State leaders call for reforms after the death of nursing-home resident Germaine Morsilli, whose condition had steadily worsened as the Health Department chronicled it.

01:00 AM EDT on Saturday, August 28, 2004

BY JENNIFER LEVITZ
Journal Staff Writer

In her death, Germaine Morsilli is inspiring the action she could not during her life.

Both Governor Carcieri and Lt. Gov. Charles J. Fogarty said this week they would write legislation for nursing-home reform. They mention Morsilli by name.

The 87-year-old woman's bedsore worsened from Stage 2 to a dangerous Stage 4 over 117 days while the Health Department gave Hillside Health Center in Providence repeated chances to improve its care. Inspectors repeatedly found her with no dressing on her wound, according to the Health Department's inspection summary of Feb. 13. Three times, inspectors found her lying in her own waste. The department finally ordered Morsilli to a new home in February, where she died six weeks later of heart disease. A Journal story on Sunday detailed the Health Department's slow response to Morsilli.

But a call for change is a long way from action.

Even laws on the books aren't always followed.

There is a law that requires inspections twice each month when substandard care is found. But no one can agree on what substandard means.

And that technicality means that a second law is flimsy. That law requires the Health Department to report substandard care to the Long Term Care Coordinating Council, whose 35 members include health-care advocates and state officials, such as the lieutenant governor. No one told the council about Hillside, which closed in May, after a two-year history of problems with finances and patient care, Fogarty said.

Another law, passed in 1988, gives the state the power to step in and appoint a receiver when a nursing home's mismanagement is causing poor care. It's never been used.

Numerous reforms have been successful. A few of them are higher wages for nursing-home employees, stricter guidelines for Alzheimer's units, an adjustment in Medicaid reimbursements.

But some efforts have been watered down. Bills have died in committee, including attempts to reinstitute minimum staffing standards.

Former state representative Denise C. Aiken tried three times, until 2000, to reinstitute a minimum staff-patient ratio at nursing homes.

Each time, her bills failed.

The Health Department had phased out the ratio in 1991, opting for a philosophy that was outcome-based. If a nursing home was running well, the size of the staff wasn't an issue. If things weren't getting done, the Health Department could order the nursing home to increase its staff. Aiken didn't agree with this logic. If more workers were on duty, she believed, problems would be less likely to occur.

Each year, Aiken, a lawyer, would pack her hearings with supporters. "I had really good hearings in Health, Education and Welfare [Committee], a terrific representation from CNAs [certified nursing assistants] and RNs [registered nurses]. And then there would be the owners. The owners would say 'We can't afford it, period.' That's where it always ended up stopping, right there."

Aiken could see their point; she did not want to see small nursing homes get priced out. She knew that Medicaid might not reimburse the operators for the cost of additional staff.

She asked for a study commission, which again recommended minimum staffing. Those bills failed. "It came down to dollars and cents," she said.

Rep. Peter T. Ginaitt, a registered nurse and Warwick fire captain, was one of the legislators who for years pushed for more inspections of nursing homes.

He would submit his bills, only to be told, "It ain't going to happen."

"It was state dollars," he said of the obstacles. "And sometimes the nursing home lobby, which . . . feels as if too much regulation is a problem. Usually they argue against the inspections."

"On the flip side, they have been supportive of the inspections of chronic facilities."

So, in 1999, Ginaitt was one of the legislators who helped propose the law that nursing homes should be inspected twice each month if they are found to give "substandard" care -- the definition that no one can agree on.

He said the definition used now by the Health Department is complicated and convoluted -- and doesn't make sense.

"BY THE TIME people reach 'substandard' care, it's gone too far," Ginaitt said.

Fogarty agreed that the interpretation of the law has gotten tangled. His staff was at the Health Department yesterday, clarifying what "substandard" means.

"I believe when we're dealing with people's lives, we have to not take such a bureaucratic approach with how we implement the law," he said. "When you're dealing with a frail and vulnerable population, you have to be a little more flexible, and responsive."

Fogarty, who formed a task force after Hillside closed, proposes strengthening existing laws and revising state law to allow the state to put a "crisis management" team in place to ensure that nursing homes carry out their pledges to correct problems.

Carcieri on Tuesday announced he would pre-file "The Nursing Home Patient Safety Act." It would give the state power to investigate the finances of private nursing homes, act more quickly against poor facilities, and intervene in homes by appointing monitors to see that patients -- such as Germaine Morsilli -- are cared for.

Carcieri said he was immediately approving a new system that would allow the Health Department to better track the hundreds of complaints that come in.

"THERE IS NO DOUBT that Germaine Morsilli and other patients with chronic or recurring problems deserved better care than they received," he said.

Other legislators are stepping forward, too, in the name of Germaine Morsilli.

Ginaitt is one of them. He said that all nursing homes should undergo a thorough evaluation now, although he said most nursing homes are running well. Then, he wants to see more surprise inspections, including in the middle of the night.

He also suggests giving the Health Department money to hire two or three after-hours inspectors to police the troubled homes, and "don't let them be converted to day inspectors because three people are out sick."

Out of "fear of God and fear of the regulator," those patients are going to be properly cared for, he said.

House and Senate majority leaders agree, and theyplan to release a statement and new policy next week, said Larry Berman, spokesman for House Speaker William J. Murphy.

Rep. Steven M. Costantino said the Joint Committee on Health had already decided it would take on nursing-home issues next.

The situation with Morsilli, he said, shows that something is wrong with the system. Perhaps the state needs more regulation or better enforcement of existing laws, he said. He questions what happens when a nursing home takes corrective action -- does the state follow up over the long term?

"We're really concerned about the regulation and why there was not a more proactive response to abuse."

E-mail Jennifer Levitz at jlevitz [at] projo.com.

DIGITAL EXTRA: Recap a special Journal report on the Rhode Island nursing home system, titled "Resident #1", at:

http://projo.com/extra/2004/nursinghomes/