Legislature(1999 - 2000)
03/11/1999 03:35 PM Senate STA
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SENATE STATE AFFAIRS COMMITTEE March 11, 1999 3:35 p.m. MEMBERS PRESENT Senator Jerry Ward, Chairman Senator Lyda Green Senator Randy Phillips Senator Kim Elton MEMBERS ABSENT Senator Gary Wilken COMMITTEE CALENDAR PIONEER HOME REVIEW WITNESS REGISTER Lisa Caress-Beu 2420 Chinook Ave. Anchorage, AK 99516 POSITION STATEMENT: Discussed her personal experiences with the Anchorage Pioneers Home. Kathy Emmons 16617 Davis St. Eagle River, AK 99577 POSITION STATEMENT: Discussed her personal experiences with the Anchorage Pioneers Home. Marty Margeson Anchorage, AK POSITION STATEMENT: Discussed her personal experiences with the Anchorage Pioneers Home. E. H. "Bud" Caress 6808 Spruce Rd. Anchorage, AK 99507 POSITION STATEMENT: Discussed his personal experiences with the Anchorage Pioneers Home. Francis Purdy Office of the Ombudsman PO Box 102636 Anchorage, AK 99510 POSITION STATEMENT: Answered questions regarding the Ombudsman's investigation of the Anchorage Pioneers Home. Patricia Senner 4021 Woronzof Dr. Anchorage, AK 99517 POSITION STATEMENT: Commented on her interaction with the Pioneers Home pharmacy and assisted living home regulations. ACTION NARRATIVE TAPE 99-5, SIDE A Number 001 CHAIRMAN WARD called the Senate State Affairs Committee to order at 3:35 p.m. Present were Senators Green, Phillips, Elton, and Ward, Chair. CHAIRMAN WARD announced today's review of Pioneer Homes was scheduled at the request of Senator Green and others, and because he, too, had concerns about how Alaskan elders are being treated in Pioneer Homes. CHAIRMAN WARD described concerns expressed by families of Pioneer Home residents as: harassment for bringing forth legitimate concerns; lack of access to medical records; and distribution and administration of pharmaceutical products to residents. He emphasized our elders are our greatest asset and should be honored. He added the people of the State of Alaska own state programs; if those programs are not working, the proper course of action is to notify the Legislature. SENATOR GREEN informed committee members she requested this hearing because of her growing concern about residents of the Palmer Pioneer Home. A third party brought some Pioneer Home residents to her office to express their concerns. Those residents prefer to remain anonymous out of fear of retaliation. She then met and spoke with employees of the Pioneer Home who were very concerned about the implementation of new procedures. She also heard from family members of residents, as well as physicians, who expressed concerns about the pharmacy and prescriptions. After hearing similar concerns from many groups, she requested a hearing to unlayer the problems that are occurring. SENATOR PHILLIPS and SENATOR ELTON both notified committee members they had to leave at 4:00 to attend other meetings. Number 112 CHAIRMAN WARD took teleconference testimony from Anchorage. LISA CARESS BEU read the following written testimony into the record. For the Record, Mr. Chairman, I am Lisa Caress-Beu. My mother has been a resident of the Anchorage Pioneer Home since 1994. I would like to thank you, Senator Ward, for calling for this hearing. I have provided your office with documents from the record files of the Anchorage Pioneer Home that show that my mother has suffered 52 falls in the last 2 years. I have documents showing a dozen medication errors that occurred in my mother's care in the last year. Fortunately none of these medication errors have resulted in permanent damage to my mother, as far as we know. I was never notified when these errors occurred and neither was her physician. Since, I have repeatedly voiced concerns about both CNAs administering medications and staffing shortages. I'd like to read the information from one of these documents - This report references a day that my mother did not receive her 2 o'clock heart medication. 'The report asks - "What contributed most to this situation? The response reads: Neither days' or evenings' shifts gave med - maybe because hall was short-staffed - there was staff on duty at this time. Communication failure among those working day shift."' I have 4 medication error reports for 1998 that show that my mother did not receive her afternoon heart medication until the night shift came on and caught the error. I have reports from three different days that show that she did not receive any of her morning medications at all. I have one that shows that she did not receive an anti- seizure medication at all for 4 continuous days. I have another that shows that she was double-dosed on her heart medication. All these errors were the result of CNAs administering my mother's medications. All of the errors were caught by a licensed or registered nurse. I have asked that my mother's medications only be administered by a licensed or registered nurse and have been given reassurances that the CNAs have been properly trained in this task. I now know that my concerns are well justified. Deputy Director Alison Elgee references the medication administration concerns of families in her March 8, 1999 letter to the Long Term Task Force Chairs about the Public Forum held at the