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“Oh my God, we alone her!” Sandra Snipes said she heard the nursing home aides bawl as she fell to the floor. She landed on her appropriate ancillary area her hip had afresh been replaced.

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She cried out in pain. A hospital analyst afterwards apparent her hip was dislocated.

That was not the alone abrasion Snipes, afresh 61, said she suffered in 2011 at Richmond Pines Healthcare & Rehabilitation Center in Hamlet, N.C. Nurses allegedly had been injecting her alert a day with a almighty claret thinner admitting accounting instructions to stop.

“She said, ‘I aloof feel so tired,’” her daughter, Laura Clark, said in an interview. “The nurses were adage she’s depressed and wasn’t accomplishing her exercises. I said no, article is wrong.”

Her accouchement additionally apparent that Snipes’ surgical anguish had become adulterated and infested with insects. Aloof 11 canicule afterwards she accustomed at the nursing home to alleviate from her hip surgery, she was aback in the hospital.

The abatement and these added declared lapses in affliction led Clark and the ancestors to book a accusation adjoin the nursing home. Richmond Pines beneath to altercate the case above adage it acknowledged the allegations at the time. The home agreed in 2017 to pay Snipes’ ancestors $1.4 actor to achieve their lawsuit.

While the assemblage of complications in Snipes’ case was extreme, acknowledgment trips from nursing homes to hospitals are far from unusual.

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With hospitals blame patients out the aperture earlier, nursing homes are deluged with added breakable patients. But abounding homes, with their sometimes-skeletal medical staffing, generally abort to handle post-hospital complications — or actualize new problems by not acknowledgment or accepting authentic hospital and physician instructions.

Patients, bent in the middle, may suffer. One in 5 Medicare patients beatific from the hospital to a nursing home backlash aback aural 30 days, generally for potentially preventable altitude such as dehydration, infections and medication errors, federal annal show. Such rehospitalizations action 27 percent added frequently than for the Medicare citizenry at large.

Nursing homes accept been accidentally adored by decades of colliding government acquittal policies, which gave both hospitals and nursing homes banking incentives for the transfers. That has larboard the best accessible patients generally ping-ponging amid institutions, wreaking calamity with patients’ care.

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“There’s this adage in nursing homes, and it’s absolutely unfortunate: ‘When in doubt, abode them out,’” said David Grabowski, a assistant of bloom affliction action at Harvard Medical School. “It’s a short-run, cost-minimizing strategy, but it ends up costing the arrangement and the alone a lot more.”

In contempo years, the government has amorphous to accouterment the problem. In 2013, Medicare began fining hospitals for aerial readmission ante in an attack to abbreviate abortive discharges and to animate hospitals to accredit patients to nursing homes with acceptable clue records.

Starting this October, the government will abode the added ancillary of the equation, giving nursing homes bonuses or penalties based on their Medicare rehospitalization rates. The ambition is to advance aboriginal signs of progress: The amount of potentially accidental readmissions alone to 10.8 percent in 2016 from 12.4 percent in 2011, according to Congress’ Medicare Acquittal Advisory Commission.

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“We’re better, but not well,” Grabowski said. “There’s still a aerial amount of inappropriate readmissions.”

The revolving aperture is an adventitious byproduct of abiding acquittal policies. Medicare pays hospitals a set amount to affliction for a accommodating depending on the boilerplate time it takes to amusement a accommodating with a accustomed diagnosis. That agency that hospitals finer accumulation by beforehand acquittal and lose money by befitting patients longer, alike admitting an aged accommodating may crave a few added days.

But nursing homes accept to hospitalize patients. For one thing, befitting patients out of hospitals requires common examinations and accelerated class tests — all of which add costs to nursing homes.

Plus, best nursing home association are covered by Medicaid, the state-federal diplomacy for the poor that is usually the lowest-paying anatomy of insurance. If a nursing home sends a Medicaid citizen to the hospital, she usually allotment with up to 100 canicule covered by Medicare, which pays more. On top of all that, in some states, Medicaid pays a “bed-hold” fee aback a accommodating is hospitalized.

None of this is acceptable for the patients. Nursing home association generally acknowledgment from the hospital added abashed or with a new infection, said Dr. David Gifford, a chief carnality admiral of affection and authoritative diplomacy at the American Bloom Affliction Association, a nursing home barter group.

“And they never absolutely get aback to normal,” he said.

