Jeffrey Downey asked: Assisted living facilities are rapidly becoming the nursing homes of the future. According to the National Center for Assisted Living, there are over 36,000 licensed assisted living facilities nationwide with an estimated 1 million residents.[1] However, because there is no common definition for assisted living facilities, this number may not adequately reflect the prevalence of these facilities. In fact, in 2002 the National Conference of State Legislatures hailed the assisted living market as one of the fastest growing long-term care options for senior citizens; the number of seniors in assisted living facilities receiving Medicaid benefits has grown nearly 50% over the past few years.[2]
These facilities tend to aggressively market and recruit residents, many times promising staffing levels or services that, in reality, are not available.[3] In an attempt to compete with nursing homes, assisted living facilities are accepting patients with higher acuity. Most major chains promote special Alzheimer’s Disease Units, and are accepting patients with significant cognitive impairment. The reality is that many of these facilities have staffing that is inferior to the staffing levels present in nursing homes and simply cannot meet the needs of the higher acuity residents. The end result is that residents throughout the county are suffering from serious injuries due to the neglect and abuse that is taking place in these facilities.
A. Assisted Living v. Nursing Home Care
Assist living abuse and neglect cases and nursing home abuse and neglect cases are similar in some respects, i.e., both involve supervision and care of the elderly, but evaluating the assisted living case involves a greater perception of the differences in the two types of facilities.
1. Standards of Care. The litigation of assisted living abuse and neglect cases, like the litigation of nursing home abuse and neglect cases, can be an effective tool in forcing the industry to comply with proper standards. However, since most states have weak regulations, it often becomes difficult to establish the legal standard of care for a particular facility. Many times a plaintiff may have to fall back on basic community practice nursing standards that will apply when an assisted living facility contracts to provide more than just room and board.
Nursing homes are highly regulated and must comply with the regulations set forth in the Omnibus Budget Reconciliation Act (“OBRA”) of 1987[4] (otherwise known as the federal Nursing Home Reform Act) which set minimum standards of care for long term care facilities that receive federal funding. Unlike nursing homes, assisted living facilities are not regulated by the federal government, and the state regulations that do exist are inconsistent and, for the most part, not aggressively enforced.
When considering the basis for liability, one must consider whether the assisted living facility breached regulatory or community practice standards in admitting the resident whose needs may have been too great to be met by the assisted living facility. Many assisted living facilities, especially those with “Specialized Alzheimer’s Units” are accepting residents with advanced dementia who would normally be admitted to a nursing home, and possibly even a skilled wing of the nursing home. In such cases, it would be advisable to obtain an expert who will evaluate the resident’s condition and the relevant admission criteria. Such an evaluation will likely be beyond the abilities of a lay person, although many admissions decisions in assisted living facilities are being made by non-medical personnel.
Almost all states prescribe some limitation on who can be admitted into an assisted living facility. For example, Virginia regulations prohibit adult care facilities from admitting or retaining patients with a variety of conditions, including ventilator dependency, dermal ulcers stages III and IV, those requiring intravenous therapy or injections directly into the vein, nasogastric tubes, and those who require continuous licensed nursing care. 22 VA. ADMIN. CODE § 40-71-150 (West 2003). Other states contain similar limitations with prohibitions aimed at excluding patients with a demonstrated need for skilled or specialized care.[5] Assisted living facilities do not provide skilled care; consequently, they are uniformly required to screen patients to determine the level of care needed and reject patients whose needs exceed their capacity. State regulation of assisted living facilities is lax and, for the most part, ineffective. Only a few facilities in the Commonwealth of Virginia have been denied a license for regulatory noncompliance. It is the opinion of this author that weak regulatory enforcement is in part due to inadequate regulations that do not adequately specify industry standards.
