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Nursing Homes Oust Unwanted Patients With Claims of Psychosis

In a New York nursing home, a resident hurled a bingo chip. At a home in Georgia, a 46-year-old woman, paralyzed from the waist down, repeatedly complained that no one had changed her diaper. In a California facility, a patient threw tableware.

In all three cases, the nursing homes cited the incidents as a reason to send the residents to hospitals for psychiatric evaluations — and then to bar them from returning.

Across the United States, nursing homes are looking to get rid of unprofitable patients — primarily those who are poor and require extra care — and pouncing on minor outbursts to justify evicting them to emergency rooms or psychiatric hospitals. After the hospitals discharge the patients, often in a matter of hours, the nursing homes refuse them re-entry, according to court filings, government-funded watchdogs in 16 states, and more than 60 lawyers, nursing home employees and doctors.

The practice at times violates federal laws that restrict nursing homes from abruptly evicting patients.

“Even before the pandemic, there was tremendous pressure to get rid of Medicaid patients, especially those that need high levels of staffing,” said Mike Wasserman, a former chief executive of Rockport Healthcare Services, which manages California’s largest chain of for-profit nursing homes. “The pandemic has basically supercharged that.” He said homes often take advantage of fits of anger to oust patients, claiming they need psychiatric care.

About 70 percent of American nursing homes are for profit. The most lucrative patients are those on short-term rehabilitation stints paid for by private insurers or Medicare, the federal program that insures seniors and people with disabilities. Poor people on longer-term stays are covered by Medicaid, which reimburses nursing homes at a much lower rate than Medicare.

The financial incentive to have more Medicare or privately insured patients, and fewer on Medicaid, becomes more pronounced when the Medicaid patients have illnesses, like dementia, that require extra care from staff.

Nursing homes have faced acute staff shortages as the coronavirus has left employees sick or afraid to go in to work. Workers said they faced increased pressure from their employers during the pandemic to get rid of the most expensive, least lucrative patients.

Invoking psychiatric problems is a popular tool. Nursing homes routinely admit patients with dementia, Alzheimer’s or similar illnesses, and angry outbursts are common.

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Credit…Alexis Hunley for The New York Times

In March, the Rehabilitation Center of Santa Monica, Calif., sent Joan Rivers, who suffered from dementia and was on Medicaid, to the emergency room at USC Verdugo Hills Hospital. The nursing home’s staff said Ms. Rivers, 87, had tossed aside her chair, scaring other residents, according to her daughter, Evon Smith, and a government-funded watchdog.

Within 24 hours, the hospital cleared her for discharge.

Ms. Smith said that she had repeatedly asked the Rehabilitation Center to take her mother back, but that it had refused. A social worker at Verdugo Hills said she, too, had tried unsuccessfully to get the nursing home to readmit Ms. Rivers.

Linda Taetz, the chief compliance officer at Mariner Health Care, which operates the Rehabilitation Center and 19 other nursing homes in California, said the center hadn’t known that Ms. Rivers wanted to return.

Ms. Rivers eventually was admitted to the Colonial Care Center nursing home in Long Beach, Calif. There, she contracted Covid-19. She died on July 20.

Federal law requires nursing homes to follow strict guidelines when they intend to evict someone: They must give 30 days’ notice and come up with a plan to transfer the resident to a facility that can meet his or her needs. If a resident goes to a hospital, the facility must hold the bed for a week.

But nursing homes frequently flout these rules, according to employees and state-funded ombudsmen who help oversee the industry. The New York Times reported in July that nursing homes were evicting an increasing number of low-income — and therefore low-profitability — residents into homeless shelters and run-down motels, apparently in violation of federal law.

There is no national data on nursing home evictions. The Times contacted ombudsmen in all 50 states. Some said they had not seen nursing homes dumping patients in hospitals during the pandemic. But in 16 states, including California, Texas and New York, ombudsmen said the problem was continuing. Some said they believed it was getting worse.

“We have been seeing these kinds of illegal discharges all the time, because nursing homes seem to have figured out that they will rarely, if ever, be penalized,” said Alison Hirschel, senior legal counsel to the Michigan ombudsman program. “It’s devastating for residents and their families all the time, but especially horrible and dangerous during a pandemic.”

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Credit…Alexis Hunley for The New York Times

Medicaid patients who require lots of staff attention “have a target on their back,” she said.

The problem predates the pandemic.

Gloria Single was a resident of the Pioneer House nursing home in Sacramento. She had dementia and pulmonary disease and was on California’s version of Medicaid. Pioneer House was receiving about $400 a day for her care.

In 2017, Ms. Single got upset and threw utensils, according to a lawsuit against Pioneer House filed in state court by Ms. Single’s lawyer. The nursing home called 911, and Ms. Single was taken to a hospital for an involuntary psychiatric hold, in which patients are held until they are determined not to be a danger to themselves or others. The hospital determined later that day that there was nothing wrong with Ms. Single aside from her pre-existing dementia.

