At age 88, Elizabeth Fee looked pregnant, her belly swollen after days of intestinal ailments and nausea. A nurse heard a scream from Fee鈥檚 room in a nursing home, and found her retching 鈥渓ike a faucet鈥� before she passed out.
The facility where she died in 2012 was affiliated with a respected San Francisco hospital, California Pacific Medical Center, and shared its name. Fee had just undergone hip surgery at the hospital, and her family, pleased with her care, said they chose the nursing home with the hospital鈥檚 encouragement.
Laura Rees, Fee鈥檚 elder daughter, said she was never told that the nursing home had received Medicare鈥檚 worst rating for quality 鈥斅爋ne star. Nor, she said, was she told that state inspectors had repeatedly cited the facility for substandard care, including聽delayed responses to calls for aid, disrespectful behavior toward patients and displaying insufficient interest in patients鈥櫬爌ain.
鈥淭hey handed me a piece of paper with a list of the different facilities on it, and theirs were at top of the page,鈥� Rees said in an interview. 鈥淭hey kept pointing to their facility, and I was relying on their expertise and, of course, the reputation聽of the hospital.鈥�
Fee had an obstructed bowel, and state investigators faulted the home for several lapses in her care related to her death, including giving聽her inappropriate medications. In court papers defending a lawsuit by Fee鈥檚 family, the medical center said the nursing home鈥檚聽care was diligent. The center declined to discuss the case for this story.
The selection of a nursing home can be critical: 39 percent of facilities have been cited by health inspectors over the past three years for harming a patient or operating in such a way that injuries are likely, government records show.
Yet many case managers at hospitals do not share objective information or their own knowledge about nursing home quality. Some even push their own facilities over comparable or better alternatives.
鈥淕enerally hospitals don鈥檛 tell patients or their families much about any kind of patterns of neglect or abuse,鈥� said Michael Connors, who works at California Advocates for Nursing Home Reform, a nonprofit in San Francisco. 鈥淓ven the worst nursing homes are nearly full because hospitals keep sending patients to them.鈥�
Hospitals say their recalcitrance is due to fear about violating a government decree that hospitals may not 鈥渟pecify or otherwise聽limit鈥� a patient鈥檚 choice of facilities. But that rule does not prohibit hospitals from sharing information about quality,聽and a handful of health systems, such as Partners HealthCare in Massachusetts, have created networks of preferred, higher-quality聽nursing homes while still giving patients all alternatives.
Such efforts to help patients are rare, said Vincent Mor, a professor of health services, policy and practice at the Brown University School of Public Health in Providence, R.I. He said that when his researchers visited 16 hospitals around the country聽last year, they found that only four gave any quality information to patients selecting a nursing home.
鈥淭hey鈥檙e giving them聽a laminated piece of paper鈥� with the names of nearby nursing facilities, Mor said. For quality information, he said, 鈥渢hey will say, 鈥榃ell, maybe you can go to a website,鈥欌�� such as聽, where Medicare publishes its quality assessments.
The federal government may change this hands-off approach by requiring hospitals to provide guidance and quality data to patients聽while still respecting a patient鈥檚 preferences. The rule would apply to information not only about nursing homes but also聽about home health agencies, rehabilitation hospitals and other facilities and services that patients may need after a hospital聽stay.
鈥淚t has a substantial opportunity to make a difference for patients,鈥� said Nancy Foster, a vice president at the American Hospital Association.
Even the worst nursing homes are nearly full because hospitals keep sending patients to them.
But the rule does not spell out what information the hospitals must share, and it has yet to be finalized 鈥斅爉ore than a year after Medicare proposed it.聽The rule faces resistance in Congress: The chairman of the House Freedom Caucus, Rep. Mark Meadows, R-N.C., has included it on a Republicans should block early next year.
The government has created other incentives for hospitals to make sure their patient placements are good. For instance, Medicare聽cuts payments to hospitals when聽聽within a month.
