Data compiled by the [Consumer Product Safety Commission] from death certificates and hospital emergency room visits from 2003 through May 2012 shows that 150 mostly older adults died after they became trapped in bed rails. Over nearly the same time period, 36,000 mostly older adults -- about 4,000 a year -- were treated in emergency rooms with bed rail injuries.
The article notes that officials have been aware of the problem since 2005. Still, no regulations have been implemented -- only "safety alerts" and voluntary guidelines."
While bed rails problems have been particularly serious, any review of federal nursing home reports shows "deficiencies" all over the place. According to Pro Publica, which has compiled the reports into a searchable database, the Department of Health and Human Services has since April 2009 identified 399 deficiencies spread across San Francisco's various nursing homes.
The deficiencies vary in severity. Pro Publica grades each deficiency from "A" (least serious) to "L" (most serious). Based on the data, San Francisco nursing homes have had just five deficiencies classified along the most serious third of the spectrum, including one "L" grade on one "K." Most of the deficiencies fall somewhere in the middle. Around 87 percent of the are graded as "D" or "E."
A February 2010 report on Golden Gate Health Care Center yielded the city's only "K" grade, for broken fire escape doors, which could potentially allow residents to wander out.
The facility's administrator ... stated the facility had initiated an hourly "head count" of all the residents starting Sunday, January 31, 2010 to ensure residents did not leave through the fire escape doors that normally have functioning alarms. The survey team questioned the administrator how accounting for each resident on an hourly basis could protect the residents from leaving the floors in between the counts. At that time ... the facility's Environment Services Manager ... added that all resident Wanderguards are working. (Note: Wanderguard is a sensor-alarm based elopement management system.)
The survey team later found a resident who did not have a Wanderguard, even though the resident's room was beside one of the broken doors.
The single "L" belonged to San Francisco Health Care. The October 2010 report claims that the facility did not "Store, cook, and serve food in a safe and clean way."
The regulators concluded:
Based on observation, interview and record review, the facility failed to ensure that food is obtained for resident consumption from sources approved, or considered satisfactory by Federal, State, or local authorities.The facility also failed to follow safe sanitation, handling and transportation practices to prevent the outbreak of foodborne illness. This was evidenced by transporting potentially hazardous food [Potentially Hazardous Food] for resident consumption in vehicles that had no refrigeration to keep the PHF safe during transport. The facility failed to store adequate food supply to meet residents' food need in cases of emergency/disaster. The facility's noncompliance resulted in increased potential risk for widespread serious harm, i.e., food poisoning, that could adversely affect the health and safety of all residents of the facility, due to the outbreak of foodborne illness, such as E. coli, or Salmonella infections.
Four nursing homes have been charged with 10 or more deficiencies in a single survey. California Pacific Medical Center at St. Luke's had 10 deficiencies on two separate reports more than a year apart, in October 2010 and December 2011. The regulators stated that the home did not sufficiently "make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents," "provide 3 meals at regular times," or "have a program that investigates, controls and keeps infection from spreading," among other claims. None of the shortcomings were graded higher than a "D" on the severity scale.
San Francisco Health Care, in January 2012, and San Francisco Towers, in July, each had a report listing 13 deficiencies. A more recent SF Health Care report, from July, noted that "six residents indicated they were not informed of their right to vote. In concurrent individual interviews with the six group interview residents in their own primary language (Cantonese/Mandarin), each one confirmed that no one informed them they may exercise their right to vote."
A May 2010 report on Laguna Honda listed 14 deficiencies -- the most of any San Francsico report in Pro Publica's database. The findings in that report listed charges such as, "rods supporting around-the-bed privacy curtains over resident beds on three units were not firmly attached to the ceiling and/or walls; ceiling sprinklers in a Ward G-6 storage room was blocked by equipment; a heater-cover in a Ward D-6 bathroom was rusted; and a dietetic service department compactor storage accessible to residents was unlocked and unattended."
Overall, though, San Francisco's nursing homes appear relatively competent. The city's 399 total deficiencies hold up well. By comparison, Seattle had more than 700 deficiencies, and Denver had more than 500 -- two cities that are less populated than San Francisco.