Vulnerable residents sometimes in dangerous living situations
By David Jackson and Gary Marx
An elderly woman is raped in her room, and police arrest a 21-year-old ex-convict with acute psychiatric problems. When the victim is interviewed by investigators five days later, she shakes with fear.
A frail man blind in one eye is slashed in the throat by a gang member, police say. About a year earlier, the same assailant allegedly had stabbed him in the face with an ice pick.
A man in a wheelchair dies of head injuries so severe that his doctor says it looked like he was hit with a baseball bat. One of the suspects is a 24-year-old mentally ill woman with a history of drug use and prostitution.
These incidents didn't happen on a street corner, in an alley or inside a drug house.
They all took place inside Illinois nursing homes in the last 17 months, highlighting a new, volatile environment in some facilities where the elderly and sick expect a measure of care and peace.
More than any other state, Illinois relies heavily on nursing homes to house mentally ill patients, including those who have committed crimes. But a Tribune investigation found that government, law enforcement and the industry have failed to adequately manage the resulting influx of younger residents who shuttle into nursing facilities from jail cells, shelters and psychiatric wards.
Mentally ill patients now constitute more than 15 percent of the state's total nursing home population of 92,225, government records show, and the number of residents convicted of serious felonies has increased to 3,000. Among them are 82 convicted murderers, 179 sex offenders and 185 armed robbers.
Yet the state's background checks on new residents are riddled with errors and omissions that understate their criminal records, the Tribune found, and homes with the most felons are among those with the lowest nursing staff levels.
Meanwhile, state authorities don't track assaults and other crimes in nursing homes, making it difficult to uncover patterns and address the problems caused by unstable individuals.
Nursing home operators say the number of violent incidents is minuscule considering the millions of hours of care they provide annually to a sometimes difficult population. The homes, they say, offer a vital public service by taking in destitute people when no one else can or will. And they describe themselves as besieged by plaintiffs' attorneys, government inspectors and journalists.
But even Illinois' largest nursing home owners' association, the Health Care Council of Illinois, told the Tribune it was concerned about the practice of mingling mentally ill criminals with traditional, geriatric residents. The council advocates creating separate, specialized facilities that would provide mental health treatment to high-risk patients with felony convictions. State public health officials also said they would support a separate licensing and regulatory process for nursing facilities that serve psychiatric patients.
Those most affected are, by and large, those most easily forgotten by society. Many of the psychiatric patients are clustered in a relatively small subset of nursing facilities whose impoverished residents have few other options.
One of those residents was Ivory Jackson, a 77-year-old retired laborer who had been rendered helpless by a stroke. At All Faith Pavilion on Chicago's South Side last year, Jackson was placed in the same room with Solomon Owasanoye, a 50-year-old Nigerian immigrant who suffered fits of delirium after a brain aneurysm and had "a history of negative, aggressive, acting-out behavior," according to a state public health investigative report.
Owasanoye screamed and kicked doors during "periods of altered mental status," but the home's only actions were walking him outside to calm him down and continuing with psychological evaluations, state investigators found.
One morning in May 2008, Owasanoye beat Jackson in the head with a clock radio while the older man slept. Jackson died of brain injuries about three weeks later, according to a police report. Owasanoye is now in a state psychiatric center after being declared mentally unfit to be tried on first-degree murder charges, according to court records and interviews.
All Faith's owners and administrator declined to comment but, in contesting a lawsuit filed by Jackson's family, denied negligence.
Jackson's stepson, Russell Smith, said he visited All Faith to learn more about his stepfather's death and came away outraged. "What struck me was their matter-of-fact attitude: Like, you know, things happen, and get over it," Smith said.
He asked: "Why would you put this guy in the room with my dad?"
New day, new waysFor much of the last century, American nursing homes fulfilled one central mission: providing long-term custodial care to seniors. But the landscape at the homes is shifting, particularly in Illinois.
America's elderly population is growing, but those who can afford it increasingly choose home health care or assisted-living options instead of traditional nursing homes. Mirroring other states, Illinois' nursing home population has dropped 11 percent in the last decade.
At the same time, the nation's decades-long drive to "deinstitutionalize" mentally ill people had the consequence of discharging psychiatric patients from state-run asylums into taxpayer-subsidized nursing homes, which can admit disabled adults of all ages. These patients typically are referred to Illinois homes by doctors and discharge planners at hospitals, mental health centers, homeless shelters and probation departments.
The facilities had a financial motive for accepting them, suggested Richard Dees, chief of the state public health department's Bureau of Long-term Care. When "the number of seniors going into nursing homes began to decline, there were facilities with empty beds," Dees said.
Last year more than 15 percent of Illinois' nursing home residents had a primary diagnosis of mental illness -- a category that does not include age-related dementia or Alzheimer's disease. The number of these patients rose from 11,808 in 1998 to 14,258.
Federal statistics show Illinois ranked first last year in the percentage of nursing home residents with schizophrenia and bipolar disorder -- two of the most disabling psychiatric illnesses. In Illinois, two-thirds of those schizophrenic and bipolar residents were younger than 65, compared with one-third in all other states.
"Illinois is really unique in its blurring of long-term care and mental health resources," said Harvard Medical School associate professor David Grabowski, who studies nursing home populations. "Many of these patients were not appropriate for placement in a nursing home -- yet Illinois didn't have an alternative place for them."
