Hawaii has the highest percentage of top-rated nursing homes of any state in the country, according to the federal government, which gives 18 of our 45 facilities five stars out of five.

It sounds reassuring, doesn’t it? It sounds like, when we reach the late stages of life, we will have the best nursing home care available in the islands.

The problem is that the government rankings raise troubling questions. For one, 40 percent of our nursing homes received the top rating, which was the basis for Hawaii’s top score in the comprehensive nationwide evaluation. But what about the other 60 percent?

photograph Cory Lum/Civil Beat

Elderly receive help at a long-term care facility.

Cory Lum/Civil Beat

Rather than draw conclusions from the percentage of nursing homes that are given five stars, it makes more sense to look at how many people are getting top-notch care versus those who are not.

Of the 4,068 available nursing home beds in Hawaii, 24 percent are in top-rated facilities. The remaining 76 percent are in facilities with ratings of four stars or less. In other words, fewer than one elderly person in four is in a five-star facility.

The five-star rating system provides an easy way to look at the care provided at any Medicare- or Medicaid-certified nursing home. The ratings are designed to help families decide which home might be best for their loved ones to live out their final years. The system focuses on three areas: Health inspections, staffing, and quality measures.

Stars were allotted to nursing homes based on whether inspectors found many or few problems at each site. The evaluations compared data on often-preventable problems for residents, including bed sores, severe pain, catheters left in bladders, infections, injuries, falls, restraints, use of antipsychotic medication, inadequate staffing, improper food handling and other health and safety issues.

Even the five-star institutions, which have fewer potentially life threatening problems, still have significant ones that need to be addressed before more residents get hurt or die.

Health inspections are supposed to be done annually, or at least every 15 months. Just last July, the state Department of Health was found to be delinquent because it did not inspect a third of all Hawaii nursing homes. The federal government even threatened to fine the state $121,000 over the inspection delays.

State officials blamed the delays on a shortage of funding for inspections. It was most pronounced on the neighbor islands at that time. The longest delay was 34 months for Hale Hoola Hamakua on the Big Island. Not having regular inspections is a sign, all by itself, that something is wrong.

So, while the big local newspaper is trumpeting our best-in-the-nation status, we need to remember that three-quarters of all available nursing home beds in Hawaii are in facilities that aren’t good enough.

Health inspectors are supposed to evaluate 180 different aspects of care, including how medications are managed, how food is handled and whether measures are in place to prevent physical and mental abuse of residents.

Each of these areas is so important to the wellbeing of our elderly that anything less than 100 percent compliance is unacceptable.

Staffing is another key component in the rating of nursing homes. Federal law requires that a registered nurse be at each home for eight hours a day, seven days a week. This is the case for the largest care home in Hawaii, which holds almost 300 residents, or the smallest, which has only 10 beds; only one RN is required on campus during the day. Just one.

Staffing also includes nurse’s aides, physical therapists, licensed practicing nurses or licensed vocational nurses. The total number of hours these professionals work is divided by the number of residents to give an overall staffing ratio. Each nursing home reports its own staff work hours, and it’s only counted the two weeks prior to the annual survey. More staff hours for each resident is preferred.

The highest rated homes in Hawaii had fewer residents, in fact over three quarters have less than a hundred patients.

But even the rating system’s very lenient method of determining staff-to-resident ratios proves that more than half of our nursing homes are not fully staffed with the personnel needed to care for their patients. This puts residents at risk of neglect and not getting the care they need in a timely fashion.

The system’s quality measures also merit scrutiny. Each home is rated on several categories.

Major falls in residents leading to bone fractures, joint dislocations, head injuries, or altered consciousness are calculated into the rating system. So are bladder infections, inadequate availability of bathroom assistance, patient reports of severe pain, the use of physical restraints, weight loss and depression.

Any one of these is a major medical concern, and can have deadly consequences for a resident.

Based on the latest survey report, more than half of Hawaii’s nursing homes failed in these categories.

So, while the big local newspaper is trumpeting our best-in-the-nation status, we need to remember that three-quarters of all available nursing home beds in Hawaii are in facilities that aren’t good enough.

In medical school, they taught us that is a failing grade.

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