The Civil Beat Editorial Board Interview: Long-Term Care Ombudsman John McDermott
How Hawaii cared for its older and most vulnerable residents during Covid, and on the need to hire more ombudsmen for the neighbor islands.
April 24, 2022 · 23 min read
About the Author
The members of The Civil Beat Editorial Board are Chad Blair, Patti Epler, Nathan Eagle, Kim Gamel and John Hill. Opinions expressed by the editorial board reflect the group’s consensus view. Not all members may participate in every interview or essay. Chad Blair, the Politics and Opinion Editor, can be reached at firstname.lastname@example.org.
Editor’s note: The Civil Beat Editorial Board and reporters spoke with John McDermott, the long-term care ombudsmen for the state of Hawaii. He began by explaining the scope of his program, which is housed in the Hawaii Executive Office of Aging within the Department of Health. This interview has been edited for length and clarity.
The program started out as a demonstration project in 1975, and back then the only long-term care facilities were really nursing homes. It was called the Nursing Home Ombudsman, and because it was very successful and Hawaii was one of the states that did this demonstration project, it became federal law in 1978. It’s part of the Older Americans Act (of 1965), but every 10 years or so they reauthorize it because they have more money, they add new programs, they may eliminate some programs that are not really working as they had expected. We came into existence in 1978 and by statute in 1979 into the Office of Aging.
Our job is to advocate for people who live in licensed, long-term care facilities. So in this state, that’s about 13,000 mostly seniors but not all, because you do have people, young people who may have had birth defects, tragic accidents, strokes, car accidents, things like that. They’re also in long-term care facilities.
We go into nursing homes, we go into adult residential care homes — the Type 1, which is five beds or less, the Type 2 which is six beds or more. We go into the community care family, foster homes, which are mini-nursing homes, no more than three beds. Only one can be private pay and the other two have to be Medicaid, unless the private pay is a married couple, then you can have two private pays.
And we also go into the assisted living facilities, and the most recent one that got some publicity was Dignity Oceanside, which closed — and Civil Beat was the one that brought that to my attention and broke that story.
That was a tragic situation because the residents were only given nine days during a pandemic to find a new home. And so we were able to force the Department of Health’s Office of Health Care Assurance to give at least 30 days notice and to make sure that everybody did find a place to live — it used to be called the Ponds at Punaluu — this is up on the North Shore right next to nothing.
Those residents (were) a tight community because there was no place to go. They lived with one another. They played cards, did puzzles, had all their meals together, and now this community was being broken up and some of them had no family, or families that live on another island and or in another state.
How do you find a new home during the pandemic? How do you pack up all your belongings when you don’t even have cardboard boxes? You don’t have access to a car or a pickup truck, or a U-Haul. During the pandemic you couldn’t really even rent a car, and a lot of the care homes were not admitting for fear that they would be bringing in somebody with the virus. It was a very emotional move.
Luckily, we did have several facilities that volunteered to take in some of these folks. We got it done, but that was really a terrible situation. And now Wahiawa (Nursing and Rehabilitation Center) has announced that they are going to be shutting their doors.
We had AARP Hawaii here a couple of months ago. At that time they were pushing House Bill 1824. There was a Senate companion as well, and it had to do with getting five full-time, long-term care ombudsmen for the neighbor islands — in other words, to reproduce you times five. Can you bring us up to date on what happened to that bill and whether that’s still going to happen?
We are very happy about that, because I’ve tried over the past 24 years to get staff. The National Institute on Medicine in 1995 said that every state should have at least one full-time paid ombudsman for every 2,000 residents. And we have almost 13,000 residents, so we should have at least six people. But currently we have just me and we have a volunteer coordinator.
This legislative session, my boss, Caroline Cadirao, was able to convince the Department of Health — because we need their permission — to request two positions in the governor’s (budget) package. But I didn’t want two — I want five. I want one for Kauai. I want one for Maui, I want one for Hilo, one for Kona, and we really need one more for Oahu because Oahu has over 10,000 residents, the bulk of our population.
Rep. Sylvia Luke of House Finance, she knew that I wanted five, and so she changed the governor’s budget to five. And then we had to cross fingers that Ways and Means would do the same with Sen. Donovan Dela Cruz. And I guess luckily because we have a surplus of $2 billion, it was (a) possibility. So the bills are no longer being heard because it’s in the governor’s package.
I’ve been doing this for 24 years and I would like to retire at 25 years, but I definitely want to stay around to hire those people and train those people. And this training would require that I go to the neighbor islands and do this one on one. So it will take at least a year to do all five of those people. But hopefully the governor sees the merit in this and doesn’t do anything about it, and this will become part of his legacy and part of my boss’s legacy as well that finally the neighbor islands do not have to wait for Johnny Boy to show up and come rescue them.
