Senior Arms-Hands
After four patients died — days after Laguna Honda's relocated them, CMS called a “pause.”

Laguna Honda: Denial, Complicity, Resistance

•••••••••• August 2, 2022 ••••••••••

Derek Kerr
Dr. Derek Kerr

At the July 19th, 2022 Health Commission meeting (at 1:42:20), Laguna Honda Hospital (LHH) representatives summarized the results of a Mock Survey conducted in late June. Designed to mimic a Centers for Medicare and Medicaid Services (CMS) recertification survey, it was conducted by 16 consultants from Health Management Associates. LHH is to be commended for disclosing the deficiencies uncovered. 

The mock survey identified problems whose “…significant number, scope, and severity demonstrate systemic deficiencies in practice and care at Laguna Honda Hospital”. The consultants concluded that LHH would have failed a real recertification survey. LHH will fix the problems identified. Then, a second mock survey will be conducted before it applies for recertification and a formal CMS survey.

CMS decertified LHH this April for 2 major deficiencies; uncontrolled drug and contraband use, resulting in 2 drug overdoses, and substandard COVID infection control procedures. Yet, LHH’s mock survey still found; “…numerous failures to adhere to infection control policies and procedures…” Oddly, there’s no mention of illicit drugs and contraband. Likewise, this critical problem isn’t mentioned in the consultants’ June “preliminary assessment” of LHH. And, LHH skipped the drug use issue in its Health Commission presentation. Has the drug problem vanished, or is this denial?

quotes

Despite these commitments to ensure safe and minimally-stressful transfers ... it did not fully grasp the number and complexity of LHH patients. So, LHH was “pigeon-holed into rules applying to standard nursing homes”

The mock survey did find that LHH “did not provide behavioral/substance use disorder treatment during outbreaks of Covid”. Henceforth, support groups will not face COVID restrictions. Further, “Residents with active substance use disorder will be monitored to ensure they have proper referrals to behavioral health services". What these fixes disregard is that a Psychiatrist and a Nursing Director had admitted to regulators that they were incapable of controlling the spread of illicit drugs and paraphernalia. Denial is evident in the claim that; “Ongoing audits will ensure those individuals with Substance Use Disorder receive appropriate treatment.” Drug users had previously defied LHH rules, searches, monitoring and treatment.

Strangely, there’s no reference to LHH’s oft-skirted Admissions Policy that limits admissions to those patients; “For whom Laguna Honda can provide safe and adequate care. "How did LHH get into trouble with uncontrolled drug use when its Admissions Policy warns; “LHH cannot adequately care for prospective residents with…significant likelihood of unmanageable behavior…including…drug trafficking, possession or use of illegal drugs or drug paraphernalia”?

Responsibility for Post-Transfer Deaths

Wilmie Hathaway
Chief Medical Officer
Dr. Wilmie Hathaway

At the July 19th Health Commission meeting, LHH Chief Medical Officer, Dr. Wilmie Hathaway, reported three deaths among patients transferred to other nursing homes. Though "saddened by this news," she explained that, "Once transferred, we no longer have regular updates about them. "Doesn't LHH make follow-up calls to ensure smooth transfers? The seemingly inert Health Commissioners didn’t ask and offered no comments.

At the more animated and revealing Board of Supervisors’ July 21st Government Audits & Oversight (GA&O) Committee hearing (at 2:02:15), we heard that a fourth LHH patient died. That person died three weeks after being discharged to the City’s Medical Respite Center. No information about the causes of these deaths emerged, but finger-pointing ensued. Interim LHH CEO Roland Pickens’ presentation differed markedly from the one he produced for the Health Commission two days before. He revealed that CMS had rejected LHH's proposals to avoid patient relocations or to conduct them over 18 months. Instead, CMS wanted a 4-month process, with a possible 2-month extension. Continued federal funding was contingent on LHH’s progress in transferring patients. According to Pickens, CMS pressured LHH - without providing written progress metrics or quotas. Somehow, that lack of guidance "has been driving the processes that we have been going through” - and by implication, its adverse outcomes.

Roland Pickens
Interim LHH CEO
Roland Pickens

However, the LHH “Closure and Patient Transfer and Relocation Plan” that won CMS approval defines its intent as “…to ensure the safe, orderly, and clinically appropriate transfer or discharge of each patient with a minimum amount of stress." Also, “the medical assessment will include screening patients for risks of transfer trauma." Transfer trauma refers to the stress medically frail patients experience from abrupt or involuntary transfers from one residential facility to another. LHH added the caveat; "Laguna Honda shall use reasonable best efforts to achieve the time frames set forth herein. "Further, "If it appears that alternate placements are not available and a good faith effort to relocate has occurred, there is a shared commitment by all parties…to identify resources and solutions on how to best serve remaining patients." The agreed-upon Plan does not call for forced or unsafe transfers. Nor does it commit to completely evacuating LHH.

