Editorial: Report blisters state nursing home for veterans

The Arizona State Veteran Home already was under intense scrutiny by the state for poor performance.

Despite having the Arizona Department of Health Services looking over its shoulder, the home was hammered repeatedly Monday in a report filed by the state agency.

The home violated 10 state and federal licensing standards when its staff discharged a patient who could not care for himself, ignored resident complaints, rigged a woman’s call light so it wouldn’t work and prevented residents from leaving the grounds without an escort.

The pressure to deliver first-class care for elderly veterans did not produce results.

The findings were part of a week-long investigation launched late last month after investigators declared the facility’s residents in immediate jeopardy. It was the second time in just over a year that the state-run nursing home has received the worst possible designation.

A shortage of nurses led to uneven care for men and women who sacrificed their life for this country.

“There were very few RNs in the building except in supervisory roles,” said Sylvia Balistreri, program manager for long-term-care licensing at the Arizona Department of Health Services. “And that starts to border on potentially not having residents receive the kind of assessment and oversight they need by an RN, especially if they are Medicare patients,”

The nursing home located in central Phoenix has 10 days to respond with a plan to correct the problems or dispute any findings. We agree with Gov. Janet Napolitano’s decision to put together a coalition of state and federal agency officials now to figure out what’s wrong at the home and fix it.

One of the worst oversights concerned call lights at the facility. Family members and some employees at the veteran home told investigators the call light of one patient was shut off because she used it too frequently.

The veteran home concluded no evidence was found that the call light had been intentionally rigged, but Balistreri said health inspectors felt the home dropped the complaint without a serious investigation.

“It is very serious if a resident does not have a call light,” Balistreri said.

Other complaints by residents include a change in policy that kept them from leaving the grounds without an escort.

The report also sheds new light on the circumstances surrounding the release of a 67-year-old man, who was diabetic and recovering from brain surgery.

Inspectors note that the man was released before a psychological evaluation that had been ordered to determine his competency and that staff members had different opinions about the man’s ability to care for himself.

According to the report, the man was confused and often did not know where he was, and staff members felt it would be too dangerous to send him home with the medications he needed.

The problems could force the home to lose its ability to admit new Medicare patients when a federal survey is released in the near future. Some of the former military veterans have nowhere else to go for care.

The Legislature held hearings in March 2007 after a survey indicated allegations of resident abuse and neglect. State lawmakers should watch closely what comes out of the governor’s coalition and step in again if they’re not comfortable with the findings.

“It bothers the living daylights out of me. To me it looks like we’re almost going back to what we had a year ago,” said Rep. John Nelson, R-Phoenix, who presided over the 2007 hearings.

“The commitments that were made are not being fulfilled,” he told the East Valley Tribune. “I’m going to watch this thing very closely.”

The home was hit with more than $20,000 in state and federal fines in 2007. Lawmakers gave the department $6.1 million over two years to make improvements.

The Arizona Department of Veterans Services’ Web site says, “We love who we serve.” Then it adds: “Out of love and respect for our veterans, we put their needs before staff convenience.”

Prove it, we say in response.

Unsigned editorials represent the view of this newspaper. Respond with a Letter to the Editor by e-mailing letters@gvnews.com.