Care Aides Get Little To No Training For Life-And-Death Tasks
By Chris Serres, Star Tribune (Minneapolis) | |
McClatchy-Tribune Information Services |
Her patient, an elderly quadriplegic man she had just met, gasped for air, his throat blocked and his eyes rolled back. Nothing in Sernett's one hour of training as a personal care attendant had prepared her for this.
Fearing the man was about to die, Sernett fumbled with a nearby suctioning machine. She had never used one, but she turned it on and inserted a long plastic tube deep into his throat.
"I was absolutely petrified," she said. "I had a man's life in my hands and had no idea of what to do."
Each day, thousands of home-based caregivers such as Sernett are thrust into similar life-and-death situations with little training and virtually no direct supervision. They perform a dizzying array of complex medical tasks -- from inserting feeding tubes and cleaning infections to monitoring intravenous fluids -- that once were provided only in hospitals or nursing homes by medical professionals.
Many say they feel overwhelmed and unqualified as they struggle to help patients with serious illnesses and disabilities.
In
Of more than two dozen personal care attendants interviewed by the
Isolated and left to fend for themselves, many home caregivers say they have no choice but to violate rules designed to protect vulnerable adults. In interviews, unlicensed personal care attendants said they routinely sterilize wounds, administer powerful prescription drugs and even inject medications into patients' veins -- even though such tasks are prohibited under the state-funded personal care assistant program.
Often, their employers don't know the risks they undertake because the caregivers are largely unsupervised.
The same pattern plays out across the country. Despite a decade of explosive growth in the
In
Personal care agencies are also required by law to employ a "qualified professional," such as a registered nurse or licensed social worker, who can train and oversee caregivers.
But at larger agencies, these professionals sometimes oversee hundreds of patients, and their house visits often amount to cursory scans of patient care plans, caregivers say.
The
This person is supported by six other staff who do ongoing quality reviews.
When mistakes happen, complaints to state and county agencies sometimes go unreported or unheeded, enabling negligent caregivers to avoid sanctions while moving from one home-health agency to the next, say county officials and caregivers.
"It's like we don't exist," said
Now, to the dismay of some patient care advocates, the state is proposing changes that could loosen its already limited oversight of the state's massive personal care assistant program, which last year cost
"We, as a society, have really dropped the ball," said
'Stuck in the middle'
For years, state lawmakers and local officials have voiced concerns about the lack of oversight. In one review of the system, the legislative auditor found that just 57 percent of patients received the visits from qualified professionals required by state law. Even when the required visits occur, the auditor found, the actual supervision was modest. One-third of those who qualified for professional supervision received less than half an hour per month, the auditor found.
The result is that many caregivers rely on ailing clients for instructions, even though the clients can have disabilities that make it difficult for them to speak.
Some caregivers around the state say they often feel pressured to perform complicated procedures, such as injecting drugs and cleaning surgical wounds, even though such tasks are considered skilled nursing care and are not allowed for a personal care assistant under the state program.
"If someone needs an injection of insulin or a painkiller, you can't always say, 'No,' or , 'Just wait for a professional,'" said
To technically comply with state
"The agencies don't want to pay for the professionals, but they also want to cover their own tails," Munoz said. "The caregiver is stuck in the middle."
Oversight lacking
Home care agencies say state rules actually discourage more active supervision by medical professionals.
Patients are allotted up to 24 hours of worker supervision and training annually from a licensed professional under the state personal care assistance program. To qualify for more time, providers must show that the worker needs more supervision or training -- a process that is time-consuming and often fruitless, providers say.
"Lack of supervision is the elephant in the living room," said
State authorities have resisted periodic efforts to expand regulation by licensing personal care agencies and their workers. Reformers proposed licensing in 1991, and again in 1997, when the program was about a third its current size. But the high cost of implementing the reforms proved an insurmountable barrier; legislators never appropriated funds so no action took effect.
The result is that unlicensed personal care assistants are not subject to the same routine inspections as nursing homes, assisted-living centers and other state-licensed facilities. Patients and relatives who complain about negligent or abusive care find themselves referred to county governments, which say they lack the resources to investigate home-care agencies.
"You could put more heavy regulation over the top of it, but then you'd take away some of that consumer direction, some of that flexibility that comes with it," Kerber said. "There is a balance there."
Neglect and a death
With home caregivers asked to perform more complex and risky tasks, the absence of training and supervision has sometimes led to fatal results.
The worst part, said Lassen, is living with the belief that his death two years ago was "completely avoidable."
Her father,
In sworn testimony, a former personal care attendant at the home described a chaotic atmosphere. The caregiver,
"Most of the employees didn't know what they were doing or didn't carry through with their jobs correctly," Crawford, who no longer works at the home, said in sworn testimony.