2. Experts. To litigate a nursing home abuse and neglect case it almost always requires the use of medical experts who will define the standard of care and address breaches in the standards. As assisted living facilities are generally not considered health care providers, one may question whether an expert is necessary. This will obviously depend on the facts of your case. But in almost every case, at the very least, you will require an expert to establish causation and damages. Since many times injuries in assisted living facilities result in the patient requiring long term care in a nursing home, you may also want to consider obtaining a life care plan from a qualified expert.
Once you have obtained records, you should have the case reviewed by a nursing expert you can rely upon. Unlike nursing homes where there DON and Administrators are RNs, many of the nurses who work in the assisted living arena are LPNs and lack the background that you may be looking for in an expert. Finding talented nurse experts who are actively involved in assisted living care is a challenging task. This author has used the ATLA list serve, and random calling of facilities to locate qualified experts.
B. Evaluating the Assisted Living Case
1. Facility Records. The first step in assessing liability against an assisted living facility will be to obtain the records from the facility and the contract that was signed. The contract will likely define the duties undertaken by the facility. Most assisted living facilities have various levels of service. Level one might be the basic service which would include only room, board, meals and activities. Level four, or the highest level of service, might include resident assessment, care or service planning, medication administration, and dementia and nursing care. The standards applied by these facilities could be analogized to standards of care applied by a nursing home that was not providing skilled care.
2. Freedom of Information Act. In addition to obtaining the records, you will need to do a Freedom of Information Act request. This will help you identify the corporate entity that actually owns and operates the facility and may also allow you to see surveys or inspections that were done on this facility. The license should always be available, and may include information about the scope of services that the defendant facility is authorized to provide. Do not expect the surveys or inspection reports to contain the wealth of information that are available for nursing homes. Many times surveys are performed by the local Department of Social Services and do not include assessments of whether or not these facilities are complying with regulatory standards of care.
3. Case Review. The following are some factors to consider early on in deciding whether or not to prosecute an assisted living facility for negligence or abuse:
a. The nature of the resident’s condition upon admission. If she was mentally competent and independent with acts of daily living, you will confront significant problems with contributory negligence and comparative fault defenses.
b. The nature of the contract and duties assumed by the facility. If they only agreed to provide room, board, and meals, the defense will argue their duties are analogous to that of a landlord in an apartment building.
c. The quality of the relationship between the personal representative and the victim. If the victim is deceased, this may take on a greater importance as the nature of that relationship may define your damages under the applicable wrongful death act.
d. Whether the family members make good fact witnesses, appear genuinely outraged by the facility’s conduct, and complained and/or removed their loved one from the facility.
e. Whether the facility had serious staffing shortages or a pattern of neglecting their residents.
f. Did the victim suffer a significant injury in the facility that adversely affected the quality of her life for the future, or caused her death?
g. Do you have strong witnesses and powerful exhibits? Do you have an insider who is willing to blow the whistle on rampant staffing shortages? Do you have color photos of that pressure?
h. Do you have significant economic specials that are not encumbered by a Medicare or Medicaid lien?
i. Is the defendant a charitable organization, religious affiliate, or part of a large assisted living chain?
C. Theories of Liability
With weaker regulation, variety in industry standards, and market competition, it is not surprising that the U.S. General Accounting Administration, in 1999, identified problems in assisted living facilities that included inadequate or insufficient resident care, insufficient trained staff, improper medication administration, and not following admission and discharge policies required by state regulation. A 2000 study by the U.S. Department of Health and Human services found that a high percentage of the staff at assisted living facilities were not knowledgeable about the normal aging process and at least 60% of the staff did not know how to properly manage difficult behavior among assisted living residents.
Liability: Improper Admission. Many times, liability based upon an improper admission results when someone is admitted into a facility that is not locked down or enclosed. Many residents with dementia have a tendency to wander and they should simply not be admitted into facilities that are not locked down or do not have appropriate wander guard systems and/or alarms on the doors.