Pioneer Home in January. She says the family concerns are about whether the pharmacy is filling expired prescriptions or whether physicians are prescribing new medications without discontinuing present medication. I assure you that is not the cause for my concern. Perhaps Ms. Elgee needs to do more research with families to find out the real causes for their anxiety. I have provided Commissioner Poe the documents that outline these medication errors and falls. He certainly has my permission to make them available to her. The Pioneer Homes say they are no longer a medical model - they are focusing on the psychosocial aspect of care - If the medical needs of these residents are not profound, why do they require an in-house pharmacy? These people are frail and many are ill and it is time that the Pioneer Homes systems wake up to that reality. Provide them with beautiful surroundings if you can afford - but not at the expense of their very real medical needs. Currently the Dept. of Administration is requesting funds to add at least 60 CNA positions statewide to the Pioneers Homes. I strongly recommend that some of these funds be dedicated to hire more registered nurses rather than exclusively CNAs. As the documents that I have provided to Senator Ward show, CNAs cannot consistently administer medication safely. These employees should not be put in the position to do things that they are not properly trained for and residents should not be put at risk because the Pioneers Homes do not allocate funds properly to ensure the residents' needs are being met competently. It is unfair to residents to make promises of appropriate care and then not provide it. I have provided you, Senator Ward, with documents that make reference to the fact that my mother used the call cord, received no response and attempted to move by herself and experienced a fall. She was then reminded that she should WAIT until the staff got there to help her. The document reports: Resident stated she wanted to get out of bed and was tired of waiting for staff to assist her. No one came, she said. The nurse explained that the shift was short-staffed and she should wait for help. Resident has been weak and unsteady lately. How long can a resident wait when they have incontinence problems? How long have residents having chest pains waited for help to come? How many residents have died because "help" did not arrive on time? After a CNA responds to a call cord in an emergency, how long does it take to locate one RN on duty at night in a home for 228 residents? This cannot be allowed to continue. Any problems will give [indisc.] here today. One solution towards resolving these problems would be addressing SB 20 that asks that the license of the Pioneer Home be transferred to the Department of Health and Social Services. I would also ask that the Department of Administration no longer be allowed to run the Homes or nursing units for those residents that need it. Thank you. CHAIRMAN WARD asked Ms. Caress-Beu to review her initial conversation with him. He asked her to elaborate on her statement that her mother was elderly and would sometimes "soil" herself and that the Pioneer Home policy only provided her one bath per week. MS. CARESS-BEU said she called for a "care conference" on February 5 and asked at that conference that her mother receive more than one bath per week because she had become incontinent. She was told that was against Pioneer Home policy. The Pioneer Home staff thought the hygiene methods they employed were adequate. She then told them she disagreed, and that her mother had an odor problem that needed to be alleviated. The outcome of the conference was that she would be allowed to come midweek and give her mother an additional bath. CHAIRMAN WARD asked if she was told the Pioneer Home rules allow only one bath per week. MS. CARESS-BEU said yes, but a Pioneer Home employee was concerned and told her that had never been a previous policy. CHAIRMAN WARD asked Ms. Caress-Beu to recount the process she had to go through to get her mother's medical error reports. MS. CARESS-BEU explained she first requested the medical error reports in a telephone conversation with a nurse. She then e-mailed Mr. John Vowell asking him for the reports, but her request was refused. She was refused again after writing a formal request. Finally, the Department of Law became involved, and because she is her mother's legal guardian with power of attorney, she was provided with copies of the reports. SENATOR GREEN referred to a letter Ms. Caress-Beu received from an Anchorage attorney asking her about her association with a certain organization, and asked how that letter impacted her. MS. CARESS- BEU stated she received a letter from Wayne Anthony Ross that was intimidating because it implied legal action against her. It asked her 21 to 22 very detailed questions. CHAIRMAN WARD asked when she requested the medical error reports. MS. CARESS-BEU answered she first requested the unusual occurrence reports, which she believed was in late January or early February. CHAIRMAN WARD asked Ms. Caress-Beu if she was familiar with the March 5, 1999 letter of instructions for the medical error reports from Leslie Brundage to Donna Burrall (ph) concerning