Because it really is not fair, and during Covid I couldn’t get a plane ticket, I couldn’t get a car. So for two years, we didn’t really know what was going on on the neighbor islands.
We really do want these folks to have a local ombudsman who’s there when things have to be investigated at night. Who’s there on weekends when you have family councils. Who’s there on weekends when you have senior fairs and other special programs where they can be guest speakers. So it doesn’t make any sense for one person to be running back and forth to all these different islands.
About 13,000 people are served statewide with these facilities and then there’s about 1,700 facilities where these beds are located. I think you said that over 10,000 of the patients are on Oahu. Does that entail a lot of neighbor island folks having to move here because there are not the proper or the needed facilities on their home islands?
Lucky we live on Oahu — we have more resources. If you live on Kauai, there’s only five nursing homes. There’s only one assisted living facility. There’s 19 community care or foster care homes and there’s six adult residential care homes.
Now these numbers, of course, always go up and down because you don’t necessarily have more nursing homes because, you know, a mainland company doesn’t understand leasehold versus fee simple. And the idea that you can build a building but you don’t own the land — that is very foreign and they’re not going to do it.
And then also, why build a nursing home that’s going to require so many RNs and so many CNAs when our state has a shortage of those people? So you’re only going to be able to staff it by increasing the pay enough to lure other people to leave their jobs and come to you.
We have a rapidly aging population and we have an exodus of young people. So who’s going to do this work?
On Maui, they have five nursing homes now — this is Maui County, so I’m including Lanai and Molokai, although Molokai is very, very sad because Molokai used to have a nursing home but they decided to phase out the nursing home. They do have, I think, three care homes, but they probably need to consider building more foster homes, which would be nursing-home level.
So, yeah, lucky we live on Oahu. People do come here from the neighbor islands because there’s nothing available for them. Sometimes they’re also here because they burned too many bridges. And everybody on the island knows them and nobody wants to admit them.
Is it an understatement to say that the demand for these facilities, these services is only going to increase tremendously given the the rapidly growing aging population here in the islands?
Well, we have two problems. We have the rapidly aging population and we have, according to the last census, an exodus of young people. So who’s going to do this work? We’re not like the mainland where we have other states next to us that we can maybe get some people to move over from California or Arizona to come here.
Our cost of living is so high, our housing situation is practically nonexistent. We’re lucky in that our senior population is probably much healthier than the mainland — people are outside all the time, gardening, swimming, walking around. We have a good parks and recreation program. We have good senior centers. So socialization is very important.
The housing situation, actually, you can flip it and say the benefit of having such limited housing is that everybody is living in grandpa’s house. And so he feels very valued because he’s the one providing three generations with a roof over their head. And probably his Social Security check is also keeping people afloat who are not working or not making enough money. But what he gets out of it is companionship and mental stimulation, and he knows who Taylor Swift is and he knows current events, things like that. So he’s not spending all day living on saltine crackers and watching “Judge Judy.” He’s got a full life, goes to church, goes to movies, things like that.
What we have to figure out is (what to do) for those family members that end up becoming full-time caregivers because they don’t want to put their mom or dad in a nursing home and there’s no beds available anyway, and they think that they can do a better job. But financially, how do we reward these people? These folks, if they went into a facility, they would be on Medicaid and we would be footing the bill, the taxpayer. So we’re saving money here. But that person now has no income. And when that person is a senior, their Social Security check will be practically zero because they weren’t putting into the system.
So why can’t we consider this an actual job? It is. And pay that person — you would get paid for taking care of somebody who’s not related to you, but somehow you’re expected to do it for free, if you’re a family member. But that’s really not financially realistic. That just doesn’t make any sense.
There have been proposals before the Legislature to have some assistance for people that need to take care of an aging parent or if a family member is ill. Can you clarify that?
Well, I have not followed those bills. I’m sorry, I can’t really comment on that. I do know that assisted living unfortunately doesn’t take Medicaid, although in some states like Oregon and Washington, they do. And I don’t know how we could convince our state to consider that because they did do it for (Dignity Senior Living at) Oceanside.
Right now, I don’t know if that model is financially sustainable. Administrators tell me that people who have pensions and had a home that they could sell are able to afford an assisted living facility. But the next generation doesn’t have the house to sell because it just was sold and a lot of jobs no longer provide pensions and people don’t stay at the same job for 24 years like I did because I wanted the pension.
And so is it sustainable? Who is going to be paying for a Kahala Nui (senior living) the next generation? I think that it’s probably going to be Medicaid. Their profit margin will be less, but they will be fulfilling a very important need. Oregon does it. Washington state does it. We have to figure out how we can do that as well.
