development and Disabilities to provide specialized and comprehensive healthcare to community members.  This collaboration would also provide training for students in the healthcare professions.

Opportunities for improvement are not an option if 2SSB 5594 passes.  This bill seeks to close Fircrest and deny current and future residents access to the necessary supports.

We need to defeat 2SSB 5594 to protect out most vulnerable citizens.  Tell your Senator to Vote NO on 2SSB 5594.

 

Who are the investigators?

Concerns regarding medical and nursing neglect for residents residing in one of our state’s intermediate care facilities has led me to ask many more questions.  Questions that I should have asked long ago before harm and  permanent damage occurred and quality of life diminished.

But on the other hand, the fact that my allegations were dismissed as “unfounded” when I knew that neglect had occurred, prompted me to do my own investigation.

In Washington State we refer to the state operated institutions (both skilled nursing facilities (SNF) and intermediate care facilities for people with intellectual and developmental disabilities) as Residential Habilitation Centers or RHCs.  This presents several problems – the first one being that the SNF and ICF have different federal and state rules and regulations.  When both the SNF and ICF are combined in one campus, residents, community members and legislators fail to understand there are two distinct entities involved with different regulations to abide by.

There is also confusion regarding “long term care facility” and “healthcare facility” and which state agency should provide oversight and licensing.  In Washington State, the ICF is not included in the definition of “long term care facility” but does fit under the definition of “healthcare facility” by the services provided at the ICF.

This issue is particularly troubling when the state ensures that those who reside in the ICF receive all their healthcare needs on campus by state employed medical providers and nurses.

The Federal Regulations are clear with these issues but Washington State is confused.

Here is just one example of an issue that at this point is unsolvable given the system that Washington State has in place for oversight, surveys and investigations.

There are allegations of multiple medication errors over several years – medications documented as being administered but the pharmacy did not dispense enough medication to account for all the documented (by licenses nurses) administrations.  The pharmacy only dispensed 12-46% of the medication the nurses documented.  There was harm done by not administering the prescribed medication.  This was the practice at the ICF for 9 medications over 5 years time – many, many nurses signed off as administering these medications.  If one looked at the medication administration record you would assume that the client received ALL the medication as prescribed –

BUT – there is another story when trying to match the pharmacy records to the nursing administration records.  There is a MAJOR problem with the SYSTEM.

The ICF is licensed by DSHS.  That means that DSHS is the state agency providing oversight and investigations.  When the state investigator goes in to look at these allegations they see the medications were documented as given, meaning that the allegations are unfounded – no medication errors and the nurses provided the care.

There are clear violations of some state nursing standards (State Nurse Practice Act),

  • Willfully or repeatedly failing to make entries, altering entries, destroying entries, making incorrect or illegible entries and/or making false entries in employer or employee records or client records pertaining to the giving of medication, treatments, or other nursing care;
  • Willfully or repeatedly failing to administer medications and/or treatments in accordance with nursing standards

Failing to meet these standards could lead to disciplinary actions but DHSH does not consider these violations because the nurse documented administration and an error was not observed.

Unfortunately, in this situation, the State Department of Health and the Nursing Care Quality Assurance Commission are unable to do anything since they are not the licensing agency for the ICF and the error is not attributed to one identified nurse. The licensing agency needs to address these violations but DSHS (the licensing agency) does not see these medication errors as violations or errors.

So – how do we as advocates, healthcare providers, parents and legislators ensure that these standards are met?

As stated in the Code of Federal Regulations and the Social Security Act Section 1905 (d)  the “primary purpose of the ICF/IID is to furnish health or rehabilitative services to persons with Intellectual Disability or person with related conditions”.

Given that the ICF is a healthcare facility and its purpose is to furnish health services, we need to have healthcare professionals involved in the oversight, surveys and investigations of the healthcare provided – Washington State is not providing the needed oversight of healthcare to this vulnerable population.

investigations-by-rns

 

 

 

 

DD Ombudsman

Hopefully soon, Washington State will have a Developmental Disabilities Ombudsman.

This past year legislation was passed (thank you  Senator O’Ban,  the legislative champion for SB 6564, providing protections for the most vulnerable people from abuse and neglect) which will provide funds to develop The Office of Developmental Disabilities Ombudsman.

dd-ombudsman

There has been a great need for this type of oversight for all people with developmental disabilities but especially for those who live in an intermediate care facility (ICF).  While the Long-Term Care Ombudsman can help in situations for those who live in a skilled nursing facility, group home, assisted living or other long-term care facility, the Long-Term Care Ombudsman is not available to assist the residents in the ICF.

These residents have been without an adjudicator if concerns regarding their care  or other issue are not addressed appropriately.  This is especially true for those residents in a state operated ICF.  Without an independent authority to help mediate differences between the person and the state, these residents may not have had an objective investigation of their concerns.

Allegations of neglect and harm have been ignored or swept under the carpet by the state agency when conducting investigations of state facilities.  The DD Ombudsman will help prevent some of this injustice to our most vulnerable citizens.

I contacted the Department of Commerce last week to inquire into the development of the Office of the DD Ombudsman given that the bill was passed last legislative session.

Below is the response that I received from a spokesperson for the Disability Workgroup:

“A stakeholder meeting was held September 29th and written comments were accepted through October 15th.

I am currently drafting the solicitation to be released later in November. Evaluations of the bid responses will be in January 2017 and an announcement of the winning proposal probably in February 2017.