this subject. MS. CARESS-BEU was not. CHAIRMAN WARD read the following section of the letter. Lately team members have expressed increasing concern about your lack of assistance. You have written up medication errors while there was still time to fix the problem, seeming to be more in a "gotcha mode" than a supportive and helpful mode. This shows a tremendous lack of trust with your co-workers, particularly when routine medication errors could be corrected and are not. MS. CARESS-BEU said she was familiar with that letter and thought it was outrageous. She stated, "I think it addresses a registered nurse doing what a registered nurse should do and she's being reprimanded for that very thing. And I don't understand how the Pioneer Home can properly track medication errors if they aren't recorded. How can they find out which employees need more training?" CHAIRMAN WARD recalled a time, 45 years ago, when Ms. Caress-Beu's mother took care of him after he was injured. He apologized for her mother's treatment. Number 292 KATHY EMMONS, a registered nurse from Eagle River, stated she was employed at the Pioneer Home from 1990 to 1996. She read her letter of resignation into the record: As you know I do not approve of the Assisted Living changes. I do not want to be held legally responsible for CNA medication administration, nor do I want to be the only RN in the building for 240 residents. My concern is for the welfare of residents. I have accepted a position at Providence Medical Center, so it is with deep regret that I am submitting my resignation to you. It will be effective April 6, 1996, at 2300 hours. MS. EMMONS then read the following testimony into the record. I am a registered nurse in the State of Alaska. I also am certified through the American credential center in Gerontology. I have worked at the Anchorage Pioneer's Home for 6 years from 1989 to 1996. Contrary to popular belief, I was not, nor have I ever been, a disgruntled employee. As far as I know, I have always had excellent evaluations. I resigned because I did not agree with the direction the home was going in and I would not participate in a program where certified nurses aides were giving medications. I did not believe it would be a safe environment for residents of Pioneer Homes. Registered nurses work within a scope of practice. Our first and foremost duty is to be an advocate and protect the people in our care, no matter what the setting. Be it skilled nursing facilities, assisted living homes, clinics, hospitals, doctors' offices, schools, or anywhere there is a person requiring our skills, the scope of practice is followed. Licensed practical nurses also have a scope of practice they must adhere to. It is recognized when the licensed practical nurse works in a team relationship with the registered nurse, the licensed practical nurse contributes significantly to each aspect of a process. However, the final responsibility for the process and its application remains with the registered nurse. Certified nursing assistants are unlicensed assistive personnel (UAP). These are individuals who are not authorized to perform nursing acts or tasks that are regulated by the Board of Nursing except pursuant to legal delegation by a nurse. The registered nurse is responsible for the management and provision of all care that a resident receives under the RN's supervision or direction. The scope of nursing practice permits an RN to assign tasks to UAPs. "UAP" refers to health care workers who are NOT licensed to perform nursing tasks though they may be certified or trained. Certified Nursing Assistants are continually placed in precarious positions by the administration of the Anchorage Pioneers Home. They are forced to administer medications with only 8 hours of training. Many certified nurse aides do not want this responsibility. Certified nursing assistants are illegally giving medications at the Anchorage Pioneer Home. Registered nurses at the home are not delegating this duty, the administration is. Three licensed practical nurses have just been promoted with raises to assisted living coordinator position. These positions were pervasively held by registered nurses. Licensed practical nurses have been placed in positions of authority over registered nurses. A license dictates authority, not a position or a promotion. Registered nurses have been subject to harassment and degradation when they have spoken out on issues related to the safety of persons trusted in their care. When medication error reports are made out by registered nurses, they are counseled by the administration. The Pioneer Home administration does not have the right to dictate to a registered nurse not to follow the guidelines of the Board of Nursing. Registered nurses were given letters of instruction by Leslie Brundage and they were also presented with two licensed practical nurses who were at the meeting also. Registered nurses were told they make too many medication errors. It is beyond my comprehension why registered nurses are continually treated with disrespect and pressured not to follow their scope of practice. Number 375 SENATOR ELTON asked Ms. Emmons if she has taken any of her concerns to the Board of Nursing, and if so, whether the