In Selvin v. DMC Regency Residence, Ltd., 807 So. 2d 676 (Fla. Dist. Ct. App. 4th Dist. 2001) a resident of an assisted living facility wandered off and was found dead in a nearby canal. Plaintiff’s complaint alleged two different theories of liability: the first was a statutory wrongful death action and the second was based on alleged violations of statutes relating to assisted living facilities. Plaintiff alleged that the facility had a common law and statutory duty to supply at least the level of services and care that all licensed assisted living facilities generally furnish elderly patients of the plaintiff’s decedent’s classification and condition. At the time of trial, plaintiff sought to introduce expert testimony about specific safety precautions that were the industry standard and further sought to show that the facility should have built a fence to prevent elders from wandering near the dangerous area of the canal. The trial court precluded this testimony, finding that the facility had no legal duty to fence off the canal to the general public. The Appellate Court reversed, finding that the facility undertook to furnish certain services of care and security which created such a duty of protection. The Appellate Court also held it was an error to exclude testimony regarding industry standards of what could have been done to protect these impaired residents from falling into the canal.
1. Liability: Falls. Another common area of liability in assisted living facilities involves falls. Expert testimony may not be required in such cases. See, Walker v. Southeast Alabama Med. Ctr., 545 So. 2d 769 (Ala. 1989).[6] However, fall assessment and fall prevention planning is usually done by a nurse or other medical provider and it may be advisable to have an expert address this issue. In large part, the need for an expert will be determined by the facts of your particular fall. If the staff simply dropped the resident during a transfer, an expert may not be necessary. However, if the resident came in to the facility with multiple risk factors for falling[7] which were never assessed or care planned and he fell one day while wandering the hallway, you should retain an expert to discuss how the standard of care for fall prevention was breached. To establish causation, she will have to testify that if appropriate standards were followed, it would have, more likely than not, prevented the particular fall which caused injury to plaintiff. As this is an area of first impression in many jurisdictions, it is advisable to educate the court with a trial memorandum addressing experts and other issues prior to trial.
D. Other Theories of Liability
Attorneys who prosecute assisted living facilities have an opportunity to be far more creative in the prosecution of these claims, given the broad range of theories that are available. Below are some typical theories that can be advanced against an assisted living facility.
1. Common Law Negligence. This is probably the most common theory of liability advanced in assisted living cases. Make sure you do not plead breaches in medical or nursing standards of care, or you may face the argument that you have pled a traditional malpractice case. You can plead the breach of regulatory standards and/or industry standards which proximately caused injury to your client. As assisted living facilities are not health care providers, they should not be subject to caps or other discovery limitations (i.e., quality assurance privileges) that apply to traditional health care providers.
2. Violations of the Consumer Protection Act. Make sure to inquire of your client what representations were made as an inducement to enter the facility. Obtain the brochures that were handed out by the marketing representative. Most consumer protection statutes provide relief for misrepresentations which were made as an inducement to enter into the consumer transaction. Case law has allowed such theories to be advanced even against health care providers, so there should be no reason that this theory could not be advanced against an assisted living facility.[8] The advantage is that many states’ consumer statutes allow for the recovery of costs and attorney’s fees.
3. Adult Protection Act. Most states have statutes that have been specifically enacted to protect the rights of elder Americans.[9] Some states, like Tennessee, specifically exempt health care providers from the application of such statutes.[10] As assisted living facilities are not health care providers, these exemptions should not apply.
4. Breach of Contract. Almost all assisted living facilities will make their residents sign a contract as a condition of admission. Scrutinize the contract carefully, as it may contain waivers of liability or waivers of the resident’s right to a jury trial. Such waivers can be asserted irrespective of whether one pleads a separate breach of contract claim. Under the laws of most states, contract damages will be limited to foreseeable economic damages, so it would be disadvantageous to plead this as your only theory of liability. However, the contract may have required that certain services be delivered to the resident (i.e., activities, assistance with acts of daily living, 24 hour supervision) which were not, in fact, provided. The resident may have suffered no physical injury from the failure to deliver such services and the defense will argue that such evidence should be excluded at the time of trial. With the contract theory properly pled, plaintiff can argue that such evidence is admissible to prove contract damages and recover monies for services which were not provided.