That organization will need to create the office, hire staff, train volunteers, etc. I anticipate them starting their ombuds duties sometime in the summer of 2017.

I hope this helps. Thanks for asking.”

Whistleblowing

Someone needs to speak up and I’ll keep speaking up until some of these serious issues of healthcare inequity are actually looked at and corrected

A recent blog posting entitled “The Journey of a Whistleblower: The Challenges, the Pains and the Price ” identifies some of the issues when one is faced with some ethical decisions.

While my son was a resident at a state operated intermediate care facility, I brought issues of concern to the administration and the medical director.  When no action was taken, I approached the Human Rights Committee of the facility.  They did not think that the issues of healthcare neglect and injury were a concern of theirs.  I then went to the advocacy group for the residents of the facility.  The president told me that their goal was only to keep the facility open – they had no say in assessing or measuring standards of care.

Obviously the healthcare and quality of life for the residents was not on the radar of any of these groups.

So, I keep trying to get people, organizations, legislators and agencies to see the serious concerns with medical and nursing care at some of these facilities.

If your loved one was dependent on the care provided in a healthcare facility, would it be important to know that all the prescribed medications and treatments were administered?  Or would it be okay for the nurses to only administer sometimes but document that all prescribed administrations were completed?

Would medication compliance rates of 11-46% be acceptable to you?  These rates are certainly not acceptable to me.

But it’s not just the low compliance rates I’m concerned about – it’s the years of falsified records across the board on a variety of medications by many nurses that is a huge concern.  Who is to know if the medications are really administered with so little oversight?

Who monitors medication administration – apparently no one and this is a major problem that needs immediate attention.

There is immediate jeopardy to all residents of the facility until the medication administration problems are examined and corrected. It is shameful on the part of our state agencies that these practices have been and still are accepted practice.

As a nurse myself, I know this practice is unethical and illegal to falsify these documents.  I question the level of integrity of the nurses working at this facility who routinely engage in this illegal activity.

This time has come to go outside the state organizations and inform others.  It is not just about keeping a facility open, it is about providing safe, quality care.  Care that is not happening at this time.

 

Healthcare at the Intermediate Care Facility

Who oversees the healthcare at the intermediate care facility for those with intellectual disabilities (ICF/ID)?  If you have a loved one who lives in an ICF/ID it may be worth looking into this to ensure that the healthcare actually does at least meet the minimum standard of care.

This was not the case in the ICF/ID that my son lived in.  I first started noticing problems the first year he lived there and I tried to work with the team and work within the system to improve the care, provide education and collaboration.  As system after system broke down and my son’s health grew worse I was making more and more trips to his home to provide the care and treatments that were supposed to have been provided by the nurses and team at the ICF/ID.

I knew the medications were not being applied but since the nurses were charting as given that was proof that the medications were being applied as prescribed. The fact that my son was not responding indicated that more potent medications were needed in addition to other medical treatments to control his inflammation.  These other treatments are not without risk and actually do increase his risk of cancer but we needed to get the inflammation under control and his immune system stabilized.

I was visiting at least 4 times a week and would apply his topical medications when I visited – knowing that he would at least be getting them when I was there.  They were actually supposed to be applied twice a day  and were charted as being applied twice a day but that is not what was happening.

After we moved our son to supported living and his care staff  applied the prescribed medications as ordered his inflammation quickly was controlled.  In about one month’s time the inflammation that had been extremely problematic for 3 1/2 years was now in total control.  His lab work was essentially normal after 3 1/2 years of having hematological problems. The medications actually did work – they were just not being administered as prescribed.

Now that I have the actual pharmacy and nursing records to review, I have found 9 medications that were falsely documented as being given for 1-3 years.  As a nurse I am totally appalled at the lack of quality and integrity that was accepted and not even questioned and do not understand how these dramatic errors can go unnoticed and uncorrected.

Below are charts of 5 of the medications showing the dates of administration, the amounts the pharmacy (at the ICF/ID) dispensed and the amounts that were charted as given. The compliance rates are unbelievable!  Who would accept these rates as meeting any type of standard of care? Why is this acceptable at the ICF/ID?

medication-1medication-2medication-3medication-4medication-5

It’s not just nursing that was the problem.  There was to be a 90-day medication review or reconciliation.  The purpose of this is to check each medication and ensure it is still needed and is indicated and the correct dose is prescribed.  Obviously the medication reviews were not done (but were signed off as being done)  since 3 of these medications were only needed for a short time (1 month or less) but remained in my son’s active  medication profile for up to 3 years dispensed and signed off as administered.   Who really knows what was given and what was just charted on as given.

How is one supposed to know if a medication is working or not when there is this type of record keeping?

There are so many problems that can be identified just with these medication errors.  This is at a state operated facility and so far the state investigation has stated that the allegations are unfounded based on the fact that the nurses charted the medications as given as ordered.

The state agency that oversees this facility is the Department of Social and Health Services.  Unfortunately, complaints to the Medical Quality Assurance, Nursing Quality Assurance, Department  of Health, Pharmacy Quality Assurance are unable to provide any guidance since they do not oversee any of the services at the ICF/ID.  It is up to DSHS and they do not see any problems.

Residential Care Services has opened up another investigation to review these issues and other allegations healthcare abuse and neglect.  My hope is that this time they will be able to see the problems and work on a plan for correction so that the residents do indeed have healthcare that at least meets the minimum community standard of care.  Currently that is not happening.