Board addressed any of those concerns. MS. EMMONS said she did when members of the Board met in Anchorage. She believes the Board is working on the problem through its process. SENATOR GREEN asked if a registered nurse can choose to allow a CNA to administer medications. MS. EMMONS replied a registered nurse may delegate that task if the CNA is competent to do so. SENATOR GREEN asked whose license would be in jeopardy if a CNA administered the wrong medication. MS. EMMONS stated the responsibility ultimately belongs to the registered nurse. SENATOR GREEN asked if all Pioneer Homes require CNAs to administer medications, or if some Pioneer Homes allow only registered nurses to administer medications. MS. EMMONS answered to the best of her knowledge, all of the Pioneer Homes require CNAs to administer medications. SENATOR GREEN asked Ms. Emmons to comment on the Pioneers Homes' policies on the use of restraints, exercise, and activity therapy for residents. MS. EMMONS read the following letter she wrote about that topic. January 11, 1999 Wilma died Saturday night. She and my mother-in-law, Margaret, had known each other for over 50 years. They met when they both had civil service jobs at Elmendorf sometime in the 40's. I first met Wilma in 1975. She lived in a small house by the airport. To say that Wilma never threw anything away would be an understatement. I looked around her house and knew that somewhere in one of the many stacks of newspapers was probably the first one ever delivered to her doorstep. She was going to read them all when she got the chance. What a good-hearted person she always was. When you met her you knew she was a true Alaskan and the first one to come to anyone's aid. Wilma never had any reason to fear anyone until she was 70 years old and she tried to help someone who wanted to hurt her. She was brutally attacked and had to be hospitalized. A lot of things changed for Wilma that night. She lost trust. The police officer who worked the case was so disgusted he quit the force after the man was sent to prison. Wilma moved into the Anchorage Pioneers Home in 1997. It was to be a safe haven where she could live out the remainder of her life secure. In April, my mother-in-law moved to Chugiak. I went to get Wilma from the Pioneer Home to surprise Margaret. I was the one who got the surprise. I was told Wilma now had a public guardian and I had to have her permission to take her out of the home. I called the public guardian and she said I could not take Wilma out of the home. Wilma had paid companions to take her where ever she wanted to go. I felt like Wilma had become state property, so I started taking my mother-in-law to Anchorage to see her friend of 50 years. On the first visit, Wilma was up walking around. The two of them held hands and strolled around. The second time I took her to see Wilma, she was tied to a chair and a man was walking around in her room. I escorted the man out of the room. I left the two old friends alone to talk about whatever an 80 year old and 83 year old talk about when one is almost blind and both have their own varying degree of dementia. When I returned Margaret said, "Kathy you know I can't see. Wilma was uncomfortable so I put pillows all around her. Will you see if I did it right?" I viewed the loving care one old friend had given the other. Wilma was surrounded with small plastic diapers. Margaret thought they were pillows. "Did I do it right?," she asked apprehensively. Both of them were looking at me for a reply. "Yes Margaret, you did a wonderful job." - I went to see Wilma on Thanksgiving Day. Behind the closed doors of Gardenview she sat tied to a reclining chair in her room. She had a wanderguard attached to her ankle, a small device designed to sound an alarm should she get near an exit. For a brief moment it flashed through my mind, "Are prisoners under house arrest treated in this manner?" NO! I think not. Christmas Day's visit found Wilma still tied to the recliner in her room. New Year's Day - still tied to the recliner but sitting staring at me like a zombie. This frail little old lady was also given tranquilizers. The holidays were causing a staff shortage even greater than normal. Wilma had been found in her room tied to her recliner with a man lying on top of her. The man was a patient transferred from Harborview. No one knew how many hours he had been there because the door was closed. There would only be one more episode. The same man I had escorted out of her room again was found sitting in her room with the door closed. I know in my heart she had to have felt terror. I am asking for this 21st legislative session to pass a "Wilma's Law." Legislation that protects all of our senior citizens in assisted living homes from physical and chemical restraints. Legislation that does not allow frail elderly persons to be victimized. Intact licensing regulations that are equal to skilled nursing home licensing. It will only be then that Wilma will truly be free from the ties that bound her. CHAIRMAN WARD asked Ms. Emmons if she was saying state employees tie people down to make their job easier. MS. EMMONS replied they also give them tranquilizers to make their jobs easier. CHAIRMAN WARD asked if Ms. Emmons brought