Just say no.

Early July saw the release of a study entitled, "Predators in America's Nursing Homes: Registered Sex Offenders Residing in Nursing Homes Analysis." It was prepared by a disability/elder rights group called A Perfect Cause and reported on 380 registered sex offenders living in 289 nursing homes, with two cases alleging the rape of elderly female residents.

This report came within weeks of exposes by three major newspapers--Newsday, USA Today, and The Washington Post--laying out egregious violations of resident safety by assisted living facilities concentrated principally in New York, Ohio, Pennsylvania, and Virginia. Cases ranged from instances of fatal neglect to resident-on-resident assault. Short staffing was cited as a principal contributor but, as with the A Perfect Cause study, another factor was front and center: Facilities had admitted residents with severe behavioral and mental disorders without providing the resources, planning, or finances to manage them.

Everyone knows about the historical process known as deinstitutionalization--the release of people with mental disorders from the cold, dark "snake pits" of yesteryear to presumably more civilized and supportive surroundings in the community. The drive to deinstitutionalize has been going on for more than 50 years; I remember interviewing, in the early 1970s, Dr. Nathan Kline, the psychiatrist whose drug discoveries initiated the process in the 1950s and made him a medical hero of the time. The U.S. Supreme Court's famed Olmstead decision in 1999, requiring that patients be managed in the least restrictive environments possible, only confirmed this trend.

Deinstitutionalization is a nice idea, but somewhere along the line it became corrupted. Financially hard-pressed states began to see the emptying of their institutions as an excellent way to save taxpayer dollars. They did so with stunning efficiency. Suddenly the streets of our cities were filled with strange people doing and saying strange things, homelessness became a major social issue--and nursing homes and assisted living facilities began to take in a new kind of resident. The facilities were not always prepared for this assignment.

There's plenty of blame to spread around: long-term care facilities, for not adequately staffing and organizing themselves; state agencies, for not always being candid about the patients they were seeking to place; states, for paying LTC facilities so poorly that any new source of income, even at per diems of as little as $28, looked good. With blame, of course, comes accountability--one hears distant rumblings of a move to federally regulate assisted living, the same rumblings one heard in the nursing home sector pre-OBRA '87. This is not a pleasant sound.

So here's a call to long-term care facilities in general and assisted living in particular, echoing a plea so eloquently stated in this magazine by Paul Willging in his column "With 'Aging in Place,' Honesty Pays" (May 2004, p. 18). Providers, get honest with yourselves and with those who would use your services. Plan up front who you want to accept and how you plan to manage them, and make your facility's unique mission plain to all. To those who don't get the message and come knocking at your door anyway with would-be residents with whom you just don't feel comfortable, just say no.

Maybe this will help persuade taxpayers to support decent services for these unfortunate people. Meanwhile, the grief you spare will be your own, and many others', as well.

BY RICHARD L. PECK, EDITOR-IN-CHIEF

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