By Marjie Lundstrom
So many newspaper stories today are rooted in data. They spring up from Excel spreadsheets and fancy mapping software, bearing all kinds of exotic fruit.
My nursing home series for The Sacramento Bee about the falsification of patient records began the old-fashioned way: from the seedling of a good idea, planted by a trusted source.
What grew from there was an intriguing examination of a narrow aspect of nursing home care that has gotten little public attention. The common term for it is “charting.”
The source, a former prosecutor turned private litigator, told me he was appalled by the prevalence of false charting in the nursing home industry.
And not just Medicare fraud. He and other attorneys who specialize in elder abuse were seeing a growing pattern of false record-keeping and blatant cover-ups that went right to the heart of patient care, he said.
Unfortunately, he explained, the state of California and local district attorneys lacked the resources or incentive to pursue these cases.
Gee-whiz, I thought. And, with that, I knew my reaction to the idea passed the time-honored journalistic litmus test. If it’s new and interesting to me, it’s probably new and interesting to readers – especially the many facing the prospect of long-term care.
How, then, to report this story?
GETTING STARTED
Despite the temptation to grab for data, seeking some regulatory trend, I went fishing first for patient stories. This, more than data, seemed to speak to the most important question of all: What does phony paperwork have to do with quality of patient care?
As it turned out, the answer is plenty. (See accompanying series: part one | part two.)
Finding patient stories was easier than anticipated.
In California, of course, it is unrealistic to try and paw through the civil filings in 58 counties and hope to find a lawsuit that mentions nursing-home records falsification.
But a quick call to Michael Connors of the San Francisco-based California Advocates for Nursing Home Reform resulted in a partial solution. The nonprofit group has an extensive electronic discussion list; many of its subscribers are attorneys specializing in nursing home litigation.
Connors posted a note to subscribers, explaining that The Bee was examining records-falsification in California nursing homes and needed examples.
Within a week, examples were pouring into my email from trial attorneys, who backed their claims with documentation – and, often, the medical records themselves.
CANHR also was able to supply vital statewide data that the California Department of Public Health collected over the years but had long since purged. The group routinely downloaded state data on licensing violations, including “Willful Material Falsification” (WMF), or doctoring records. Each citation was accompanied by a narrative, which briefly outlined the details of the case.
While some reporters are reluctant to use any material from advocacy groups, the CANHR data was straight from a public source – only more comprehensive, because of state-imposed limitations.
Using the group’s short, written summaries of WMF citations, I was able to assess trends.
I also was able to ask the state Department of Public Health for specific files that interested me. The department responded quickly to my numerous requests for WMF citations.
Be sure not to limit your request. In California, for instance, both the citation and the facility’s plan of correction are public information. Both documents are full of great detail.
DETECTING PATTERNS
Armed with details and accounts from lawsuits – which are privileged and fair game – as well as statewide data and actual citations, the story began to take shape.
Most trial lawyers readily agreed to put me in touch with patients and/or family members. I also talked with licensing inspectors, criminal investigators and nursing home workers.
Patterns quickly emerged in the falsification cases. The most common themes included:
- Covering up bad outcomes, or altering records to minimize blame and legal liability.
- Filling out charts en masse, out of laziness or necessity because of under-staffing.
- Improperly dispensing medications, actions that were uncovered when charts fail to correspond with pharmacy records.
- Medicare fraud, in which therapists continue billing high-priced therapy for patients too ill to participate.
Finding the patterns linked the falsification issue directly to patient care. In some instances, vulnerable nursing home residents died because their medical charts failed to reflect their true conditions.
DRILLING DOWN
This story still needed a more human touch.
Representatives of the nursing home industry challenged the notion that paperwork fraud ever hurt anybody. Instead, they presented a David-and-Goliath scenario – with the industry as the “little guy.”
As they see it, today’s regulatory and paperwork burdens have become so onerous for nursing homes that mistakes are inevitable.
“The reality is, mistakes are going to happen when you have that much documentation you have to do,” said one attorney who frequently defends nursing homes.
“The bottom line is – and should be – was appropriate care given?”
Sadly, in many instances, the answer is no, The Bee found.
We decided to drill into one case, in which a 77-year-old woman died after a short stay in a nursing home. In a lawsuit which settled in their favor, the family had accused the facility of falsifying, altering and improperly handling the woman’s medical chart as far back as the day of her admission.
Because the case settlement didn’t include a confidentiality clause, we were able to plow through hundreds of pages of court filings, medical charts, autopsy findings, photographs, videotaped depositions – material easily transferred to a flash drive.
This paperwork became the foundation for a close-up examination in how “just paperwork” profoundly affected the life of Johnnie Esco and her devoted, surviving family members.
TIPS AND TRAPS
The story was not without setbacks.
For one thing, I picked the story up and put it down so many times over the course of two years that I had to re-report it seven or eight times. The civil cases were moving targets and, with the passage of time, the story was constantly changing under my keyboard.
In the end, I lost a couple of good examples because the cases settled – with confidentiality agreements.
When juggling numerous legal cases, better to attempt it in one solid stretch.
Other lessons:
- Learn the language of the industry. As in child welfare, long-term care is an alphabet soup of acronyms. Be sure to bone up and don’t look confused when you hear the word “sniff” (translation: SNF, or skilled nursing facility). Most public health websites have basic primers.
- Don’t be afraid to use the resources of reputable nonprofits, whose contacts and electronic discussion lists can help you make vital links.
- Data is powerful, but so are accumulated personal stories – especially because they can describe a condition or circumstance previously unknown. While we were unable to quantify the magnitude of the falsification problem, the fact that it existed in facilities up and down the state was important consumer information.
- Don’t let the lack of data deter you. In this story, cases reported to the state were down, suggesting at first blush that the incidence also was down. Based on numerous interviews, we believe it merely reflected waning enforcement. You just have to use some common sense and dig deeper.
- Hard evidence can be gathered in different ways, especially in court documents, which, again, are privileged. For example, I was able to get documents actually showing the false charting – blatant overwrites and scribbled out entries with no explanation. Other examples were more subtle, but equally harmful to vulnerable patients.
- Look for a slice within a broad topic. This series was never about “the nursing home industry.” It was about falsification of records, period, and keeping to that theme prevented the story from straying into an unwieldy and unfocused mega-series.
Marjie Lundstrom is a reporter at The Sacramento Bee. She won a Pulitzer Prize for National Reporting in 1991, with Rochelle Sharpe, for reporting hundreds of child abuse-related deaths go undetected each year as a result of errors by medical examiners. Lundstrom can be reached at mlundstrom@sacbee.com.
