Published 10:17 p.m. UTC Sep 4, 2018
BEDFORD, Mass. – The nurse’s aide was busy getting a patient ready for bed when she noticed a commotion behind a privacy curtain on the other side of the room. She heard Russ Bonanno, a 94-year-old veteran, shout, “Ow, ow, ow.”
“It sounded like fighting,” said Julee, who asked that her last name not be used out of fear of retaliation. When she went to check what was happening, she saw another aide trying to hoist Bonanno from his wheelchair to his bed, normally a two-person job.
Julee said she watched the other aide simply toss the elderly dementia patient onto the bed.
“Let me tell you how brutal that guy was with the veteran,” Julee wrote to her supervisor two days after the alleged incident May 18. “After he was done, (we) went and checked Mr. Bonanno. The guy was wet. Everything needed to be changed.”
The aide accused of roughly handling Bonanno quietly resigned, but Julee, the aide who blew the whistle, was fired two weeks later. She said her supervisor told her she had attendance problems.
Welcome to one of the lowest-rated nursing homes for veterans in the nation run by the U.S. Department of Veterans Affairs. The facility, at the VA hospital in Bedford, Massachusetts, is among 11 nationwide to earn the lowest-possible one-star rating from the agency based on both overall quality and the results of surprise inspections. The ratings are on a scale of one to five, with one being the lowest.
The others are scattered from Lyons, New Jersey, to Prescott, Arizona, and from Dayton and Chillicothe, Ohio, to Tampa, Florida.
Bedford’s rating reflected an array of problems with care provided to the more than 200 veterans who live there, including bedsores, high rates of medication and decline of veterans’ health, according to statistics outlined in documents obtained by USA TODAY and The Boston Globe, which have jointly investigated VA nursing homes.
The poor grade for surprise inspections in part reflected the staff’s treatment of residents. In 2017, inspectors from the Long Term Care Institute found several instances of neglect, including a veteran lying naked in bed covered by a urine- and feces-stained sheet. Their report cited another veteran who struggled to shove food into his mouth with his hands after trying unsuccessfully to use a spoon. Staffers were nearby.
The report came against the backdrop of another resident who died in his bed in July 2016 while the nurse’s aide who was supposed to check on him played video games on her computer. The aide, who has since resigned, was supposed to check on Bill Nutter hourly because he had a condition that could cause his heart to stop without warning.
Joan Clifford, the Bedford VA hospital director who also oversees the nursing home, defended the quality of care there and said the team always strives to improve it.
“On my first day there, I walked all the units, and I was struck at how well cared for the nursing home patients were,” she said.
Clifford said Julee was fired for reasons she could not discuss and not for her reporting of the alleged abuse of Bonanno. She acknowledged that the aide accused of poor care was allowed to resign. If he hadn’t, she said, disciplinary “action would have been taken.”
Clifford said the one-star quality rating the facility received from the VA didn’t take into account the complexity of the patient population, which includes many patients with dementia or psychiatric problems.
“There have been improvements, and we’re expecting a better score next time,” she said.
'Dandruff and heavy stains'
Her reassurances mean little to the family of Charles Amidon, a highly decorated veteran who once served as medical adviser to the South Vietnamese army. For four years, the retired lieutenant colonel has lived in Bedford VA’s Building 4, where Nutter died.
“We have experiences with civilian hospitals,” Amidon’s son, Christopher, said, noting that his father had stayed at a private, long-term care facility. “You see the level of care. It was like night and day. ... (In Bedford,) I noticed patients in wheelchairs sitting in the hallway who hadn’t been bathed. They had dandruff and heavy stains.”
Clifford said she couldn’t discuss individual veterans' cases without the necessary releases from the patient or the family members.
The troubles in Bedford are part of a larger concern for the VA’s care of elderly veterans across the country. This year, the Globe and USA TODAY revealed that internal ratings showed 60 VA nursing homes – nearly half of the agency’s nursing homes nationwide – received the lowest ranking for quality as of Dec. 31, 2017. (Among the homes rated lowest for quality in the first quarter this year, only 11, including Bedford, also got one star ratings for surprise inspections.)
The agency released the ratings to the public only after the two news organizations asked questions about them.
Three months earlier, the VA gave one star to just 13 of its nursing homes nationwide, including Bedford. The number of worst-rated facilities increased to 60 when the VA changed the ratings to compare VA nursing homes with private facilities rather than just with each other.
Under the new system, Bedford rated worse than private nursing home averages on 10 of 11 key quality indicators last year, including rates of bedsores and residents in serious pain. Across the country, more than 100 VA nursing homes scored worse than private nursing homes on a majority of indicators.
After the reports by USA TODAY and the Globe, the House Veterans Affairs Committee launched an investigation and expects to hold a hearing this fall on VA nursing home care.
VA spokesman Curt Cashour said the agency uses the data “to drive improvements across the system,” noting that only one VA nursing home saw a significant decline this year. The VA has 133 nursing homes that serve 46,000 veterans annually.
Cashour has said agency nursing homes score lower on key quality indicators because they have residents with more complicated medical conditions, but “overall,” the VA nursing home system “compares closely” with the private sector.
He said the VA has worked since June to have patient information redacted from inspection reports of VA nursing homes by an outside contractor, Wisconsin-based Long Term Care Institute. He said the VA would release them once that is done.
In the meantime, they remain confidential, as they have been for nearly a decade.
Writhing in pain
The Bedford inspection report was one of two obtained by USA TODAY and the Globe. The other was on the VA nursing home in West Palm Beach, Florida, which also received one star out of five based on poor inspection findings.
Inspectors in March cited facility staff there for letting a resident sit for hours in soiled sheets. They left another with a bloodied boot. Two residents had bedsores, a potential sign of neglect.
Staff failed to medicate a resident who appeared to be writhing in pain during wound treatment and dressing changes, the report said. The resident, who suffered from dementia and Parkinson’s disease, moaned and groaned, grimaced, clenched his jaw and balled up his fists.
Inspectors found another resident crying out in pain who couldn’t participate in daily activities such as therapy. “The resident did not receive the care and services necessary to address the resident’s pain,” the report said.
Cashour said the facility has since recruited a new nurse manager who is “overseeing a robust improvement plan” for resident pain management and care delivery.
At the Bedford nursing home, Charles Amidon is largely bedridden with Parkinson's disease. His wife, Helga, said he can’t read or watch TV much because the VA-issued glasses don’t help his poor eyesight. Before early July, he hadn’t showered since April, though he may have been cleaned with a cloth in his bed. Last year, he came down with scabies, a contagious skin rash, that went undiagnosed for five months.
Amidon’s son, Christopher, said he saw a nurse mock the way his father walked, hunched over and breathing heavily. His father and other veterans sometimes waited hours for nurses to respond when they pressed their buzzers for help. In January, he said, his father called and said the staff had been slapping him.
Amidon himself said the care was “adequate.”
“There are some good people here,” he said.
His family said they believe he fears that if he complains, he will be treated even worse. His wife and son say that now that Amidon's Parkinson’s disease has advanced, they are less afraid to speak their minds about the quality of the care in Bedford. Previously, they had feared, like him, that anything they said could result in worse care.
“If I won the lottery, I would take my father out of there,” Christopher said, explaining that placing his father in a high-quality private nursing home was unaffordable – costing tens of thousands of dollars a month.
All they hope for is to take Amidon to the family’s summer home on Orrs’ Island in Maine one last time, though they doubt their wish will come true.
“The morning light there is beautiful,” Helga said.