Federal inspectors report a concern with nursing homes in Ohio discharging patients to homeless shelters.
A woman using a walker had shown up, incontinent and carrying “a large bag of medications.” She was diabetic, managing a tibia fracture and alcohol-related dementia, and she was “dumped” at the shelter, according to federal inspectors. “The staff member Resident #83 was unclear of what was going on, scared, and not sure who dropped her off there,” inspectors for the Centers for Medicare and Medicaid Services, which
The incident was what industry experts described as a rare but increasingly common instance of a nursing home in Ohio transferring its patients – who are often older, poorer and medically fragile – to a homeless shelter. CMS has faulted Eastland and six others in the past few years related to efforts to discharge patients to homeless shelters, most of which were ultimately carried out.
The woman had been caught drinking beer at her residence in the Eastland Rehabilitation and Nursing Center, in Columbus, prompting an involuntary discharge. Staff tried to get her into rehabilitation for substance use, but no beds were immediately available. Eastland staff never called the county’s psychiatric bed board to find a spot for the woman, according to the inspectors. Instead, they took her to the shelter. There, about 100 people sat ahead of her on the waiting list. The shelter at first declined to admit the woman, leaving her outside in the late-summer heat. Staff eventually relented, letting her sit in the lobby with a glass of cold water while they summoned a city rapid response team, including the fire department and a social worker.
“In addition, the events of what occurred at the addiction recovery center or how/why Resident #83 ended up at the homeless shelter … could not be determined as the facility was unable to provide any additional information regarding Resident #83,” the inspection report states. The administrator at Eastland declined to return phone calls about the inspection. Facility staff declined to provide contact information for Garden Healthcare, the corporate owner of the nursing home, which operates five other facilities, according to CMS data. It doesn’t publish any contact information online.
Most of the patients in these situations are older, homeless, unemployed and lack support networks of family or friends that might be checking in on them, according to Chip Wilkins, who leads the city of Dayton’s Long Term Care Ombudsman program, which acts as a legal advocate for long term care patients. “We are starting to deal with it more and more. The facilities are so closely monitored on discharges, but yet they still try and send them to hospitals and not take them back. Or drop them off at homeless shelters,” he said in an interview.
Leilani Pelletier, the statewide ombudsman, said she didn’t have ready access to data that could confirm whether the discharges to homeless shelters have increased in frequency statewide. But health care is as subject to macroeconomic forces like inflation as other sectors of the economy. And Medicaid, which pays for most nursing care, is under increasing cost pressure as federal lawmakers have reduced program funds. The challenges nursing facilities in Ohio are facing reflect a broader and concerning trend affecting facilities across the country, said Scott Wiley in a statement, CEO of the Ohio Health Care Association, an industry trade group. “This issue has been growing as more residents face unstable housing,” he said. “State oversight and resources are needed to help tackle the issue on a larger scale to find meaningful, long-term solutions for Ohioans who struggle with homelessness. It will require a collaborative approach that a single nursing facility provider is not equipped to manage on their own.”
The state ombudsman’s office gets copies of every involuntary discharge from a nursing home in Ohio. One of the first things they check, Wilkins said, is the proposed discharge location. Homeless shelter discharges are priority cases because they’re almost always unsafe, he said. They can’t manage the 10 to 20 medications they might need daily. Some rely on wheelchairs or walkers. “Invariably, that ends up being a horrible experience for the individual because they’ll go to the shelter, and typically, within two to three days, the shelter will send them to the hospital because they can’t meet their needs,” Wilkins said.
Often, the issues trace back to insurers, including Medicaid and Medicare, that cut off residents’ benefits. Sometimes the facilities cite aggressive behavior or substance use. Homeless shelters aren’t built to handle medically fragile patients. They aren’t medical centers. Some may require residents to climb to a top bunk, a tall task for older patients. Marcus Roth, director of communications of the Coalition on Homelessness and Housing in Ohio, said the practice puts the shelters in a tight spot. They’re tending to a population they’re not equipped to handle, but they’re also the de facto safety net. “The emergency shelter system, to the extent we have a system, is often the only thing available when other interventions don’t work,” he said.
Pelletier emphasized in an interview that such involuntary discharges to shelters against residents’ wishes are rare. That said, she estimated about 13,000 Ohioans are discharged from a nursing home each month. Nursing homes, she said, have legal obligations to make sure that discharges are “safe and appropriate.” And it’s not up to the facilities, she said, to unilaterally decide where a person should go. Whether a shelter is “safe and appropriate” is a fact-specific question. Pelletier said there are instances where it could be, pending the care needs of the resident and abilities of the shelter. It’s the kind of thing that ombudsmen hone in on when reviewing discharges. “The real issue is when people are discharged to a homeless shelter and there’s been no work or investigation done on if that would be a safe or appropriate discharge,” she said.
It didn’t matter that its patient was diabetic and struggled to manage his blood sugar. Neither did his history of glaucoma, cataracts, or suspected autism, or his 22 years of residency at the nursing home. The man told CMS inspectors in an interview that nursing home staff never told him he was being taken to a homeless shelter.
nursing home residents must be given at least 30 days’ notice before a discharge, barring health and safety emergencies. But the patient at Laurels, who isn’t identified in the investigation, wasn’t given any. According to his former roommate, facility staff misrepresented the discharge, claiming he’d be going to an assisted living apartment as opposed to an emergency shelter that would only house him for up to 90 days. The man wasn’t taught to manage his medications and showed up at the shelter without any needles to use. He struggled to see with his cataracts. He had no driver’s license, birth certificate or other documents he would need to get a job, income or housing. “I can’t believe they would do someone dirty like that,” the patient’s roommate said to CMS inspectors. Laurels of Hillsboro, via a receptionist who declined to provide her name over the phone, declined to comment but said the facility is now in “substantial compliance” with the state.
In some of the facilities cited by CMS, the providers allegedly failed to ensure patients got their medications as they were discharged to homeless shelters. And some failed to provide patients their 30 days of notice before an involuntary discharge. Meadowbrook Manor, in Trumbull County, sought to discharge a patient with an array of long-term illnesses and a history of substance use and homelessness,
He was given two weeks’ worth of medications, but no prescriptions, medical appointments or care plan. The shelter staff identified a “mismatch” given the man had trouble walking and couldn’t climb a ladder to reach a top bunk, as the facility requires.
At New Lebanon Rehabilitation and Healthcare Center, a woman’s insurer sent her a termination letter for her treatment for a series of neural and spinal disorders, plus depression and arthritis. While she was entitled to 30 days’ notice, the facility gave her roughly 24 hours before discharging her to a homeless shelter. The facility’s social services director said he didn’t know where the woman actually went, only that a friend picked her up.
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