Holly Hill Nursing Home Administrator Sally Schutte takes her job personally.
Now, she knows how it feels to be caught between a rock and a hard place, between the Devil and the deep blue sea. In fact, she is caught between her commitment to give excellent health care to residents of Holly Hill Health Care & Rehabilitation Center, 501 S. Murphy Ave., and paperwork that didn't accurately reflect the quality of care given at the home.
It is the paperwork that resulted in Holly Hill's recent $5,250 fine.
A news release from the Indiana State Department of Health said, "The fine is based on the findings of a survey that was completed -- on Sept. 22, 2003.
"The survey said that the facility failed to ensure that five of five residents reviewed had their care plans updated to ensure implementation of adequate supervision and assistive devices to prevent accidents."
A later survey, on Oct. 31, showed the issues cited in the Sept. 23 survey had been corrected. But, unless the department's ruling is overturned, the fine will have to be paid and Holly Hill will get a black eye in the process.
Schutte realizes the state health department personnel are doing their jobs and it is important that nursing homes give excellent care to those in their charge.
"We're trying to do our best," Schutte said Wednesday. "We are conscientious.
"The sign out front says 'Holly Hill', but I think of it as Sally's Place. Every day, I ask myself, how can we improve?"
One reason Holly Hill and many other homes have been investigated in the past is due to the large number of requirements they must meet without exception.
There are 203 pages of federal regulations and 136 pages of state rules. If one rule or regulation is broken, the nursing home may be fined or greater action may be taken. Nursing home administrators must be licensed and nursing homes may be closed, if inspectors find infractions to be too great. Administrators may be held responsible.
"It has been said we are more heavily regulated than nuclear energy," Schutte said. "That is not a joke."
Schutte uses the last annual inspection as an example her facility is giving high quality care. At each annual survey, inspectors spend 7-10 days examining each facility. At Holly Hill's last inspection, two tags (regulations) were found to be out of compliance: Schutte had failed to issue "two pieces of paper to residents we discharged. That was all," she said.
In the case of a complaint filed before the Sept. 22 sur vey, Holly Hill was fined due to incomplete paperwork. Care plans had not been updated to ensure five residents who had fallen would not fall again.
A fall does not have to result in injury, Schutte said. A fall occurs when a resident may slide to the floor, roll out of bed or lose their footing.
Holly Hill takes various measures to assure safety, even though inspectors found care plans did not reflect that adequate steps had been taken.
The home has low beds, just inches above the floor, with medical mattresses on either side. These are for residents who may try to climb over the bedrails on traditional nursing home beds. Holly Hill also has personal alarms that are triggered if a wheelchair-bound resident leans too far forward and is in danger of falling. Pad alarms are also used for residents who may try to get out of a wheelchair without proper supervision. Padded clothing is often provided residents with Huntington's Disease. Those residents may be able to walk, but the disease causes unexpected movements that may cause residents to fall.
Since 1987, nursing homes have been prevented from using any type of restraints on residents, because restraints interfere with a patient's rights and personal dignity, Schutte said.
"Where I'm coming from as an administrator is, how do you -- with respect to residents' rights and dignity -- keep an independent resident safe? We do not want residents to fall."
One scenario regularly causes problems for nursing homes: A resident is liable to fall, but refuses to let a nursing home employee stay in the rest room while they use the toilet.
An aide or nurse tells the resident, "OK, I'll wait outside. Let me know if you think you will need help."
Many times, the resident performs the act without assistance, sometimes they become unsteady and fall.
It becomes an issue of safety or dignity, in Schutte's mind.
"This is one of their last areas of control in life -- whether or not they want someone in the bathroom with them," she said. The law states the nursing home must preserve both a patient's dignity and their safety, but the two may be mutually exclusive.
Holly Hill's recent fine was for breach of Federal Regulation 324: "Each resident receives adequate supervision and assistance devices to prevent accidents." Yet a 1987 law (mentioned above) prevents nursing homes from using restraints because restraints violate a patient's rights.
"I just want to know how we can adequately protect residents and not violate their rights and dignity?" Schutte asked.
Schutte instructs her staff to cooperate when alert residents use the bathroom by themselves, refuse help, even if they risk falling.
The State had no problem with the number of staff members or the quality of care given at the Brazil facility. Holly Hill was fined because care plans were not adequately updated.
When a person is admitted to a nursing home in Indiana, an assessment of their condition is made, care plans are established for the person and follow-up assessments are made to assure the care plans meet the resident's needs. Weekly meetings are conducted to assess each resident.
Patient falls led inspectors to discover the inadequate paperwork.
Holly Hill has since changed its procedures. Now, when a resident falls, care plans are immediately reviewed to be sure adequate measures are being taken to avoid another fall.
Despite the fine, which Holly Hill is fighting, Schutte believes care is more important than paperwork.
"I'll take a hit on paperwork any day, if we're doing our job, because paperwork does not always reflect performance," she said. "I hope other facilities learn from our experience and do their paperwork."
The recent fine and subsequent reports in various news media have not affected Holly Hill's reputation among its residents. No one has left the home because of the reports and a few former residents have since asked if they can return to Holly Hill.
Although the building was designed for a capacity of 103 residents, the home has asked the State to reduce the number to 62.
"I feel that leads to a more cozy home environment," Schutte said in her office at the nursing home she likes to think of as Sally's Place.