But Pioneer House would not let her return. The California Department of Health Care Services concluded that Pioneer House had violated the law and ordered it to let her go back. The home still refused. After about five months at the hospital, Ms. Single was moved to another nursing home. She died last year.

“You can get $1,000 extra a day by getting rid of the Gloria Singles of the world and replacing them with someone on Medicare,” said Matthew Borden, Ms. Single’s lawyer.

John Supple, a lawyer for the Retirement Housing Foundation, which operates Pioneer House, said that its medical director had deemed the home unsuitable for Ms. Single’s medical needs and that Pioneer House had never received the medical records it needed to readmit her. (Ms. Single’s lawyer disputes that. The lawsuit is ongoing.) Mr. Supple said Pioneer House had held Ms. Single’s bed for months and had not replaced her with a Medicare patient.

During the pandemic, nursing homes in Illinois and Michigan have repeatedly sent elderly and disabled Medicaid patients to NeuroBehavioral Hospital in Crown Point, Ind., said Kimberly Jackson, a discharge planner at the psychiatric hospital. In one case, a resident who yelled at a staff member was branded as being violent and having a psychotic break.

“The homes seem to be purposely taking symptoms of dementia as evidence of psychosis,” Ms. Jackson said. (Christy Gilbert, the chief operating officer of the hospital’s parent company, said instances when nursing homes dumped patients in her company’s hospitals were “very few and far between.”)

In June, Life Care Center of Plainwell, Mich., sent Nicki Safapour, a Medicaid patient who needs a wheelchair, to NeuroBehavioral Hospital. Because of a developmental disability, Mr. Safapour, 55, has the mental capacity of a 5-year-old, according to his brother John, who is his legal guardian. He said Life Care had told him that Mr. Safapour assaulted an employee and another resident.

A state health inspector later determined that the discharge was illegal, according to a copy of the inspector’s report reviewed by The Times.

“It seemed like they were just trying to get rid of Nicki,” John Safapour said. “He took up a lot of staff time.”

A spokesman for Life Care, Davis Lundy, said that privacy rules prohibited him from discussing Mr. Safapour’s case, but that Life Care had a significant number of residents on Medicaid and that “we never discharge patients based on their payer source.”

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Credit…Nick Hagen for The New York Times

The families of some evicted patients have had to take them into their homes, although they lack the training or equipment to care for them.

In June, Connie Rodina got a phone call from the Richmond Healthcare and Rehabilitation Center in Richmond, Kan. Her 63-year-old brother, Jon Fowler, who suffers from mental illness and dementia, had hit another resident. Ms. Rodina, her brother’s guardian, was told that she needed to pick him up immediately.

By the time Ms. Rodina arrived, Mr. Fowler was already being transported to an emergency room. The hospital was ready to discharge him a couple of days later, after treating him for a urinary tract infection. Ms. Rodina said Richmond Healthcare wouldn’t take him back.

“You can’t just put somebody out like that,” said Camille Russell, a regional ombudsman who filed a complaint against the facility with the Kansas Department for Aging and Disability Services. The complaint is pending, she said.

Ms. Rodina couldn’t find another nursing home that would admit Mr. Fowler, who needs near-constant care. After her brother had been in the hospital for weeks, she reluctantly moved him into her home.

“It’s basically taken my life away from me,” Ms. Rodina said. “It’s impossible for me to care for him.”

Representatives of Richmond Healthcare didn’t respond to requests for comment.

In some cases, nursing homes have ignored orders from regulators to take back patients they sent to emergency rooms or psychiatric hospitals.

Charles Borden, a stroke victim with dementia, had been staying at the skilled nursing facility at Tahoe Forest Hospital in Truckee, Calif. Medicaid was covering his long-term stay. But in April, after Mr. Borden elbowed a nursing assistant and cursed at her, the nursing home sent him to the hospital’s emergency room for a psychiatric evaluation.

Within hours, the emergency room cleared Mr. Borden to return to the nursing home. But it wouldn’t take him back, according to court records. (While the nursing home and the main Tahoe Forest hospital share a campus and are owned by the same organization, the nursing home is financially independent from the hospital.)

Later that day, the nursing home dropped off all of Mr. Borden’s possessions at the E.R. and moved another resident into the room that Mr. Borden had shared with his wife, Beverly.

Two days later, on April 22, Mr. Borden’s son appealed the decision to California’s health care agency. It determined that the nursing home was legally required to take Mr. Borden back. The nursing home refused.

The state agency said it had no authority to force the nursing home to let Mr. Borden return, aside from fining it $50 for every day it refused.

Matt Mushet, a lawyer for the nursing home, said it “is committed to the optimal safety of all patients and team members.” He said that he couldn’t comment on Mr. Borden’s case but that “it’s important for the public to understand there is more than one side to this story.”

