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    Secret VA nursing-home ratings hid poor quality care from public

    11veterans -- Nick Bonanno pushes his father, Russ Bonanno, down the hallway at the VA in Bedford. Nick visits his father several times a week to push him around the building in his wheelchair along with throwing a ball around. Nick tries to engage his dad as much as possible when he comes to visit. (Kelsey Cronin)
    Kelsey Cronin
    Nick Bonanno pushed his father, Russ Bonanno, down the hallway at the VA in Bedford.

    World War II veteran Rosario “Russ” Bonanno was facing worsening dementia when his family took him last year to the Department of Veterans Affairs nursing home in Bedford. He had been in assisted living, but after six years, some family members thought he needed more specialized care.

    Within days after Bonanno arrived, his son Nick said the 94-year-old was “dazed, confused, disheveled” as staff began medicating him. And he wasn’t the only resident who looked drugged. “Everyone looks like a zombie,” Nick said.

    What Nick and his family didn’t know was that the Bedford facility ranked among the worst of 133 VA nursing homes across the country, in part for giving so many residents antipsychotic drugs.

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    But the VA knew.

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    The agency has tracked detailed quality statistics on its nursing homes for years but has kept them from public view, depriving veterans of potentially crucial health care information. Nearly half of VA nursing homes nationwide — 60 — received the agency’s lowest ranking of one out of five stars as of Dec. 31, 2017, according to documents obtained by USA Today and The Boston Globe.

    The VA finally made some of its ratings public last week after receiving questions from the Globe and USA Today about all the secrecy. VA officials claimed that President Trump wanted to release the ratings all along and blamed the Obama administration for not making them public earlier.

    Statistics the VA has not released paint a picture of government nursing homes that scored worse on average than their private sector counterparts on nine of 11 key indicators last year, including rates of antipsychotic drug prescription and residents’ deterioration. In some cases, the internal documents show, the VA ratings were only slightly worse. In others, such as the number of residents who are in pain, the VA nursing homes scored dramatically worse.

    The worst-performing VA nursing homes in the ratings were scattered across 32 states, including Pennsylvania, which had five one-star facilities, as well as Texas and California, which had four each. The VA facility in Bedford and another in Brockton were the only one-star nursing homes out of six in New England.

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    But VA officials argued that the nursing home system overall “compares closely” with private nursing homes despite caring for typically sicker residents.

    VA spokesman Curtis Cashour called it “highly misleading” to compare pain levels at the VA to private nursing homes because VA residents have more challenging medical conditions.

    The VA quality tracking found that its nursing home residents were five times more likely to report being in pain than private nursing home residents.

    Cashour added that 60 VA nursing homes have improved their ratings over the last year, while only one had a “meaningful” decline.

    “We are committed to continuous improvement efforts in all of the [VA nursing homes] and demonstrating performance that is as good [as] or better than private sector facilities,” Cashour said.

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    The VA’s hospitals have drawn intense criticism for repeated scandals with veterans’ health care in recent years, including preventable deaths, but the agency has largely operated its nursing homes with scant public scrutiny. VA nursing homes serve 46,000 veterans annually in 46 states, the District of Columbia, and Puerto Rico.

    ‘I still can’t get over that this information is not available to people who are looking for a veteran’s home; that’s just unacceptable.’

    Internally, the agency has long monitored care at its nursing facilities through quality indicators and unannounced inspections, and, since 2016, through star rankings based on the indicators. But until now, it has kept all of these quality measures from the public.

    Under federal regulations, private nursing homes are required to disclose voluminous data on the care they provide. The federal government uses the data to calculate quality measures and posts them on a federal website, along with inspection results and staffing information. But the regulations do not apply to the VA.

    The VA has “got this whole sort of parallel world out there that’s hidden,” said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “I still can’t get over that this information is not available to people who are looking for a veteran’s home; that’s just unacceptable.”

    VA spokesman Cashour blamed the Obama administration for resisting making quality data public. “But under President Trump’s leadership,” he wrote in a June 12 statement, “transparency and accountability have become hallmarks of VA.”

    However, the VA’s decision to release the quality data came after first asking USA Today and the Globe for more time to answer questions about the secret ratings. Then the VA released the quality ratings while the reporters waited for answers.

    The agency did not release the more detailed information that underlies the star ratings, such as rates of infection and injury.

    Alex Howard, a transparency advocate and former deputy director of the Sunlight Foundation, said the VA should release all the data immediately — and on an ongoing basis. He said the underlying information is critical to understanding what the stars mean..

    “There shouldn’t be a gap between the reality of how we’re treating people under the government’s care and public understanding of it,” said Howard. “This is not a situation where we’re concerned about some matter of national security, this is simply being honest about how well things are going.”

    ‘I was told how good it is — by VA, of course’

    After 38 years of marriage, Leslie Roe made the gut-wrenching decision to place her husband in a nursing home.

    Earl James “Jim” Zook, 72, was suffering from dementia and had taken to wandering away from their home in Coosada, Ala., and she worried she would lose track of him.

