With end of costly registry, will elderly pay?

Florida's abuse and neglect registry was created to help nursing homes and assisted living homes weed out employees who mistreat the elderly and disabled. Critics called the registry inefficient and expensive, and the Legislature abolished it as of Sept. 1.

By STEPHEN NOHLGREN

© St. Petersburg Times, published July 5, 2000

At 85, Valerie Radar was a gobbler.

Many of her teeth were missing, and dementia had robbed her of all propriety. Give her food, she'd scarf it down without much chewing. Leave someone else's food within reach, she might grab that too.

When she arrived at St. Petersburg's Swanholm Living Center two years ago, Radar's feeding instructions were explicit. Her doctor limited her to a puree diet: nothing too hard, nothing too bulky.

Catherine Sprunger had logged a half-century of nursing before she made a terrible mistake on April 1. An hour or so after dinner, Radar had just grabbed another resident's graham crackers and milk.

"Are you hungry?" Sprunger asked.

"Yes," said Radar.

The nurse handed her a peanut butter and jelly sandwich, which Radar gobbled in two bites.

Radar set off down the hallway in her wheelchair, using her foot to inch herself along. After a few minutes, Radar's head jerked back. She wasn't breathing.

Sprunger and an aide squeezed her in the Heimlich maneuver, and a piece of bread the size of a quarter popped out. They laid her on her bed and pushed on her chest. Her breathing started again, and her color returned to pink. They put her on oxygen.

About five minutes later, Radar gasped for breath and died.

Fragile old people in institutions are expected to die. Caregivers are usually well-intentioned. What may seem like telltale signs of neglect in one case -- like weight loss, incontinence and bone-breaking falls -- can't be avoided in another.

As a result, Florida confirmed only 65 cases of abuse or neglect in institutions last year. Those nurses and aides can no longer work with the elderly, but it cost $2.5-million to make those determinations and defend them in court.

The Legislature and Gov. Jeb Bush don't think it's worth it.

***

Valerie Radar worked as a secretary for an insurance company in New York, bore five children and buried two husbands before moving to Palmetto about 25 years ago.

She read, smoked, took care of her dog, Putsey, and slid into dementia more than a decade ago. Her court-appointed guardian said she ran away from several Manatee County nursing homes. He placed her in St. Petersburg Health Care Center, a down-at-the-heels nursing home on Dr. M.L. King (Ninth) Street S.

Regulators closed that home in March of 1998, and Radar was moved to Swanholm on west Central Avenue. Rated "superior" by regulators, Swanholm was the first nursing home in Florida to join the Eden Alternative, a New York-based movement to make institutions more homelike.

Dogs, cats, birds and fish were brought in as communal pets. A garden with low-lying planters allowed residents to tend plants and vegetables from their wheelchairs. Staffers were encouraged to bring in their children and let them interact with residents.

Taking care of Radar on the 3 to 11 p.m. shift was nurse Sprunger, who gave only a brief interview for this story before her attorney told her to stop.

Radar lived in wing called Ace's Place, named after the portly golden retriever who slept on a big, square pallet in the hallway.

Like many Alzheimer's sufferers, Radar would grow agitated at night and talk about going home. "She'd say, "But what about the babies?' She was always regressing to the babies," Sprunger said.

"I would try to pacify her. I'd say, "You can go as soon as I do this thing or that thing.' That would appease her. Or I'd say, "You sit here and watch TV and wait for the bus.' "

Sprunger told investigators that she knew Radar was on a puree diet when she gave her the peanut butter and jelly sandwich but didn't think it would hurt. Nursing notes show she had done it twice before.

When Sprunger reported the death to Radar's doctor by telephone, she made no mention of the peanut butter sandwich, the choking or the Heimlich maneuver. She wrote nothing about it on Radar's medical chart.

Radar was a demented longtime smoker with heart disease, lung disease and Parkinson's disease. So the doctor listed the cause of death as natural and ordered that her body be released to Abbey Parklawn crematorium in Palm Harbor, which cremates indigents for Pinellas County.

Director of nursing Duane McGrath agreed with that decision. He saw no connection between the choking and the death, he said, because he had seen Radar resume breathing for several minutes and had watched her color return to pink.

Nobody from the nursing home reported the death to the Department of Children and Families, which investigates medical neglect of the elderly, or to the Agency for Health Care Administration, which regulates nursing homes.

Five days later, the abuse and neglect hotline received an anonymous tip: A patient at Swanholm had choked to death on a sandwich, and the staff was covering it up.

Veteran abuse investigator Ethel Moody quickly confirmed the peanut butter incident, but McGrath insisted that the choking and the death were unrelated. Radar's body had been cremated, the nursing home said, so no autopsy could be performed.

Moody alerted St. Petersburg police investigators and suggested that they explore possible charges of criminal negligence, but she said they were reluctant to pursue it because there was no autopsy connecting Radar's death to the sandwich.

Finally, 11 days after Radar died, Moody suggested that they double-check the cremation.

As it turned out, indigent burials require a lot of paperwork, and 11 days in the refrigerator at Abbey Parklawn is not unusual. Radar's body was still there, due to be cremated the next day. It was sent to the medical examiner's office, where an autopsy found a large hunk of sandwich lodged deep in Radar's throat.