A new study — I’m just going to read from it — says “The percentage of under-staffed long term care facilities in the U.S. has doubled during Covid. And Hawaii is at number 21, the most impacted state, saying that means about 25% of our facilities are understaffed.” That’s a doubling since 2020, and this caught me by surprise as well as that 23% of all Covid deaths have occurred at long-term care facilities, in no small part because of the staffing concern. Your thoughts on this?
The state has drafted a transition plan, but I just got that email today, so I haven’t actually read it yet. But we did have facilities that deliberately stopped admitting people, and maybe were only half full because they didn’t have the staff. And so that, of course, seriously hurt the bottom line. But they said, in good faith, we cannot admit anymore if we know that we’re not going to be able to provide the necessary care because the staff, they’re just not there.
People kind of forget that initially we didn’t understand that Covid could be asymptomatic, that you could feel perfectly healthy, come into work and you’re spreading this virus all over the place because you feel strong and healthy. Now we know that and now we have all these new variants coming and our state relies so heavily on tourism. And we have this judge, a Trump appointee, who just said no masks can be required on airplanes. So we’re going to have a lot of people coming to this state on airplanes not wearing masks, and I’m nervous about that. And the facilities are very nervous about that, because it’s like we’ve already gone through two years of hell and we really don’t want to be repeating this again.
And everybody is saying, oh, “the new variants, yeah, they’re more contagious, but they don’t seem to be as deadly.” Well, that may not be the case for seniors who already have compromised medical conditions, and some of them didn’t get vaccinated. So everybody’s worried about what’s going to happen. Our governor was criticized for being a little bit maybe too cautious, but I think a lot of us are actually grateful that he was cautious and that our lieutenant governor was cautious, because if you don’t control the situation, then variants again morph into newer variants and we don’t know how dangerous it can be. Shanghai is still in a lockdown. We don’t want to go through that.
Our staffing situation, we have to rely on visiting nurses from the mainland. That was a bit of a problem. We really don’t want to be relying on mainland folks who don’t know the way we communicate here. The Centers for Medicare Medicaid Services, what they did is they lowered the requirements that instead of having to have certified nurse aides, you could have people who were just nurse aides, not certified. And so that means very limited training. It could also mean somebody who tried to be certified but couldn’t pass the test. That’s a little bit of a red flag.
Everybody did the best they could with the available resources. But again, in the middle of the Pacific, we have no states that can come to our rescue. Luckily, we did have the National Guard, so we had help from the military.
The worst case was the (Yukio Okutsu State Veterans Home) in Hilo where they actually kicked out Avalon, the management company, and replaced them with Hawaii Health Systems Corporation, because they made a lot of really basic infection-control mistakes. So hopefully we learned from that.
The care homes and the foster homes, unfortunately, did not get as much support from the Department of Health as I would have liked, and so we worked closely with AARP to develop a manual that included protocols and then the Department of Health signed off on that as well. But they were coming to us saying that, you know, seems since there’s all this great information (getting) to the nursing homes, (but) we’re not getting this information. The nursing homes have the Health Care Association of Hawaii. We don’t have an organization like that, a powerful organization like that.
So it was very complicated and people were kind of making up things on the fly and we were trying to get the Department of Health to standardize every care home, every foster home, since they should all be kind of doing the same thing. And they’re looking towards you for guidance on what they should do and you’re basically telling them, “Figure it out.”
You talk to a lot of residents and you hear about bad behavior by staff. You hear about other things. I take it that the ombudsman’s office does not do the investigation of those complaints because I think only a few states do (that). So who investigates?
Well, if the resident brings or the family member brings a complaint to our attention, we do investigate. We’re not the surveyors in the sense that we don’t give deficiencies, we don’t cite a facility. But we do investigate and we have to have permission from the resident to do so. Sometimes they’re just venting and they really don’t want us to follow up at that time. They may change their mind later on, but when we’re in a facility, we always have an exit interview with the administrator.
And so we feel that as we walk out of this facility with all this great information plus our own observations, but we don’t share that with the administrator. We did not make this facility better and that’s what our focus is.
Administrators work with us because they know that they have nothing to lose. By doing that, they’re only going to get better. So during Covid, we were not able to go in for a while until we got CMMS to kind of agree that we are also essential workers. And just like the state, surveyors can go in and we can go in as well. So when you’re moving people around because you’re creating a Covid wing versus a wing where people are not Covid, things get lost.
One of the complaints that we had was “my mom came home from the nursing home. She was there for three months. She’s got no clothes.” Everything was lost because periodically they moved her from place to place and staff didn’t know what clothes she came in with. I would have known (because) I’m the son, and I would have said, “That’s my mom’s red dress. You got the wrong person wearing my mom’s dress.”