Mr. Borden has spent the past five months marooned in the hospital. His dementia makes it hard for him to understand what is going on, his son said, but Mr. Borden asks every day to see his wife.

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‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents

On a chilly afternoon in April, Los Angeles police found an old, disoriented man crumpled on a Koreatown sidewalk.

Several days earlier, RC Kendrick, an 88-year-old with dementia, was living at Lakeview Terrace, a nursing home with a history of regulatory problems. His family had placed him there to make sure he got round-the-clock care after his condition deteriorated and he began disappearing for days at a time.

But on April 6, the nursing home deposited Mr. Kendrick at an unregulated boardinghouse — without bothering to inform his family. Less than 24 hours later, Mr. Kendrick was wandering the city alone.

According to three Lakeview employees, Mr. Kendrick’s ouster came as the nursing home was telling staff members to try to clear out less-profitable residents to make room for a new class of customers who would generate more revenue: patients with Covid-19.

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Credit…Los Angeles County Sheriff’s Department

More than any other institution in America, nursing homes have come to symbolize the deadly destruction of the coronavirus crisis. More than 51,000 residents and employees of nursing homes and long-term care facilities have died, representing more than 40 percent of the total death toll in the United States.

But even as they have been ravaged, nursing homes have also been enlisted in the response to the outbreak. They are taking on coronavirus-stricken patients to ease the burden on overwhelmed hospitals — and, at times, to bolster their bottom lines.

A Lakeview official said the company’s evictions were appropriate and weren’t an attempt to free space for Covid-19 patients. But similar scenes are playing out at nursing homes nationwide. They are kicking out old and disabled residents — among the people most susceptible to the coronavirus — and shunting them into homeless shelters, rundown motels and other unsafe facilities, according to 22 watchdogs in 16 states, as well as dozens of elder-care lawyers, social workers and former nursing home executives.

Many of the evictions, known as involuntary discharges, appear to violate federal rules that require nursing homes to place residents in safe locations and to provide them with at least 30 days’ notice before forcing them to leave.

While the popular conception of nursing homes is of places where elderly people live, much of their business is caring for patients of all ages and income levels who are recovering from surgery or acute illnesses like strokes. Medicare often pays for short-term rehabilitation stints; Medicaid covers longer-term stays for poor people.

Nursing homes have long had a financial incentive to evict Medicaid patients in favor of those who pay through private insurance or Medicare, which reimburses nursing homes at a much higher rate than Medicaid. More than 10,000 residents and their families complained to watchdogs about being discharged in 2018, the most recent year for which data are available.

The pandemic has intensified the situation.

With nursing homes not allowing visitors, there is less outside scrutiny of their practices. Fifteen state-funded ombudsmen said in interviews that some homes appear to be taking advantage of that void to evict vulnerable residents.

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Credit…Andrew Cullen for The New York Times

Many nursing homes are struggling in part because one of their most profitable businesses — post-surgery rehab — has withered as states restricted hospitals from performing nonessential services.

Treating Covid-19 patients quickly became a popular way to fill that financial void.

Last fall, the Centers for Medicare and Medicaid changed the formula for reimbursing nursing homes, making it more profitable to take in sicker patients for a short period of time. Covid-19 patients can bring in at least $600 more a day in Medicare dollars than people with relatively mild health issues, according to nursing home executives and state officials.

“They could be big money for nursing homes,” said David Grabowski, a professor of health care policy at Harvard Medical School.

It is not always about the money. Several states, including New York, New Jersey and California, urged nursing homes to accept Covid-19 patients to help relieve pressure on hospitals. Some nursing home employees worried that would endanger their vulnerable residents.

There is no national data on the number of nursing home residents who have been moved into homeless shelters, motels and other facilities. The New York Times contacted more than 80 state-funded nursing-home ombudsmen in 46 states for a tally of involuntary discharges during the pandemic at facilities they monitor. Twenty six ombudsmen, from 18 states, provided figures to The Times: a total of more than 6,400 discharges, many to homeless shelters.

“We’re dealing with unsafe discharges, whether it be to a homeless shelter or to unlicensed facilities, on a daily basis, and Covid-19 has made this all more urgent,” said Molly Davies, the Los Angeles ombudsman, whose office works with residents at about 400 nursing homes.

In Connecticut, a nursing-home resident was told he had less than a week to pack his things and move to a homeless shelter, according to the resident’s lawyer. In Philadelphia, a nursing home planned to discharge a resident with schizophrenia to the city’s office of homeless services, which was closed during the pandemic. A lawyer said she intervened to stop the eviction on the grounds that it was unsafe.