this to anyone's attention when it happened. MS. EMMONS replied the nurses who work at the Pioneers Home bring these things to the attention of the administration but she did not know what action, if any, was taken. Number 375 SENATOR ELTON asked whether the nurses or administration offered any explanation of why the restraints were used. MS. EMMONS stated she was told they had a physician's order, however physicians' orders for restraint are only used if a patient is in imminent danger, and patients are only to be restrained for a brief period of time. She added nursing homes are "restraint-free," yet assisted living homes have no regulations regarding restraints. MS. EMMONS concluded by saying she hopes her testimony emphasized how dangerous it is for elderly people to be in this situation. Number 482 MARTY MARGESON gave the following testimony via teleconference from Anchorage. Her father is a resident of the Anchorage Pioneer Home. He suffers from Alzheimer's Disease and, because he can no longer speak coherently, she is his health care advocate. He is a private pay patient who pays over $2800 per month for a semi-private room. He shares a bath with women in the adjoining room. With numerous falls and assaults this past year, he has back and knee pain, and because the doctors ordered a weekly jacuzzi to ease his pains, he must now forfeit his weekly bath. Unlike other assisted living and nursing homes, the Pioneer Home will not administer the MD- prescribed nutritional supplements recommended for corrective care and preventative holistic medicine, so he pays an additional $300 per month for someone to give him supplements. Prior to admission, the staff nurse approved the administration of these supplements but a new pharmacist was hired who has criticized nutritional supplements. Families must now pay extra to have them administered. No other Anchorage assisted living home refuses to administer nutritional supplements ordered by an MD. MS. MARGESON continued. My dad's physical and mental handicaps make him totally dependent on the Pioneer Home for safety. On August 29 another resident entered my dad's room, pummeling his face, so I had to take my dad to ER for X-rays for his eye sockets, nose and chin, and stitches above his eye. The administration suggested my father must have done something to cause the assault. He was sitting alone on his bed watching TV and the police found no evidence that he had been able to defend himself from the attack. Less than a week later, the same individual again attacked my dad and injured his hand. The same individual attacked at least two other women, injuring a wheel-chair bound lady before beating another lady's face and breaking her fingers as she lay in bed. These attacks on vulnerable adults in the Alzheimers-Dementia Unit are examples of insufficient staffing and an insufficient plan to protect the safety of all residents. My dad has been assaulted six times and had six falls this year. There were no staff witnesses in seven of the 12 incidents, again, indicative of a staff shortage. Although the Pioneer Home advertises 24 hour RN coverage, there was no RN available to medically assess my dad's injuries in seven of the 12 incidents. In fact, when I requested an [indisc.] injury, I had to wait until after midnight for staff to locate an RN to come in for work. There may have been more assaults. I was only called by the staff half of the time. I discovered most of the assaults. The Pioneer Home is not required to notify families of falls, assaults, medication errors, or [indisc.] incidents. The emotional damage my father had suffered from this violence has left him emotionally battered and wanting privacy. His physicians recommend a private room. Most of the Pioneer Home residents have private rooms, however the AD/RD Unit has few private rooms. My dad has been passed over for at least five private rooms. They say he is not critical enough. I believe this is because I openly advocate for his care and safety. The Pioneer Home needs to recognize and compensate its victims of assault, abuse and neglect by creating therapeutic activities in a therapeutic environment so these residents can heal. With a population of over 80 mentally and physically handicapped residents, the Anchorage home needs to hire a geriatric certified activities specialist to design day care and weekend activities, comparable to our adult day care. Currently AD/RD residents sit in a circle of boredom, despair and loneliness. Last week, the same female resident who previously assaulted my dad on three previous occasions, and who is involved in five previous assaults I witnessed, pushed an 87 year old women who broke her hip. She may never walk again. I worry for my dad and others. No extra staff has been assigned to watch this assaultive woman. Staff attempts to control her [indisc.] have obviously failed. There are frequent staff shortages because of a multitude of staff meetings. My attempts to talk with the director have been ignored. The assisted living coordinator has no answers. This woman has caused more injury than my dad's first assailant, who was sent to API. This resident needs to be removed immediately. I believe she is a former Harborview resident. The