Despite these commitments to ensure safe and minimally-stressful transfers, CEO Pickens blamed CMS for pressuring LHH to discharge more patients, regardless of their condition. He portrayed CMS as rigid in its requirements and nebulous or lagging in responding to questions. Although CMS has surveyed LHH for decades, Pickens felt that it did not fully grasp the number and complexity of LHH patients. So, LHH was “pigeon-holed into rules applying to standard nursing homes."

Complicity and Conflicts of Interest

Supervisor Myrna Melgar
Supervisor Myrna Melgar

The Board’s GA&O Committee decried the plight of residents and families facing relocation. Essentially, the four patient deaths were ascribed to CMS’s “lack of due process” and unreasonable demands imposed upon LHH - a hapless victim, devoid of agency. However, Supervisor Myrna Melgar touched on two core issues; complicity and conflicts of interest; “We have been complicit in essentially sending patients to a death sentence by complying with these ludicrous demands." Supervisor Melgar asked LHH Chief Medical Officer, Dr. Hathaway, about the sometimes conflicting goals of patient welfare versus hospital sustainability. Dr. Hathaway responded, "We are the strongest advocates for our patients." Then, she acknowledged, "Ultimately, the goal is to save Laguna Honda so we can get recertified…so we can continue to provide services to the people of San Francisco."

Ethical Dilemma: Funding v. Patient Care

The threat posed by CMS is the loss of federal funding — not of revoking LHH's license or shutting it down. Accordingly, the relocation plan only applies to Medicare and Medicaid beneficiaries — those that CMS pays for. That group comprises 98.4% of LHH patients. CMS pays LHH around $550,000 per day or roughly $200 million yearly. CMS’ demands are leveraged by money. LHH could continue to operate without CMS payments — if the City paid $16 million or so per month. It's an economic issue.

We don’t know the cause of death of the three transfers and one discharge. But four deaths among 57 patients relocated or discharged yields a 7% mortality rate. If, as the Public Guardian’s Office told the Chronicle, two of the transferred patients were receiving Hospice Care, their deaths were likely expected. Still, transferring terminally-ill patients requires justification. Meanwhile, only 1.7% of patients remaining at LHH died during this period. However, 106 patients were sent to other hospitals for acute illnesses or interventions. Did some die off-site during their “Leave of Absence”? Nonetheless, the apparent excess mortality should have led LHH doctors to pause the relocations — and investigate the mortalities.

If transfer trauma contributed to these deaths, then LHH bears some responsibility. Safe patient transfers require providing instructive interdisciplinary Care Plans to the receiving facility. However, LHH’s own mock survey found that; “Resident care plans are generic and not resident-centered to each resident's care goals." That flaw could add to relocation stress. Mainly, ensuring safe transfers is the responsibility of attending physicians. Granted, there are regulatory and administrative pressures to discharge or transfer patients. But the buck stops with the physician. Patients cannot be discharged or transferred without a physician’s order. 

Medical Ethics

The American Medical Association’s Code of Ethics addresses “Physician Responsibilities for Safe Patient Discharges." While recognizing that physicians are stewards of hospital resources, it emphasizes that; "Physicians’ primary ethical obligation to promote the well-being of individual patients encompasses an obligation to collaborate in a safe discharge plan for the patient. As advocates for their patients, physicians should resist any discharge requests that are likely to compromise a patient's safety."

The AMA Code of Ethics provides guidance in navigating potential conflicts of interest between serving individual patients' well-being and the hospital's economic survival (and the MD's job). The "Conflicts of Interest in Patient Care" section advises, "Where the economic interests of the hospital, health care organization, or other entity are in conflict with patient welfare, patient welfare takes priority."

We now know that the City Attorney is appealing the drug-related citations that led to LHH’s decertification. The Mayor’s Office negotiated with CMS overseers to halt the relocations. On July 26th, the Board of Supervisors adopted Resolutions calling for the same. Community groups, patients and families lobbied to stop the transfers. What were LHH doctors doing?

Well, on July 28th, CMS issued a statement expressing concern about the post-transfer deaths. It emphasized that LHH was “required to perform thorough and adequate medical assessments of every resident before a transfer or discharge…." Further, CMS “expects that all transfers and discharges be paused while an assessment occurs over the coming weeks." CMS installed a "facilitator" at LHH for this purpose.

In 2004, LHH physicians opposed the fiscally-driven DPH Flow Project because it endangered patients. Today’s medical staff could have resisted a fiscally-driven agreement between CMS and LHH, if it imperiled patients. Instead of complying with potentially harmful administrative directives, physicians can abide by the Hippocratic precept; Primum non nocere – “First, do no harm."

Acknowledgement: Thanks to Patrick Monette-Shaw for sharing records of City appeals.

Dr. Derek Kerr is a San Francisco investigative reporter for the Westside Observer Contact: watchdogs@westsideobserver.com

AUGUST 1, 2022

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