The families couldn’t come in. They couldn’t notice those kinds of things. When somebody is admitted to a facility, there’s an inventory sheet and you’re supposed to list everything that the person has. But because families were not coming in with the resident, some facilities got a little sloppy and were not doing those inventory sheets. So that was a mess.
We had three cases of wedding rings that were missing. And that’s very tragic because, you know, a woman who was wearing that same ring for 30, 40, 50 years, whatever, it’s not the monetary value of the ring. It’s the emotional impact.
What is the result of your investigations? Do you have any sort of enforcement mechanism?
No, but the administrators know that we can report things to the Office of Health Care Assurance. They know that we have gone to Civil Beat, that we can go to the media. We can go to the Attorney General’s Office. We’re not going to just let it drop. Administrators really want to work with us and they understand that we’re not trying to embarrass anybody. We’re trying to just fix the situation.
Abuse of the elderly has been a decades old problem. If you had all the resources that you needed, is there a solution?
Getting the five (ombudsmen) positions for the neighbor islands is definitely going to be a major, major improvement because we will be there much more often and staff will be more on their toes. It’s amazing to me because I’m not a surveyor, but I go into the building and within 10 minutes, everybody in that building knows the ombudsman is here. Local contact is essential. And having somebody on the neighbor islands will also make it so much easier to recruit volunteers.
Residents know in Hawaii that the nail that stands up gets hammered down. They are afraid to speak up and if they have children who have moved to Vegas, California or whatever and they have nobody here anymore, they’re afraid to speak up because they do fear retaliation. That ombudsman who’s visiting on a regular basis becomes a family member. And when they trust that person and they know if something goes bad, he’s coming back next week. I’m going to be able to talk to him and tell him what happened to me because of my making that complaint. We will resolve that very quickly. We will not allow that to happen to him.
There must be cases in which, if a resident tells you that a CNA has been hitting them or something, there must be cases where you don’t work with the administration to solve the problem but just report directly to the state licensing board or something. Aren’t there cases like that as well?
Well, one of the unique things about the ombudsman program, which is written into federal law, is that we are not mandated reporters. So if the resident, for whatever reason, does not want us to report that they were abused, we can’t do anything now. The only exception is that if we witnessed it — if we walked in and we saw the abuse, then we don’t need the resident’s permission because we’re the ones who witnessed it. But if we’re only hearing about it from the residents, all we can do is say, “Look, you know, if we don’t report this, that person doesn’t get fired and can still come back and abuse you again can also abuse other residents, and you maybe should consider taking some ownership about that because you could have helped prevent that.”
And so by reporting this, we can make sure that person is not allowed to work on this floor ever again. Or maybe if it turns out that everything that you’re saying is true, that person loses their certification, they will never work in a long-term care facility again. So we would definitely do everything possible to encourage residents to let us report it. And as far as I know, we have always gotten the client to do that.
The one case that is more complicated is when it’s a family member abusing the residents. Financial abuse, of course, is very common — you know, stealing the Social Security check. So that’s an issue.
If someone is looking for a place in Hawaii, a nursing home, an assisted living facility, an adult residential care home, can you give us a couple of tips? What should we look for and what are the red flags?
Well, of course, people can always call us because we’re happy to give that information. I think the No. 1 thing that people should do is a visit because somebody had a bad experience for whatever reason and tells you it’s a hell hole. Somebody else loves the place and raves about it, and it’s the same place. That happens all the time.
And I would say the least important thing is really the furnishings. Too often people are judging a place by how pretty it is. And that tells you nothing about the quality of care. So you want to look at residents to see, do they look happy? Is this environment therapeutic or is it a warehouse or people just waiting to die here? Or are they thriving and they’re happy and they’re engaged?
The activities program, I think, is very, very critical because when you’re living at home, you’re busy, you’re cooking, you’re doing the laundry, you’re washing your toilet, you know, you got a million things that you want to do, and you look forward to a half an hour that you can rest in front of the TV.
Now, all of a sudden, you’re in a long-term care facility and all of that is done for you. And so if they don’t have an activities program, you are bored to death, and who wants to spend the whole day watching TV? That’s not good.
Facilities that have outdoor space — are they utilizing that to the fullest? Because, again, people in Hawaii, especially seniors who had houses, they have backyards. They’re doing gardening, they’re raising flowers. They want to be outside. And so if now you’re in for the rest of your life, it’s going to be 24-7 indoors under fluorescent light bulbs, that’s going to be very miserable. So that’s important as well.
Do they have a strong resident council or do they have a strong family council? I think that indicates a lot, that they want the feedback from the families. We can’t get better unless we know what we’re doing wrong.
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