Pioneer Home cannot accommodate psychiatric residents. Thankfully, the Attorney General ruled that I can have my dad's med-error reports. My personal log shows over 75 med errors in eight months. The Pioneer Home med-error report shows only 11 errors in 11 months. I believe CNAs are not filling out the med-error reports in the AD/RD Unit. The physician cannot provide good care if medications are not given. I find pills on the floor. I worry when I see aides giving shots. I worry when my six-year old finds a hypodermic needle on the floor. The Pioneer Home has such a longstanding excellent reputation that most families trust the care of their loved ones without question. Dropping the nursing license and concentrating on admitting high-needs without increasing staff was a mistake. My dad needs the same level of care as a low-level nursing home. Bring back the nursing license and our RNs. The Anchorage Home needs at least the staffing ratio for the mentally-physically handicapped as the Juneau Home. Often there is one RN for two hundred residents. We need more RNs. The Juneau Home has a one RN for 47 residents staff ratio. We need more CNAs. Juneau has a one to six staff resident ratio; Anchorage has a one to 11. The AD/RD residents need skilled staff. They can't talk to describe pain. The RN has to read body language. It is clear from the news coverage, the assaults and falls at the Anchorage Pioneer Home, it is not staffed or managed as well as the smaller homes. Alzheimer's is a dreadful disease. It takes away our memory, our ability to dress and feed ourselves, walk and control body functions. These, our most vulnerable seniors, need 24 hour line-sight protection that we give our children in day care. No assault is acceptable. Assaults should be minimal. Medication errors must cease. Threatening families who seek decent care and safety with Wayne Ross letters is unacceptable. Writing letters telling residents they can move out [indisc.] is unacceptable. In my dad's case this is a threat because with his advanced Alzheimer's and battered personality, we have no place to move. Both Mr. Poe and Mr. Bot (ph) [indisc.] I move my father out. We know how to treat our seniors better - let's do it now. I offer the following 12 suggestions. 1. Restore the nursing home license to AD/RD and Comprehens ive. Bring a doctor back on staff and abolish the residency requiremen t so we can fund these changes and qualify for federal funds and Medicaid. 2. Stop promoting administrators and instead hire direct patient care RNs and more CNAs. Install time clocks. The self-directed team approach is not working and residents are being left alone. 3. Promptly investigate and report to families all assaults, medication errors, abuse, and abandonment of duty. We need safe staffing. Sick staff must be replaced immediately. Weekends and holidays are dangerously understaffed. Today at lunch were only 3 CNAs to feed and assist over 20 AD/RD residents. 4. Postpone "Edenizing." This is a luxury program for the cognitive resident who is already happy. Moving in dogs, cats, bunnies and birds brings [indisc.], pet food, allergies and potential injury. 5. Support HB 16, SB 20. 6. Start supporting the Ombudsman, Fran Purdy. Her office is understaffed. She is the only one who had the courage to promptly intervene, without her intervention my dad's assault could have been an untimely wrongful death. 7. Close the pharmacy which is a source of danger and antagonism to families and residents, and is, according to Mr. [ndisc.], "run on a break-even basis. There are no profits." 8. Stop using the capital budget for plump, plush leather furniture, expensive oak tables and chairs, and carpeting, which causes pain to handicapped individuals like my father who has worn a hole in his shoe in just a few months and endured a constant pain from shuffling on carpet at a heightened risk of falling on carpet nap. Remove the carpet to provide safe walking areas for residents. Use the capital budget for safety. Repair the numerous code violations. Paint for dementia so residents can find their rooms and bathrooms. Create an institution with painted floors with bathroom symbols, arrows directing mentally challenged and create individualized room colors so residents can find their own rooms. A safe, understandable, affordable environment reduces aggression. Return the big screen TV to AD/RD. Crowding 20 residents who, according to Mr. Collins, bite and pop each other, around a 20 inch TV, is setting the stage for aggression. Provide safe night lighting. Two of my dad's roommates have fallen and broken their hips at night. 9. Hire male staff. One-third of the Anchorage AD/RD residents are men, many of whom are old fashioned, modest folks, agitated by the female caregivers. Provide male activities. The Pioneer Home provides few male activities, but does cater a Super Bowl Party and Monday Night Football, but AD/RD residents are excluded because there is no staff to accompany them. 10. Make AD/RD safe so other Pioneer Home residents and volunteers will visit and help. 11. Physical therapy is overcrowded and understaffed. Bathing is minimal because there's not enough staff to provide more than one bath per week. Hire staff. 