Messenger House Care Center was fined $9,000 this week by the Washington State Department of Social and Health Services, for violating state and federal care standards.

The state’s unannounced inspection in January of the island nursing home – a 90-bed facility licensed and operated by Seattle-based Soundcare Inc., and serving Medicare, Medicaid and private residents – resulted in seven citations, for “deficiencies related to the use of chemical and physical restraints, to prevention of abuse and to quality of care.”

Three violations were termed “immediate jeopardy,” for infractions that indicate residents have suffered harm or are at a high risk for harm.

The report pointed to medically unwarranted use of restraints, such as bed rails and back-release seat belts; restraints employed without the consideration of less restrictive means, as required by law; and instances of bed rails pulled upright without without explanation of the risks, or a consent form signed by a resident’s legal representative

The DSHS report noted one instance in which side rails remained in an upright position even after a resident had become entangled, a situation that carries the risk of injury or death. According to the DSHS report:

“After the facility had knowledge of the resident’s attempts to get around the restraint and after the resident was entrapped in the restraint, they failed to recognize that a least restrictive approach should be attempted as the side rail was not keeping the resident ‘safe.’ They continued to use the side rail restraint and added a wheelchair to the end of the bed as an obstacle to restrain the resident.”

The report also found unchecked aggressive behavior by some residents in an Alzheimer’s unit; residents seated near a steam radiator with a cracked valve; residents with access to unsecured toxic cleaning agents; and one resident found sleeping in her own urine, left there by a nurse and a nursing assistant.

The DSHS fine was levied at the maximum level set by law for such infractions.

“It’s unusual for a nursing home to be cited on an ‘immediate jeopardy’ level,” said Elaine Odom, DSHS regional administrator for Pierce and Kitsap counties. “It’s something we don’t do on a regular basis. We have to see that residents are at high risk from harm.”

Scott Churchill, administrator at Messenger House since November 2000, said managers and staff at the facility have been aggressive in addressing the problems identified by the state.

“We have worked very hard as a team to correct all the deficiencies we received in our 2002 survey,” Churchill said. “We feel that we have corrected all those deficiencies, and we have an improved quality assurance program to ensure continued compliance with all state regulations.”

As a result of the report, caregivers released five patients from bed rail or seat-belt restraints.

DSHS officials confirmed that Messenger House corrected the other deficiencies within a week of notification.

“What we hope is that facilities will correct (problems),” said Linda Ronco, state enforcement officer for nursing home standards.

“We want them to hear what the law is saying. We felt that they did by the actions they took.”

State law allows DSHS to impose fines of up to $3,000 for each unmet requirement. Also, the agency’s statement of deficiencies and the nursing home’s plan of correction are made available for public review.

Defined as “nursing homes” by the 24-hour nursing care offered there, such facilities are inspected yearly by a team of nurses and environmental specialists.

Before a physical inspection, the team reviews results from previous year’s surveys; looks for patterns of complaints; considers comments from a cadre of volunteers who advocate for residents under a regional ombudsman; and reviews a facility’s mandated self-reporting.

At Messenger House, the inspection team interviewed staff and spoke to residents singly and in a group, conferred with residents’ family members and observed residents’ daily activities.

“We look at ‘dignity’ issues and ‘resident rights’ issues, as well as ‘quality-of-care’ issues,” Ronco said.

The DSHS announcement coincided with, but was independent from, publication of findings from a pilot survey of nursing home conditions in six states, including Washington.

The study was undertaken by the federal Centers for Medicare and Medicaid Services. Messenger House and another Bainbridge facility, Island Health and Rehabilitation Center, were included in the survey.

The project was aimed at better informing potential nursing home care consumers, and to improving delivery of services.

Nursing homes were evaluated for the percentage of such “red flag” indicators as patient pain, delirium, infection, weight loss and bed sores.

Both Messenger House and Island Health and Rehabilitation compared favorably in most categories to the averaged results of other Washington facilities.

Both were higher in terms of the number of patients in physical restraints, although Churchill said Messenger House has since eliminated the use of restraints.

But the results have generated controversy among health care professionals, including Brian Tappia, Island Health and Rehabilitation Center interim director and regional director of operations for Wisconsin-based Extended Care, IHR’s parent company. The outfit manages 217 homes nationwide.

Tappia says comparisons among nursing homes are more complex than the survey suggests, because different services are delivered to different populations.

Island Health, for example, has a higher percentage of residents receiving “intensive therapy” geared toward rehabilitation, while Messenger House has an Alzheimer’s unit that houses long-term residents with diminished cognitive capacity.

A scholar and author in the field agreed with their assessments.

“Many long-term care professionals are quite critical of the new ‘quality indicators’ because they may be more confusing than elucidating,” said Jeannette Franks, University of Washington School of Social Work professor and author of “Washington Retirement Options: The Statewide Guide to Independent and Assisted living Communities.”

“It is extremely challenging to provide good care in nursing homes today,” Franks said, “because of the financial constraints, regulatory climate, employment issues, and lack of understanding of – or unwillingness to deal with – issues relating to the frail elderly such as appropriate end-of-life care.”

Tappia says that managing nursing home facilities has become more difficult over the last five years, with many homes forced out of business by the cost or unavailability of insurance. But the job can still be done well.

“Running nursing homes is not rocket science,” Tappia said. “You have to have people who care – and good systems in place.”