Better Than A Nursing Home?

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Underlying the problems is the very freedom from regulation that makes assisted living so attractive. This has allowed operators to cater to the aesthetic desires of their customers--to sport plush carpeting where nursing homes have only linoleum--and still keep costs down. The average nursing home, funded largely by Medicaid, costs nearly $4,000 a month. The average assisted-living facility, where residents typically pay out of their own pocket, costs about $1,800 a month. Disparities in regulation, though, leave seniors vulnerable to huge variations in everything from the quality of food to the number of registered nurses available. Most assisted-living centers do not even have a full-time nurse on staff; nursing homes of comparable size have four or five, which is the major reason they cost so much. Yet studies show that nationwide, on average, people in assisted living actually receive more medication than do patients in nursing homes. They may not be sicker, but they still need plenty of attention.

It has taken a series of tragedies for public officials to begin to notice. In California regulators moved to revoke the licenses of nine facilities run by Regent Assisted Living Inc. after Lucille Giroux, 79, bled to death in her rocking chair at Sunnyside Court in Fremont. According to the state's investigation, she twice pressed her call button and no one came; Regent says no call for help was made. In Falls Church, Va., a 93-year-old woman was killed in May when, after she fell down outside, her facility's van ran over her. Lawmakers in Virginia are re-evaluating the state's regulations.

The industry's problems are partly a case of growing too big too fast. Assisted living first became popular in the late 1980s, but it wasn't until the mid-'90s--when assisted-living companies went public--that the industry exploded. Wall Street investors, eyeing the impending retirement of millions of baby boomers (the number of elderly needing long-term care is expected to double over the next 20 years, to 14 million), fell all over themselves trying to catch a piece of the boom.

By the summer of 1998, Alterra was opening a facility every three days, quickly becoming the largest U.S. assisted-living provider. The memory-care center in Eagan, a fast-growing suburb of St. Paul, Minn., opened that August; in 10 months it filled its 52 beds. Glossy brochures promised "peace of mind, for you and your loved one." Families said they were told there would be a 1-to-7 ratio of staff to residents. But the primary caregivers, who were often paid less than $9 an hour, didn't just have their seven or so residents to care for; they also had to clean the hallways and bathrooms, set and clear the tables at mealtime and do laundry. The company says it takes pride in having its staff provide such "holistic" care. Nonetheless, turnover was high, and since training was spread out over six months, some caregivers never received key lessons in patient transfer and behavioral control. "I had so little time for my residents," says Laura Schad, 50, who quit her job as a resident assistant at the Eagan center after a year. "I was passing out 25 medications a day. I had very little training. It was dangerous."

Early in the evening of Jan. 1, 2000, a nearby hospital telephoned the Eagan center to inquire about a resident brought in earlier that day; no one answered the phone. The hospital called the police, who had become accustomed to dealing with the Eagan center. (According to police records, aides there had called for emergency assistance 58 times in the previous year, sometimes for simple patient-care issues.) An officer was sent to the facility, where an aide who spoke almost no English answered the door. She said she was a cook and had not been taught how to use the phone. The officer found just two other staff members, neither of whom spoke English well. Alterra maintains that eight resident assistants were on duty that evening.

That incident, along with complaints by Levang and other residents' families, prompted Minnesota attorney general Mike Hatch to sue Alterra for consumer fraud. The suit was settled, with Alterra agreeing to pay for an outside monitor. The center hired more staff, including a housekeeper, and modified its brochure, replacing the phrase "professionally trained" staff with "trained" staff. But for many of its other Minnesota facilities, Alterra insists having staff provide "holistic" care is effective.

"We could have done a better job," says Alterra president Steven Vick about what happened at the Eagan center. He says such problems are rare. "These events are disappointing, but we work every single day to correct them." Karen Wayne, president of the Assisted Living Federation of America, one of the industry's main trade groups, says problems such as those at the Eagan center have been exaggerated. "When you look at the number of people we serve," she says, "these are isolated accidents and tragic events."