Experts point out that mentally ill people, when receiving adequate treatment through medication or therapy, are no more likely than others to be dangerous. But several national studies question whether they receive meaningful psychiatric care in nursing facilities.
A pending class-action lawsuit, brought by the Bazelon Center for Mental Health Law and the American Civil Liberties Union, describes some Illinois homes as filthy, frightening holding pens where "groggy" residents watch TV in crowded, noisy common areas or are directed over loudspeakers to wait for medication and meals in long lines.
The growing population of mentally ill nursing home residents overlaps with another group: convicted felons younger than 65, who can be placed in government-supported nursing homes if they have a psychiatric disorder or physical disability.
As of June, the state had identified 3,000 criminals in Illinois nursing homes who had been convicted of felonies including rape, murder and aggravated assault, health department records show. Three years ago, state authorities noted 812 such "identified offenders."
Better screening likely accounts for part of the increase, but from February to June, long after the screening process was well-established, the number of felons in nursing homes increased by nearly 10 percent.
Terry Sullivan, regulatory coordinator for the Health Care Council of Illinois, suggested the numbers are rising because state budget cuts make it less likely that people with mental illness get treatment at clinics and hospitals. Instead some are landing in jails after committing crimes. Once released from custody, "they're going to nursing homes because there's nothing else out there," Sullivan said.
These mentally ill criminals are not spread evenly through Illinois' 1,129 nursing homes. Nine out of 10 facilities house five or fewer felons, a Tribune analysis of health department data found. And some 800 facilities -- about 70 percent of the state's nursing homes -- have none.
Just 50 nursing homes in Illinois house more than half of the 3,000 offenders, according to the Tribune's analysis. In Chicago, many of those homes are clustered in a few ZIP codes in Uptown and on the South Side.
Because of poor tracking by the state, it is impossible to tally the violence taking place at nursing homes. But a Tribune analysis of preliminary Chicago police data -- which do not always specify whether the alleged offenders and victims were residents, staff or visitors -- gives a clue.
Those police reports show that since March 2008, police reported 511 cases of assault or battery, 27 cases of criminal sexual assault and 24 narcotics violations in city nursing homes. Nursing home operators asked about these figures said many of the allegations are petty or unfounded.
Safety breakdownsCritics have long said that the haphazard blending of psychiatric patients and seniors in some Illinois nursing homes serves neither population.
The Tribune in 1998 published a series, "Warehousing the Mentally Ill in Nursing Homes," that documented the violence erupting after mental patients were dumped into ill-prepared nursing facilities. More than a decade later, the problem has grown.
Breakdowns at every level put vulnerable residents at risk, reporters found in an examination of recent police files, state inspection reports and other public documents.
For instance, the 50 homes accepting the most criminals typically have the lowest staff levels, even though experts call intensive staffing a critical factor in protecting the vulnerable, a Tribune analysis of federal and state data shows.
Federal reports released in July rated 36 of these 50 homes "much below average" or "below average" for overall nursing staff hours. Two were average; 12 had not yet been rated. None was above average.
"I don't think the problem is with the laws as written -- the major problem is adequate staffing to implement the laws," said Southern Illinois University School of Medicine professor Marshall Kapp, who has studied nursing home safety.
Illinois' Medicaid program pays nursing homes an average of $117 per day to care for patients -- less than almost any other state, according to the health care council. The low rate means facilities struggle to offer competitive wages to aides and nurses, which can lead to high staff turnover.
The Illinois Department of Public Health is responsible for inspecting homes and ensuring that residents live in a safe environment. But state authorities cannot say how many injuries and attacks occur at nursing homes each year and how many involve identified offenders.
The Tribune documented instances in which nursing homes failed to report attacks to the state health department as required by law. At the same time, state inspectors do not compile incident reports in a central location. And because the health department's computerized case-tracking software is antiquated and ineffective, department officials have difficulty assembling and analyzing the facility reports to uncover patterns of attacks at unsafe homes, the Tribune found.
Even the health department fines meant to deter safety and care violations amount to a relatively minor cost of business. For example, an alleged rape at Elgin's Maplewood Care in January resulted in a $20,000 fine, but that home listed 2008 revenues of $7.7 million and profits of $624,000 in cost reports filed with the Illinois Department of Healthcare and Family Services. State authorities say they are appealing a recent court ruling that limits their ability to impose heftier fines.
The limited state oversight extends beyond the public health department. The Illinois State Police helps root out and prosecute abuse at nursing homes, but the department says it has only four officers assigned to nursing homes in the Chicago area, where tens of thousands of patients live.
Meanwhile, health department inspectors are not required to seek out reports from local police, and those departments generally do not forward their records to the state authorities.
One facility cited in Chicago police data is Rainbow Beach Care Center, a brick building in the 7300 block of South Exchange Avenue. Facility administrators and owners declined interview requests.
State records from June show Rainbow Beach's roughly 200 residents included 24 felons. Chicago police list 12 battery or assault reports there since March 2008, and three arrests for narcotics possession. In July police arrested a 34-year-old resident with a history of prostitution convictions who had six packets of crack cocaine stuffed into her shoes and pants.
Dwayne Andre Cypress, 38, worked as a Rainbow Beach security guard for nine months before leaving this year because, he said, state authorities objected to a years-old criminal conviction on his record.
"I've been thrown into walls, been rassled, snagged with a knife," Cypress said of his time at Rainbow. "It was like working in a penitentiary almost."
Tribune reporters Joe Germuska and Darnell Little contributed to this report.