By Tippy Irwin, Executive Director
For years I have been saying that the mixing of mentally ill clients alongside our frail elders in nursing homes is a lethal mix. And my voice is not a lone voice in the wilderness. Others too have been writing on this very issue. Based on numbers from Center for Medicare and Medicaid Services we have seen a 41% increase since 2002 in the number of clients with mental illness residing in nursing homes.
Several months ago we had a case that highlights the many problems that can arise from this mix in a nursing home. Resident A, a 74 year old monolingual Chinese woman was suffering from severe paranoia but undiagnosed because she refused to be assessed by the facility’s medical director. In the depth of the night she got out of bed, fashioned herself a weapon from the bamboo sticks that hold up the orchids in her room, and attacked her roommate, Resident B, a very frail, elderly woman. We have no knowledge of what provoked the attack. The victim of this violence was taken for treatment to a hospital in San Francisco. The perpetrator was sent on a 5150 to a psychiatric center at a local hospital.
Thereafter followed a litany of errors compounding the omissions that had already occurred. Firstly, the facility that was home to these two residents had failed to do a comprehensive assessment of Resident A. Staff at nursing homes are trained to take care of the frail elderly, and when confronted with clients that suffer from a range of mental disorders, have no background to fall back on to provide what is needed. Not only was resident A the perpetrator of a violent act, but she also fell victim to a system that had completely failed her. The hospital, evidently not wanting to keep Resident A for 72 hours which would have been permissible, wanted her out as soon as possible. As the facility refused to take her back, stating that the hospital could not possibly have done an assessment in the two hours since the incident occurred, and as the daughter stated she was unable to provide the necessary care for her frail, mentally ill mother who was receiving dialysis three times a week and had other serious underlying medical issues, the hospital turned her over to local law enforcement who placed her in county jail where she languishes till now. The courts in the meantime have deemed her incompetent to stand trial and have ordered her to be transferred to Napa State Hospital for the criminally insane, where she will stay until she is well enough to stand trial (which may be never).
Resident B, the victim of this act of violence, has since passed away, not from the effects of the attack which resulted in superficial lacerations to the face, but from the other serious issues from which she suffered. We will never know for sure how the attack impacted her emotionally or what effects it had on her already weakened condition.
As for resident A, what I see is a frail elder suffering from many serious health conditions often related to aging, but also struggling with her own mental health issues, being caught up in a sytem that has totally failed her. It is our belief that she could well be placed in a geropsych unit where she could receive appropriate medications and care that would enable her to live out the remainder of her life in an environment more conducive to her condition. Both these residents have been failed by a system that has been reduced to lumping together two very different sets of clients with distinctly different needs, and compounding that with inadequate training of staff in the nursing homes.
Carla Johnson of the associated press identifies the following issues as driving the problem:
• The closing of state mental institutions
• A shortage of hospital psychiatric beds
• Nursing homes have beds to fill because today’s elderly are healthier than those before them and more likely to stay in their homes. (In addition CMS is driving the transition of nursing home residents back to lower levels of care where it is less expensive to provide for them and to comply with a Federal Supreme Court Decision that permits/encourages individuals to live in the least restrictive environments possible.)
• Mixing the mentally ill with the elderly makes economic sense for states. As long as a nursing home’s mentally ill population stays under 50 percent, the federal government will help pay for the residents’ care under Medicaid.