    So Roe moved Zook, a Vietnam-era Navy veteran, into a VA home an hour away in a rural, wooded swath of Tuskegee. She said VA staff put a bracelet on his wrist warning he was a flight risk and placed him in a secure ward.

    But just three months after Roe checked Zook into the Tuskegee facility, staff lost track of him. Zook simply walked out into the woods; Roe said she was told there was a faulty door.

    She had no idea that the facility ranked among the worst VA nursing homes in the country last year, scoring only one out of five stars in the agency’s rankings. She had to rely on what the VA said.

    “I was told how good it is — by VA, of course,” Roe said

    The VA assigns stars based on 11 indicators that can be tip-offs to larger problems with overall quality. For example, high rates of falls or bed sores may indicate understaffing or neglect.

    The Tuskegee nursing home scored worse than private nursing home averages on eight of the 11 criteria as of Dec. 31, 2017, including rates of residents being in pain, receiving antipsychotic drugs, and contracting urinary infections.

    Ironically, this year, the Tuskegee nursing home improved from one star to two stars. But that was too late for Zook.

    He hasn’t been seen since he walked out of the Tuskegee facility in January 2017. Searches by helicopter and with tracking dogs turned up nothing.

    “We finally declared him legally dead,” Roe said earlier this year. “Because there was no way he could have lived without his medication.”

    “Anybody that deals with VA, I feel sorry for them,” she said.

    Cashour said that after Zook’s disappearance, which he called an “unanticipated outcome,” the VA implemented more safety measures, including adding GPS to an alarm system that notifies staff if patients leave the facility.

    11veterans -- Nick Bonanno pushes his father, Russ Bonanno, down the hallway at the VA in Bedford. Nick visits his father several times a week to push him around the building in his wheelchair along with throwing a ball around. Nick tries to engage his dad as much as possible when he comes to visit. (Kelsey Cronin)
    Kelsey Cronin
    Nick visits his father several times a week to push him around the building in his wheelchair along with throwing a ball around.

    ‘They break their spirit’

    The VA has relied for more than a decade on an outside company, Wisconsin-based Long Term Care Institute Inc., to conduct inspections of VA nursing homes and report back to the agency.

    The VA banned the public release of institute reports after the Pittsburgh Tribune-Review in 2009 published the findings from one report detailing “significant issues” at the VA nursing home in Philadelphia, including poor resident grooming and pest control. In one case, a patient’s leg had to be amputated after an infection in his foot went untreated for so long his toes turned black and attracted maggots.

    The VA said the reports are internal quality-assurance documents “protected” from disclosure under federal law. However, in their announcement last Tuesday releasing the nursing homes’ star ratings, VA officials said they would also release the long-term care reports. They didn’t say when.

    Such reports might have been helpful to Bonanno, the WWII veteran whose family moved him from a private assisted-living facility to the Bedford VA last April as his dementia worsened.

    An inspection report obtained by The Boston Globe shows reviewers from the Long Term Care Institute found several instances of neglect at the nursing home in April 2017. They saw a veteran lying in bed covered only by a urine-and-feces-stained sheet. They saw another veteran struggling to eat, using his hands to shove food in his mouth after trying unsuccessfully to maneuver food onto a spoon. Staffers were nearby, the report said.

    By then, inattentive patient care in Bedford had already proven to be fatal to one resident. Vietnam veteran Bill Nutter died in 2016 while an aide who was supposed to check on him hourly allegedly played video games on her computer and didn’t check on him at all. She later resigned, and Nutter’s family has sent a demand letter to the VA seeking $10 million in damages.

    Bonanno’s family would learn about the conditions the hard way.

    His son said Bonanno, a happy-go-lucky retired mechanic, would always wake up early for breakfast. But for the first few months in the Bedford facility, he was fast asleep when his son arrived after 11 a.m. for a visit. According to Nick, the staff woke him up at 6 a.m. to put him back to sleep.

    They gave him an antipsychotic drug and a sedative, Nick said.

    “They medicate them until they break their spirit and make them passive. I guess it’s easier for the staff to deal with them,” Nick said. “In six years in assisted living, he’d never been medicated during the day.”

    Staff told Nick that his father was “agitated” and needed the medication — a contention Nick disputes.

    Cashour said many of the veterans at Bedford live with “chronic mental illness” related to their military service and require psychotropic medication “to reduce distress and manage behavior.” After the veteran is stabilized, he said, the VA works to reduce the use of these drugs.

    Nick’s brother, Russ, who lives in Indiana, said that he and his sister, who also lives outside of Massachusetts, believe that their father’s overall health has improved and he is properly medicated.

    “My sister and I both agree he’s getting care that’s high quality and appropriate for his needs,” he said.

    Still, Nick said as their father became more and more groggy, he participated in fewer activities; he went from walking with help to sitting in a chair for hours, doing nothing.

    “There are ways to care for people with dignity and allow them to be themselves,” said Nick, who plays catch with his father indoors, using a small rubber ball, when he visits several times a week.

    “I was lucky to have Dad in a place that was pretty good for six years. It was a huge drop-off in the way they provide care at the VA versus a private facility.”

    Andrea Estes can be reached at andrea.estes@globe.com.