12. Hire a geriatric certified activities specialist to design and maintain a day care activity program for AD/RD residents. The Pioneer Home is a great place for cognitive residents. We have misrepresented and shortchanged our mentally challenged and physically handicapped residents. Now is the time to change that. Thank you Senator Ward for this opportunity. TAPE 99-5 SIDE B CHAIRMAN WARD asked if Ms. Margeson believes her father has been retaliated against because of the suggestions she gave to the committee. MS. MARGESON said that is absolutely true. A senior citizen who has been assaulted six times and has fallen six times is in a critical situation that merits a private room. The previous resident who received a private room was only assaulted once, and the other resident who just received a private room got one because she is a smoker. Number 562 SENATOR ELTON asked Ms. Margeson whether she believes 60 new staff, budgeted for in the supplemental budget, will alleviate the problems for Pioneer Home residents. MS. MARGESON said if the ratios of staff to patients in the Pioneers' Homes are equalized, 60 will help. SENATOR ELTON stated that applying the goal of the national standard of 3.2 hours of personal care every 24 hours would help to equalize the ratio. MS. MARGESON said we forget that the Anchorage Pioneer Home is taking in the Alzheimer/Dementia residents who cannot be safely accommodated in a "mom and pop" home. Those residents would be in nursing homes in other states but they are not accepted into Alaska nursing homes unless they have medical needs. CHAIRMAN WARD pointed out the committee will be looking at the entire allocation process for all of the Pioneer Homes as well as whether additional appropriations can be made, and the mission of the Pioneer Homes. Number 534 W.H. "BUD" CARESS testified via teleconference from Anchorage and addressed three points: the Eden Alternative Plan used at the Anchorage Pioneers Home; Leslie Brundage's performance appraisal to an RN; and his work with a national news program. MR. CARESS stated the Eden Alternative Plan was sold to the State of Alaska to be implemented in the Pioneers Homes as a means to assist and contain costs for care of Pioneer Homes residents. The needs of the Pioneers Home residents vary, and the assessment and implementation of these needs must come from trained and dedicated people. These professionals need back-up staff who are caring and compassionate, and are those who work on the front line. The Eden Plan emphasizes an environment with gardens, pets and children, yet Pioneers Home residents are more in need of staff who can properly administer medication and closely monitor patients. The Eden Plan de-emphasizes program activities, the role of prescription drugs, and a top-down bureaucracy in favor of a team approach. That approach undercuts the expertise of the registered nurses. Pioneers Home registered nurses are being disciplined for writing up medical error reports and are being counseled into fixing the problem instead. He read an excerpt from a disciplinary memo written by Leslie Brundage, an administrator, to a registered nurse. He felt error reports should be looked at as an opportunity to correct problems, not something to be covered up. The status quo of any kind of business would spell doom, and striving for excellence should be a must. MR. CARESS informed committee members he worked with a national news program. The news program monitored his mother's room via a camera it installed. Cameras were installed in other residents' rooms also. The news program has the film but has not determined whether to use it. He cautioned that televising the film on a national news station could embarrass the State of Alaska. Number 436 CHAIRMAN WARD stated whether privatization or realignment of the Department or another solution is necessary, the State of Alaska owes its senior citizens assurance that they will not feel intimidated by public employees. Number 426 FRAN PURDY, Long Term Care Ombudsman, Department of Administration, stated her office issued an investigative report regarding the Pioneer Home pharmacy. Many of the recommendations put forth in the report have not been implemented. Regarding staffing levels, she recommends that the Pioneer Home follow the recommendations of the National Citizens' Coalition for Nursing Home Reform which suggests having one full-time equivalent staff per five residents during the day, per 10 residents during the evening, and per 15 residents at night. In addition, a ratio of one full-time direct on-care nurses should be available for each 15 residents during the day, 20 residents in the evening, and 30 residents at night. These recommendations apply to nursing homes that do not have high- intensity medical issues, such as residents on respirators. The Pioneers' Home fiscal request for FY 2000 comes close to that goal. Number 386 SENATOR GREEN asked what the rule of thumb is for the ratio of nurses to CNAs in similar types of homes. MS. PURDY replied Alaska has no regulation governing a ratio. The statutes require that each home develop a care plan that addresses all of the health, safety, welfare, and mental health needs of the residents. Each home must provide adequate staff, both