Lassen said staff failed to detect obvious signs that her father had a serious infection. He had difficulty walking, complained of foot pain and became increasingly lethargic, Lassen said. When a laboratory report revealed that Ell had an elevated white blood cell count, indicating an infection, she said three-and-a-half days passed before the staff sent the lab report to a physician's clinic.
By the time Ell was admitted to a hospital, it was too late. The infection had spread so rapidly that, after his lower right leg was amputated, he died of multi-system organ failure. His 89-year-old mother was so overcome with grief that she threw herself on his lifeless body as it lay sprawled on the hospital bed.
"It makes me so incredibly mad," said Lassen, who lives in
It argued that, during Ell's stay,
Workload more demanding
The type of work demanded of home caregivers has changed dramatically in the past two decades.
Hospitals, under pressure from insurance companies to reduce costs, are releasing more patients while they are still sick or recovering, effectively shifting the burden of medical care to the home. Caregivers have had to master the operation of respiratory ventilators, intravenous feeding tubes and home dialysis, while responding to medical complications such as wound infections and low oxygen levels.
More than 80 percent of home caregivers provide nursing care, while more than 50 percent provide help with highly complex medical tasks, according to a survey of 1,926 home care workers who cared for adult
"The burdens placed on [home caregivers] have never been greater," said Dr.
Between medical tasks, caregivers are often expected to do laundry, cook meals and perform other household chores for their clients. In
Job takes physical toll
On a hot July afternoon, sweat poured down
The work is also physically demanding, as many caregivers must push, pull and lift disabled patients on a daily basis. In 2012, the average home health aide missed 14 days of work from injuries and illnesses, 55 percent more than all occupations nationally, according to the
For some personal care attendants, the strain can be too much.
And if the red light on the ventilator stopped blinking? Call 911.
"I kept thinking, 'What if I end up killing this person?'" Ali said. "I could not understand why this woman was not receiving care from a skilled nurse."
Sernett said she has not seen a licensed supervisor in more than four years working as a personal care attendant for a severely disabled client. Yet Sernett, 50, performs a wide range of complicated medical tasks that, if not done correctly, could prove fatal.
On a recent weekday morning her client,
Calmly, Sernett inserted a clear plastic tube into his tracheostomy, a permanent opening in his neck connected to a respirator, and drained the excess phlegm. Moments later, she rolled his 190-pound body over so she could wipe his bottom with sterile gloves and clean a reddened sore on his lower back. Then she injected a syringe full of pink Milk of Magnesia into the feeding tube attached to his intestines.
For these and countless other tasks, Sernett said she received "absolutely no training" from the home care agency that employs her. Sernett said she learned how to suction a tracheostomy and administer a feeding tube from the patient's wife,
"This ought to be illegal," Sernett said, as she cleaned the skin around the man's feeding tube with a cotton swab and a washcloth. "I find it completely outrageous that a man's life rests in the hands of people who are completely unsupervised and untrained."
The living room of the couple's
Six months from now, Sernett will no longer be able to care for Jarvis after five years. She will graduate from nursing school and Medical Assistance will no longer pay for her services. "I really love Gary, so it makes me so sad that I can't stay with him as a nurse," said Sernett, her eyes tearing up. "He should be getting skilled nursing care every day because his needs are so technical."
Empowering consumers
Soon, families across
Families who highly value a caregiver could encourage the person to stay by paying more than the
The proposed changes, which must still be approved by federal authorities, could also greatly reduce financial waste. Currently, hundreds of individual home care agencies handle their own payroll and taxes, even though many of the agencies employ just a few caregivers. In the future, people could bypass the agencies and these administrative tasks would be handled by several large state contractors. The resulting savings from consolidating overhead costs likely would free more money for patient care, some disability advocates say.
"This is about consumer empowerment," said
Still, some county officials and providers worry that the new program will end the requirement that patients receive home visits by a nurse or other qualified professional. In many cases, these visits are the only professional help that a caregiver receives -- and one of the few ways for a provider to know if an elderly or disabled client is receiving adequate care, say county officials.
To Lassen, the balance already has shifted too far away from clear government oversight. During a recent trip to her father's grave in
She regrets not asking more questions when she discovered her father alone and disheveled in the dark basement of the group home. She regrets not asking staff why no one had shaved or showered him for what seemed like days; and why he grimaced in pain as he walked to the dinner table to eat the banana cream pie she brought for him.
As family surrounded the open casket at his funeral, Lassen slipped a small, handwritten note into the breast pocket of her father's suit. "I wanted him to know how sorry I was that he had to go through so much pain," said Lassen, as she wiped away tears. "My fear is that, if nothing changes, it will happen again to someone else."
Staff writer
Twitter: @chrisserres
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