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Credit…Hiroko Masuike/The New York Times

In New York City, the epicenter of the pandemic, nursing homes tried to discharge at least 27 residents to homeless shelters from February through May, according to data from the New York City Department of Homeless Services. Ombudsmen and city officials blocked many of the discharges, which they said were medically unsafe.

But those figures are most likely a dramatic undercount. “What we’re seeing is just the tip of the iceberg,” said Susan Dooha, executive director of Center for Independence of the Disabled, a nonprofit group that is the home of the Long Term Care Ombudsman Program in New York City.

Traditionally, ombudsmen would regularly go to nursing homes. In March, though, ombudsmen — and residents’ families — were required to stop visiting. Evictions followed.

“It felt opportunistic, where some homes were basically seizing the moment when everyone is looking the other way to move people out,” said Laurie Facciarossa Brewer, a long-term care ombudsman in New Jersey.

Nursing homes are allowed to evict residents if they aren’t able to pay for their care, are endangering others in the facility or have sufficiently recovered. Under federal law, before discharging patients against their will, nursing homes are required to give formal notice to the resident and to the ombudsman’s office. They must also find a safe alternative location for the resident to go, whether that is an assisted living facility, an apartment or, in rare circumstances, a homeless shelter.

But some homes have figured out a workaround: They pressure residents to leave. Many residents assume they have no choice, and the nursing homes often do not report them to ombudsmen.

That is what David Mellor said happened to him. Mr. Mellor, 54, was recovering from spinal surgery that left him numb from the neck down at a nursing home in Fremont, Calif. In April, Mr. Mellor said, the staff at the Windsor Park Care Center, an 85-bed facility, told him that he had to go to a hotel to clear the way for coronavirus patients. Mr. Mellor, who had been trying to arrange long-term housing, felt he had no choice and agreed to leave.

“I saw what was going on,” Mr. Mellor said. “They were forcing people out.” At the Radisson Hotel in Oakland, which was being used to house the homeless, Mr. Mellor said there was no one to help him learn to walk again or to assist him with the medications he takes to control his blood sugar and pain.

A spokesman for the Windsor Park Care Center declined to comment. It is part of a chain owned by Lee Samson, a major fund-raiser for President Trump. “Whatever my political affiliation, Windsor’s commitment to protecting its residents will never be compromised,” Mr. Samson said.

Nursing home evictions can be disruptive and dangerous during normal times — and even more so during a pandemic that preys on the elderly and those with underlying medical conditions.

In March, seven groups that represent nursing home residents wrote to New York’s health department, urging it to stop nursing homes from evicting residents because they are “particularly vulnerable to the Covid-19 virus.” Such discharges, especially to homeless shelters, they wrote, “pose particular public health risks, due to the close living quarters in shelters.” The letter also warned that sending patients from nursing homes — hotbeds of the coronavirus — into the community could hasten the spread of the disease.

Advocates for nursing home residents have also urged California’s health department to halt evictions.

While at least four states have restricted nursing homes from evicting patients during the pandemic, New York and California have not. Some companies appear to be taking advantage.

In California, Rockport Healthcare Services, which manages the state’s largest chain of for-profit nursing homes, has repeatedly been cited by state regulators for illegal evictions.

  • Frequently Asked Questions and Advice

    Updated June 16, 2020

    • I’ve heard about a treatment called dexamethasone. Does it work?

      The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.

    • What is pandemic paid leave?

      The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.

    • Does asymptomatic transmission of Covid-19 happen?

      So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.

    • What’s the risk of catching coronavirus from a surface?

      Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.

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      The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.

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      Mass protests against police brutality that have brought thousands of people onto the streets in cities across America are raising the specter of new coronavirus outbreaks, prompting political leaders, physicians and public health experts to warn that the crowds could cause a surge in cases. While many political leaders affirmed the right of protesters to express themselves, they urged the demonstrators to wear face masks and maintain social distancing, both to protect themselves and to prevent further community spread of the virus. Some infectious disease experts were reassured by the fact that the protests were held outdoors, saying the open air settings could mitigate the risk of transmission.

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      States are reopening bit by bit. This means that more public spaces are available for use and more and more businesses are being allowed to open again. The federal government is largely leaving the decision up to states, and some state leaders are leaving the decision up to local authorities. Even if you aren’t being told to stay at home, it’s still a good idea to limit trips outside and your interaction with other people.

    • What are the symptoms of coronavirus?

      Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.

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      If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)

    • Should I wear a mask?

      The C.D.C. has recommended that all Americans wear cloth masks if they go out in public. This is a shift in federal guidance reflecting new concerns that the coronavirus is being spread by infected people who have no symptoms. Until now, the C.D.C., like the W.H.O., has advised that ordinary people don’t need to wear masks unless they are sick and coughing. Part of the reason was to preserve medical-grade masks for health care workers who desperately need them at a time when they are in continuously short supply. Masks don’t replace hand washing and social distancing.

    • What should I do if I feel sick?

      If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.


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