鈥淗ospitals didn鈥檛 use to care that much,鈥� said David Grabowski, a professor of health care policy at Harvard Medical School. 鈥淭hey just wanted to get patients out. Now there鈥檚 a whole set of payment systems that reward hospitals for good discharges.鈥�
But sometimes hospitals go too far in pushing patients toward their own nursing homes. In 2013, for instance, regulators faulted聽a Wisconsin hospital for not disclosing its ties when it referred patients to its own nursing home, which Medicare rated below聽average. In 2014, a family member told inspectors that a Massachusetts hospital had 鈥渟teered and railroaded鈥� her into sending聽a relative to a nursing home owned by the same health system.
Researchers have found that hospital-owned homes are often superior to independent ones. Still, a third of nursing homes owned聽by hospitals in cities with multiple facilities had lower federal quality ratings than at least one competitor, according to a Kaiser Health News analysis.
The Lowest Rating
A family photo of Elizabeth Fee shortly before she died in 2012. (Robert Durell for KHN)
Medicare鈥檚 Nursing Home Compare gave the nursing home where Elizabeth Fee died one star out of five, meaning it was rated聽鈥渕uch below average.鈥� The hospital鈥檚 case managers told Fee鈥檚 family that the nursing home was merely an extension of the聽hospital and that 鈥渕y mother would receive the same excellent quality of care and attention,鈥� said Rees, her daughter.
But state inspectors found shortcomings in seven visits to the nursing home between August 2009 and October 2011, records show.聽Inspectors found expired medications during two visits and, at another, observed a nurse washing only her fingertips after聽putting an IV in a patient with a communicable infection.
Just four months before Fee arrived, inspectors cited the nursing home for not treating patients with dignity and respect and for failing to provide the best care. One patient told inspectors that her pain was so excruciating that she couldn鈥檛聽sleep but that nurses and the doctor did not check to see whether her pain medications were working.
鈥淣obody listens to me,鈥� the patient said. 鈥淚 was born Catholic, and I know it鈥檚 not right to ask to die, but I want to die just to get rid of the pain.鈥�
Fee ate little and had few bowel movements, according to the state health investigation. Fee鈥檚 family had hired a private nurse, Angela Cullen, to sit with her. Cullen became increasingly worried about Fee鈥檚 distended belly, according to Cullen鈥檚 affidavit taken as part of the lawsuit. She said her concerns were brushed off, with one nurse declining to check Fee鈥檚 abdomen聽by saying, 鈥淚 do not have a stethoscope.鈥�
On the morning of her death, an X-ray indicated Fee might have a bowel obstruction or other problem expelling stool, the inspectors鈥櫬爎eport said. That evening, after throwing up a large quantity of matter that smelled of feces, she lost consciousness. She聽died of too much fluid and inhaled fecal matter in her lungs, the report said.
Bills Of More Than $150,000
An undated family photo of Elizabeth Fee as a fashion model. (Robert Durell for KHN)
In a court ruling, Judge Ernest Goldsmith of the San Francisco Superior Court wrote that Elizabeth Fee鈥檚 younger daughter, Nancy,聽鈥渙bserved her mother drown in what appeared to be her own excrement.鈥� Kathryn Meadows, the family鈥檚 attorney, said in a court聽filing that the nursing home鈥檚 bills exceeded $150,000 for the three-week stay.
Sutter Health, the nonprofit that owns the medical center and the nursing home, emphasized in court papers that Elizabeth Fee arrived at the facility with a low count of platelets that clot blood. Sutter鈥檚 expert witness argued that the near-daily聽visits from a physician that Fee received 鈥渇ar exceeds鈥� what is expected in nursing home care.
The physician and his medical group have settled their part of the case and declined to comment or discuss the terms; the case against Sutter is pending. California鈥檚 public health department fined Sutter $2,000 for the violations, including for delaying 16 hours in telling the physician about Fee鈥檚 nausea, vomiting and swollen abdomen. Last year, Sutter closed the nursing home.
A week or so after Fee died, a letter addressed to her from California Pacific Medical Center arrived at her house. It read: 鈥淲e would appreciate hearing about your level of satisfaction with the care you received on our Skilled Nursing Rehabilitation聽Unit, the unit from which you were just discharged.鈥�
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Clarification:聽This story was updated to correct a reference to Elizabeth Fee.