A hoped-for rehabilitation becomes a horrifying trap

For many families, skilled nursing facilities (SNFs) – commonly called nursing homes – are the go-to resource when an older or disabled loved one needs extensive rehabilitation and nursing care after a hospitalization.

But in Florida, longstanding issues with poor quality of care, overworked or uncaring staff, and a dangerous lack of training, can turn a stay in one of these facilities into a nightmarish trap. Such a nursing home can wreck, rather than restore, a patient’s health.

That’s what happened to Jane and John, a Tampa couple whose 52-year marriage came to a sad end with John’s death, six months after his nine-week stay in a Tampa-area SNF.

Their story echoes concern about the quality of care in Florida long-term care facilities voiced by experts’ studies, former staff members of long-term care facilities, and advocates for older Floridians.

Jane and John met when they were attending Ohio University in Athens, Ohio, marrying in 1969. The couple lived much of their lives in New Jersey but moved to Florida in 2007 to be close to their adult children. An expert in heating, ventilation, and air-conditioning, John had authored three books on his field. Jane, a former schoolteacher, became a school counselor, then a life coach and eventually a certified clinical hypnotherapist and author. 

A strapping 6-foot-three-inch, 230-pound man, John had managed his Type 1 diabetes successfully for 50 years. But as he grew older, health issues piled up. He developed chronic lymphocytic leukemia, which builds up white blood cells and depletes red blood cells. A heart attack led to congestive heart failure. On April 1, 2021, he collapsed at the couple’s home and broke his leg.

After a week in a hospital and an operation to install metal pins in his broken leg, a hospital discharge counselor worked with Jane to find a rehabilitation center where he could get additional physical therapy while he recovered. 

Jane chose between two five-star-rated facilities within driving distance of their home, making her eventual selection on the most basic of criteria – someone at one facility answered the phone. At the other facility, the phone rang and rang with no answer.

A medical transport delivered him to the SNF late on a Friday afternoon, and problems began immediately: The bed he was given was simply too short for someone of his height. “His feet were pressing against the footboard,” Jane recalled. “I told them that he had a diabetic foot problem and that pressure on the soles of his feet could cause problems.”

But it was late on a Friday and the staff member assigned to arrange for a longer bed was already off duty until Monday.

All weekend, John lay in the too-short bed, despite repeated requests from Jane for a longer bed. The SNF staff provided a longer bed on Monday. “But by then, the damage was done,” Jane said. John had developed foot blisters that eventually would become open sores. 

It was the first indication of a poor quality of care at the facility that would deepen into a nightmare for the couple:

• Because of his broken leg, John could not go to the bathroom without assistance. Staff members relied on adult diapers rather than trying to get him to the toilet, which usually required two staff members helping him. But they were slow to change soiled diapers, at times leaving him to sit in his own wastes for six hours or longer. Eventually, he developed more open sores.
  
• Staff training was spotty. No one at the facility seemed trained to handle an insulin pump, so Jane had to help. Some staff appeared not to know how to change a bandage or how to clean a resident after they had relieved themselves in a diaper. John required intravenous medications. But on one occasion, his IV bag wasn't changed through three nursing shifts. The intravenous feed was allowed to come loose, feeding too much fluid into his arm, leaving it hugely bloated. Staff members would bring food that was too sugary or inappropriate for his diabetic diet. Jane resorted to bringing in food she knew was right for him. In just over two months, he lost 30 pounds.
  
• Staff members also ignored calls for help. John was given an air mattress to try to help deal with the pressure sores, but the mattress developed an air leak one evening and completely deflated. A fragile diabetic suffering from pressure sores, John lay directly on the metal bed frame in agonizing pain overnight. The call button had been moved out of his reach again.
  
• Nursing care and coordination with John’s doctors was poor. One nursing supervisor cancelled an appointment with a doctor to have the surgical dressing changed on his broken leg, saying that the nursing home would not pay for stretcher transport to the doctor’s office. Jane reinstated the appointment and volunteered to pay for medical transport, but the delay meant the bandage remained on his leg for 10 days unchanged, leading to sores developing on the surgical site.
  
• The facility proved unable to handle a problem that prevented John from getting the physical therapy he came there to receive – a condition that led him to pass out whenever he stood up. Meanwhile, he developed other issues, including urinary tract infections and a “superbug” medication-resistant infection that required advanced antibiotics.  

Eventually, John became desperate. He told his wife he had to get out of the facility or he was certain he would die. “I got a text from him on June 10. He said, ‘I’ve got to get out of here.’ He was petrified to spend another weekend there.”

Finally, Jane brought John home, arranging for home health aides to assist in his care. It was a big responsibility, requiring her to take his vital signs eight times a day and care for him from early morning until after 10 pm. “But at least he’s getting better care now,” Jane said.

Editor’s note: On Dec. 12, 2021, John passed away, having never recovered from his stay in a poor-quality nursing home.