in numbers and quality, to implement its care plan. If the care plan is not fulfilled, the licensing unit could hold the home in violation. Nursing homes are held accountable for providing individual activities and necessary care by the nursing home licensing agency. SENATOR GREEN stated the reason she asked Ms. Purdy is because she is trying to develop language for the supplemental budget to address the ratio of RNs to CNAs. She asked if one RN to 15 CNAs is a reasonable ratio. MS. PURDY repeated the National Citizens Coalition recommendations. She added that the day and night shift numbers differ because the majority of contacts between RNs and physicians about the health needs of the residents occur during the day shift. SENATOR ELTON asked Ms. Purdy to rate the Pioneer Home system compared to other facilities that she has been in, and whether some Pioneer Homes are doing better than others. MS. PURDY replied the Pioneers Homes differ and most, other than Anchorage, have an adequate RN to CNA ratio. Those homes do not have the same high number of high needs residents living at the Anchorage Pioneer Home. Juneau's Pioneer Home is one of the better homes because it has a team staff approach that works smoothly. The CNAs and recreational people actually work as a team, communication with families is good, the Home is open at all times, and volunteers and families flow in comfortably. Juneau's Home is also smaller, and its staff has been working as a team for a long period of time. The Anchorage Pioneer Home has problems with its size and the high needs of residents. It has almost a full nursing home wing that it tries to operate as an assisted living home. Number 294 SENATOR ELTON asked Ms. Purdy to rate the Anchorage Pioneer Home with private facilities and private non-profit homes. MS. PURDY stated the Anchorage Pioneer Home is almost like two different homes. In the part of the Home in which the residents are semi- dependent on staff, the Home is comparable to the other homes in Anchorage. In terms of the other enhanced assistance, AD/RD and comprehensive clients, the Anchorage Pioneer Home must be compared to nursing homes, which have different standards and staffing ratios. The Anchorage Pioneer Home does not have all of the amenities and activities that one would expect for residents at that level of need. It has two staff for every 16 people which is inadequate. SENATOR ELTON asked Ms. Purdy if she believes the problem at the Anchorage Pioneers Home is caused by a lack of finances or a lack of professionalism. MS. PURDY stated the Anchorage Pioneers Home has some very big financial problems; the lack of adequate staff levels prevents accurate checking of medications. No quality assurance check has been done by an outside agency. Nursing homes have the benefit of a nursing home licensing agency that gives guidance and has the ability to enforce changes. The licensing agency has the ability to stop the use of restraints and to minimize medication errors. She added the Ombudsman's Office has repeatedly brought complaints on behalf of families to the Anchorage Pioneer Home and most of those complaints have not been resolved. She said she hopes SB 20 will be calendared quickly so that licensing and enforcement can begin to turn around many attitude problems. The other half of the equation will be funding for more staff. Number 203 PAT SENNER, a registered nurse, testified via teleconference and described her previous work with the elderly. She stated through the years, on the federal level, a lot of legislation was enacted to protect the elderly from abuse. That legislation was incorporated into skilled nursing facility regulations. When facilities changed from skilled nursing facilities to assisted living facilities, all regulatory control over quality of care was essentially lost. At the same time, facilities were no longer required to have registered nurses, who implemented internal regulatory controls. New quality control protections are needed. She discussed the staffing ratio at the Mary Conrad Center and a feedback mechanism to physicians regarding medications. That feedback mechanism at the Pioneer Home was totally lacking. She discussed a situation in which one resident's medication was substituted by the Anchorage Pioneer Home pharmacist and the resident had an adverse reaction. The pharmacist again changed the medication and never once contacted the resident's physician. Recently the pharmacist alerted the same physician that he did not have a medication prescribed by the physician. In a skilled facility, a physician would send an order for a medication change to the nursing staff who would pass the order on the pharmacy. At the Pioneer Home, the pharmacist acts as the caregiver which is a strange arrangement which is not working. She suggested eliminating the in-house pharmacy and raising the RN to CNA ratio. CHAIRMAN WARD announced that Commissioner Poe was present during the meeting and that he would be before the Committee again to respond to today's comments. He assured teleconference participants that no one who testified would be retaliated against. CHAIRMAN WARD then adjourned the meeting at 5:05 p.m.
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