New scrutiny being focused on adult-family-home deaths

A Seattle police detective has started investigating most deaths in the city's adult family homes to rule out possible cases of abuse or neglect.

The King County medical examiner and prosecuting attorney are collaborating on the sensitive new initiative, which has the support of the state's long-term-care ombudsman. But it has also sparked concerns and questions among some care providers, families, doctors and regulators.

Because of limited resources, the effort is focusing only on adult-family homes, which can care for as many as six people, in Seattle. Compared with nursing homes, these smaller facilities have fewer employees and typically are more isolated from public scrutiny.

The effort is part of an evolving mission to combat crime against elderly and vulnerable people and to help assure they receive proper care. The project also gives experts more experience in determining what is a natural death in an aging adult and what isn't.

"The aging population is increasing," said Dr. Richard Harruff, King County's chief medical examiner. "The economic burden is increasing. The questions about adequacy of care are increasing."

After Detective Suzanne Moore gets a call from the Medical Examiner's Office that a death has occurred, she goes to the adult-family home, observes the cleanliness of the surroundings and condition of the body: skin, hair, teeth and nails.

She examines a care plan that's supposed to document treatment of conditions such as bed sores, which can be deadly. If she has questions or doubts, she calls in a medical examiner, who decides whether to take jurisdiction over the body.

So far, a handful of such cases have not been resolved. None has been referred to the prosecutor.

"It's the type of death we probably haven't looked at as closely over the years," said Capt. Tag Gleason, supervisor of the police department's violent-crimes section.

"As we start to look at these situations, we find people whose neglect has been criminal. We find people triple-wrapped in diapers, people with impacted bowels, food impacted in their teeth, abscesses that go to the bone."

The focus on adult-family homes, which began in May — doesn't mean that such facilities are bad or that crimes have been committed. The majority provide good care, say state inspectors and police. There are more than 2,000 across the state and about 200 in Seattle.

"I have found that everything is fine until a complicated event happens," say, when a resident's health declines rapidly because of an unrecognized injury, Moore said. "Then the caretaker may not have the training on how to address the issue."

Moore also responds to reports about crimes in nursing homes and assisted-living facilities. For the first time, police are using search warrants in some cases to obtain documents from facilities to review the history of a resident's care.

"It's exhausting. It's beyond anything I've ever had," said Moore, a 22-year veteran of the police force,

Touchy topic

Not only is the work complex legally, it's emotionally and politically sensitive.

Families may think their privacy has been invaded. Home operators may fear police intrusion. Rumors and questions about what's going on have circulated among some providers, hospice services and state regulators.

In response, the prosecutor's office last month invited about 40 people from agencies and the long-term-care industry to a meeting.

Doctors questioned the investigative process. State regulators — who say it's always been their goal to work with law enforcement — thought it wasn't good for police to remove original documents about a deceased resident without leaving a copy. They said that thwarted the regulators' job of conducting routine inspections and investigating complaints.

While it's up to the state to see that facilities follow regulations, keep residents safe and respect their rights, the state doesn't determine if crimes have been committed.

Some found the meeting helpful. But at least one hospice director worried that adult-family homes may no longer want to provide end-of-life care if it means a police investigation. And nursing homes don't have enough room to handle an overflow of dying people, he said.

"We're not really foes in this. We want to collaborate," said David Bucher, director of Providence Hospice of Seattle, the largest provider of hospice care in the state. Still, Bucher hopes "it won't be necessary in the future to investigate every single death in an adult-family home."

Aaron Mountain, president of the state's largest adult-family-home association, supports getting rid of abuse and neglect but asked, "Why are we looking only at adult family homes?"

The state long-term-care ombudsman, Kary Hyre, wants the investigations extended to long-term-care facilities statewide. The ombudsman has asked lawmakers for nearly $500,000 to recruit and train 100 volunteers to work as resident advocates in adult family homes.

What's happening here is under way in a few other places.

In 1999, Arkansas was the first state to require all nursing homes to report deaths to the county coroner, who then decides how aggressively to pursue the reports.

In Little Rock, the Pulaski County coroner conducts a physical examination of every death in a nursing home. He credits a decrease in suspicious deaths to the presence of medical investigators.

"The most important link is the front-line investigator," said the coroner, Mark Malcolm. "You can't ask the facility to provide information over the phone that will determine whether you will go examine the body."

Tweaking procedures

Washington requires that the deaths of long-term-care residents be reported to the medical examiner if the person died without medical attendance in the preceding 36 hours.

The high volume of such deaths prevents the medical examiner from investigating every case at the scene. So the medical examiner commonly takes the word of the person calling in a death that it was due to natural causes.

As a safeguard, the state also designates certain individuals — such as nurses, staff and hospice workers — as so-called mandatory reporters who must alert officials to abuse and neglect. Mostly it's up to them and families to report concerns.

But families often don't know where to turn, said Harruff, the medical examiner. He soon will push to tighten procedures that go beyond making a phone call for reporting deaths in long-term care. He wants information about the essential features of a person's disease progression, the treatments given, cause of death, surrounding environmental conditions and date a doctor last examined the patient.

While Moore's job is to help detect suspicious cases, proving a death was caused by abuse or neglect is extremely difficult.

The medical examiner can determine cause of death. But questions also need to be asked about the context of that death. For example, did workers make appropriate decisions about the resident's care?

Families also have a responsibility for their loved one's quality of life in a facility. They have the right to ask questions and should not simply assume all is OK, experts said.

"Check the care yourself," Moore advised. "Pull the covers down and look."