‘She Looked Like A Wet Washcloth’

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Communication lapses amid physicians and nursing homes is one alternating account of rehospitalizations. Elaine Essa had been demography thyroid medication anytime aback that gland was removed aback she was a teenager. Essa, 82, was active at a nursing home in Lancaster, Calif., in 2013 aback a bender of pneumonia beatific her to the hospital.

When she alternate to the nursing home — now declared Wellsprings Post-Acute Affliction Center — her doctor bare a acute apprenticeship from her acceptance order: to resume the thyroid medication, according to a accusation filed by her family. The nursing home telephoned Essa’s doctor to adjustment the medication, but he never declared them back, the clothing said.

Deborah Ann Favorite holds a photograph of her mother, Elaine Essa. The nursing home and Essa’s primary affliction convenance acclimatized a accusation brought by the family. (Heidi de Marco/KHN)

Without the medication, Essa’s appetence diminished, her weight added and her activity vanished — all break of a thyroid imbalance, said the family’s attorney, Ben Yeroushalmi, discussing the lawsuit. Her doctors from Garrison Ancestors Medical Accumulation never visited her, sending instead their assistant practitioner. He, like the nursing home employees, did not the account of her decline, although her thyroid action was acutely acclaimed in her medical records, the accusation said.

Three months afterwards her acknowledgment from the hospital, “she looked like a wet washcloth. She had no blush in her face,” said Donna Jo Duncan, a daughter, in a deposition. Duncan said she accepted the home’s nurses assay her mother’s claret pressure. Aback they did, a administrator ran over and said, “Call an ambulance appropriate away,” Duncan said in the deposition.

At the hospital, a physician said tests showed “zero” thyroid hormone levels, Deborah Ann Favorite, a daughter, recalled in an interview. She testified in her degradation that the doctor told her, “I can’t accept that this woman is still alive.”

Essa died the aing month. The nursing home and the medical convenance acclimatized the case for arcane amounts. Cynthia Schein, an advocate for the home, beneath to altercate the case above adage it was “settled to everyone’s satisfaction.” The clothing is still advancing adjoin one added doctor, who did not acknowledge to requests for comment.

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Dangers In Discouraging Hospitalization

Out of the nation’s 15,630 nursing homes, one-fifth accelerate 25 percent or added of their patients aback to the hospital, according to a Kaiser Bloom News assay of abstracts on Medicare’s Nursing Home Compare website. On the added end of the spectrum, the fifth of homes with the everyman readmission ante acknowledgment beneath than 17 percent of association to the hospital.

Safely Home Or Aback To The Hospital?

Download the abstracts to see how accomplished nursing homes in the U.S. performed on two metrics of quality.

Many bloom action experts say that advance shows how abundant advance is possible. But accommodating advocates abhorrence the attack adjoin hospitalizing nursing home patients may backfire, abnormally aback Medicare begins bond readmission ante to its payments.

“We’re consistently afraid the bad nursing homes are activity to get the bulletin ‘Don’t accelerate anyone to the hospital,’” said Tony Chicotel, a agents advocate at California Advocates for Nursing Home Reform, a nonprofit based in San Francisco.

Richmond Pines, area Sandra Snipes stayed, has a higher-than-average rehospitalization amount of 25 percent, according to federal records. But the family’s lawyer, Kyle Nutt, said the accusation claimed the nurses initially resisted sending Snipes back, insisting she was “just drowsy.”

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After Snipes was rehospitalized, her claret thinner was discontinued, her hip was reset, and she was absolved to a altered nursing home, according to the family’s lawsuit. But her hospital trips were not over: Aback she showed signs of alternate infection, the additional home beatific her to yet addition hospital, the accusation alleged.

Ultimately, the accusation claimed that doctors removed her prosthetic hip and added than a liter of adulterated claret clots and tissues. Nutt said if Richmond Pines’ nurses had “caught the over-administration of the claret thinner appropriate off the bat, we don’t anticipate any of this would accept happened.”

Snipes alternate home but was never able to airing again, according to the lawsuit. Her husband, William, cared for her until she died in 2015, her daughter, Clark, said.

“She didn’t appetite to go aback into the nursing home,” Clark said. “She was terrified.”

KHN’s advantage of these capacity is accurate by John A. Hartford Foundation, Gordon and Betty Moore Foundation and The SCAN Foundation

Jordan Rau: [email protected], @JordanRau

Heidi de Marco: [email protected], @Heidi_deMarco

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