It was as if she had inhaled it, the examiner wrote. Most likely, some oxygen passed by the sandwich at first, until moisture and mucous made it swell up and completely block the air passage. That would explain why Radar could breathe for a few minutes.

Determining that Sprunger committed medical neglect was a no-brainer. She violated a doctor's order, which led directly to a resident's death.

The Department of Children and Families also determined that director of nurses McGrath committed neglect by not calling 911 when the Heimlich maneuver failed to produce an immediate and full recovery. Paramedics might have saved her, the department said.

Swanholm fired Sprunger, and McGrath resigned. In the past, the black mark on their names would be listed on the abuse and neglect registry; no nursing home or assisted living home could hire them.

As of Sept. 1, however, the registry will go out of business.

***

Hiring employees is a constant headache for nursing homes and large assisted living facilities. Good nursing aides, particularly, are in short supply. At some homes, yearly turnover tops 100 percent. A marginal employee who wouldn't have found work 10 years ago now has a good shot at a job.

To protect residents, Florida law requires homes to make two background checks of potential employees: Florida criminal history and the adult abuse registry.

With computers and fax machines, the criminal check usually takes only 24 hours or so. But the abuse registry check can take a week.

For nursing aides hoping for an $8-an-hour job, a week's wait might send them to McDonald's instead.

"It was presenting a strong impediment to getting people on the floor," said Ed Towey, spokesman for the Florida Health Care Association, the state's primary nursing home trade group. Job seekers "want to go to work now. When the facility says we need to run a check, they can go to the hospital across the street, where the requirement isn't in place."

According to a study by the House committee on Elder Affairs and Long-Term Care, these background checks rarely netted any miscreants.

For every nursing aide identified by the registry as a confirmed abuser, about 1,700 cleared the screening. Nursing homes had to pay $18 per name, which meant they were collectively spending about $30,000 to cull out one bad apple.

Most alleged abusers filed appeals to keep working, which usually succeeded. To hear and defend those appeals, state agencies spend about $2.5-million a year.

The House committee recommended that the Legislature drop the registry and redirect that money toward elder abuse prevention programs. That's what happened five years ago when the child abuse registry was eliminated, with no apparent ill effect.

The Legislature eliminated the adult abuse registry, all right, but didn't dedicate any money for prevention.

Opponents of the registry note that the homes can still screen out workers who have mistreated patients through the criminal background check and by references from previous employers.

But nursing homes, like many businesses, usually won't provide candid references after they fire a bad employee.

"Employers are very concerned about whether they might be open to suit for sharing unfavorable information," said Janet Keller, assistant administrator at St. Petersburg's Bon Secours Maria Manor. "Usually we only get the fact that they were employed there and whether they are eligible for rehire."

A provision in the original legislation would have required one facility to give another facility complete information on former employees, but that was deleted from the final bill.

Criminal checks might catch an employee who battered or raped a resident, but even gross negligence rarely results in prosecution.

Four years ago, for example, an aide at a St. Petersburg nursing home left a paralyzed man in a 140-degree whirlpool bath for 15 minutes without checking the temperature, scalding him so badly that his legs had to be amputated.

Though placed on the abuse registry, the aide was never prosecuted because the threshold for criminal negligence is so much higher than for regulatory action or civil lawsuits.

The last time Pinellas-Pasco prosecutors tried to bring medical negligence charges was the Lisa McPherson-Scientology case, and they ended up with egg on their faces.

***

On the advice of her attorney, Catherine Sprunger gave up her nursing license during the criminal investigation into Valerie Radar's death. At 76, she will look for work elsewhere, she said. Her patient's death devastated her: "I feel awful, but I don't feel guilty, because it was an accident."

The Pinellas-Pasco State Attorney's Office recently decided not to prosecute her for medical neglect. The peanut butter sandwich was misguided, it said, but not malicious.

Duane McGrath, 60, a nurse for 31 years, said he was thinking of retiring soon, anyway, because the nursing home industry has become so litigious. Radar's death pushed him over the edge. "I made it very clear to them that I resigned. No more nursing homes, no more hospital work, no more home health care." Owner of a schnauzer, an Airedale terrier and an Afghan hound, he hopes to volunteer on Swanholm's dog committee.

The Agency for Health Care Administration cited Swanholm for several deficiencies involving Radar, including not providing her with dentures so she could chew better. Swanholm corrected the deficiencies by holding staff training sessions.

Radar's obituary listed no next of kin, based on information available to the funeral home. In fact, a daughter lives in another Pinellas nursing home, beset by her own mental and physical problems. Radar's sons live in New York.

The oldest, Michael Schuster, used to visit his mother every few years but lost track of her two years ago after the state moved her from one nursing home to another. Her guardian had also moved and didn't leave forwarding phone numbers, Schuster said. The Social Security Administration would only say that she was alive.

He discovered where she ended up when abuse investigator Ethel Moody called and told him about his mother's death.

Last year, calls to the adult abuse hotline rose 16 percent.

© St. Petersburg Times. All rights reserved.