Taking charge of elderly care

On Wednesdays, nursing home patient Delores "Dee" Fleming is taken out to lunch at a Dairy Queen in Monticello, Ill., by family members who include daughters Judy (from left), Sandy Born and Sue Kinney. Last year, Fleming's family moved her out of a Mount Zion nursing home where she was given psychotropic drugs and became catatonic. (Tribune photo by Antonio Perez / June 10, 2009)

Delores Fleming's relatives tried to keep her in her house as long as they could. But her Alzheimer's disease made that impossible.

Placed in a nursing home near Decatur, Ill., she scored 23 out of 30 on a mental exam and was deemed to be "moderately impaired," state inspection records show. Nurses found the grandmother to be pleasant and talkative.

But after she repeatedly had crying spells and tried to wander away, her doctor prescribed two antipsychotic drugs, even though she was not psychotic. The doctor doubled the dosage of one medication no fewer than four times, putting her above the recommended limit, the records state.

A neurologist, called in after Fleming's family complained, found that she was glassy-eyed and "catatonic," scoring zero on the mental test.

The neurologist urged that Fleming be weaned off the drugs. Once again, she became aware and responsive. "A new person," the neurologist told investigators.

State regulators cited the nursing home, Heritage Manor of Mount Zion, in November 2008 for the misuse of psychotropic drugs.

Yet in cases like these, the people primarily responsible for the patients' medication -- the doctors who prescribed the drugs -- typically emerge with no citations, no penalties and spotless public records, a Tribune investigation has found.

When the Tribune reviewed 40,000 state and federal inspection reports filed since 2001 on 742 Illinois nursing homes, numerous instances emerged in which regulators cited facilities for misusing psychotropics even though the patients' doctors had created the problems.

When physicians or psychiatrists prescribe a drug for a patient, facilities must administer it as long as the order is consistent with state and federal nursing home regulations. If inspectors determine a violation occurred, they cite the nursing facility, not the doctor.

"There's no downside for the physicians" who order inappropriate psychotropics, said Robert Hedges, a former regulator with the Illinois Department of Public Health who now co-owns five nursing facilities.

"Physicians aren't being fined," he said. "Physicians don't have any citations against them."

The Tribune found that inspectors documented many cases in which doctors prescribed powerful antipsychotic drugs without adequate justification or in doses that were too high.

The doctors also sometimes failed to provide adequate follow-up care, the inspection records show. They are required to see their nursing home patients only once every 60 days, though some do not visit even that often.

The difficult task of monitoring for side effects is left to nurses, some of whom, the records show, are poorly trained in the use of psychotropic drugs.

The Department of Public Health enforces nursing home regulations by issuing citations against facilities based on inspectors' visits. It cannot discipline doctors, though it can report alleged wrongdoing to the Illinois Department of Financial and Professional Regulation.

That agency can fine physicians and suspend or revoke their licenses, but its enforcement actions against dangerous doctors have been criticized in recent years as slow and weak. Problems identified in a 2006 Illinois auditor general's report include inadequate staffing, inconsistent disciplinary actions and excessive time prosecuting cases.

Agency spokeswoman Susan Hofer said it does not track how many nursing home doctors have been disciplined, and she could not immediately think of any.

Suddenly, a new doctorWhen families place a loved one in a nursing home, one of the first things they often must do is choose a new doctor. Many people's regular doctors do not make rounds in nursing homes, and the patients may be too frail to go to their offices.

Nursing homes supply families with a list of physicians who visit their facilities. Families might choose from the list knowing little about the doctors. Likewise, the doctors often take on medically complex patients they have never met.