Be wary that the defense may argue that since plaintiff failed to quantify the extent of services that were not provided, any award of contract damages would be based on speculation. As such, you should make an attempt to have your client provide a good faith estimate in percentage terms as to what services were not provided. However, if you have a strong negligence claim based on a discreet event (i.e., a fall causing a hip fracture) you may not want to confuse the jury with a lot of collateral facts and issues that may not have a strong bearing on your damages.
5. Negligent Hiring and/or Retention. Consider this claim where you have intentional torts committed by an employee and some evidence that the defendants knew or should have known that this was a troubled employee. Many assisted living facilities don’t adequately screen their employees. This evidence may not be revealed until the discovery process begins and it is essential that you obtain the employee’s personnel file early on in litigation so you can amend your complaint if necessary. Depending on the tolling provisions of your individual claim, the cause of action may still relate back because it arguably arises out of the same set of operative facts. It is also a good idea to sue the employee individually. The same defense firm may represent both the employee and corporation, making it impossible to argue that the employee was not operating within the scope of his employment.
6. Wrongful Death. In any case where there is evidence that the facility’s negligence caused or contributed to the resident’s death, a separate wrongful death claim should be asserted. If there is any good faith basis to conclude that the negligence contributed to plaintiff’s death, you should plead both survivorship and wrongful death claims. Any long term care case has greater value if you can argue that defendant’s neglect caused plaintiff’s death. You may also have separate claims for injury that in no way contributed to the resident’s death. Such claims should be pled with your survivorship claims. Research the law in your jurisdiction to determine what forms of damages are recoverable under a wrongful death statute. If you’re in one of those unfortunate jurisdictions that allow only economic damages, you may not want to plead a wrongful death claim.
7. Punitive Damages. As the nature of economic damages in an assisted living case may not be impressive, and as your client will likely have suffered from several preexisting conditions that may weaken your compensatory damage claim, you should, whenever possible, plead punitive damages. Successfully pleading a punitive damage claim will also provide you with the basis for exploring defendant’s conduct with respect to other residents who were neglected in substantially similar ways to that of your client. Cases from around the country have upheld such punitive damage claims against nursing homes, and there is no reason that such precedent would not apply equally to assisted living facilities. [11]
8. Americans with Disabilities Act/Fair Housing Act. The Fair Housing Amendments Act of 1988 (FAA)[12] prohibits discrimination in virtually all housing and related activities, whether such conduct takes place in the private or public sector. This law is complemented by the Americans with Disabilities Act,[13] which, while it specifically does not include entities covered by the FAA, applies to non-housing functions of a facility, such as common areas, meeting rooms, cafeterias, adult day care, or long term care under Title II (state and local) and Title III (public accommodations) programs.
E. Selected Case Results
A survey of reported cases reveals very few published cases throughout the country. This author has litigated fall cases, negligent admission resulting in pressure sores cases, and one case involving an unfortunate resident who caught fire in the recreation room. The manner in which he was ignited was never explained by the facility.
In one assisted living case taken to verdict in Virginia, plaintiff had fallen during the evening and was placed back in bed (with a hip fracture) by a nurse aid who denied the fall ever happened. Plaintiff was alive at the time the case went to verdict and required ongoing nursing care because of her injuries. The jury rendered a verdict of $1.5 million in compensatory damages.
A brief survey of published assisted living cases results and verdicts across the U.S., reveals the following:
1. **** v. Bixby Knowles Towers; No. NC 021 371, verdict date 04/15/1998. Plaintiff was walking through the dining room when she felt hot coffee spill onto her neck, back and shoulder. She turned away from the coffee and stumbled and fell. One employee acknowledged holding two pots of coffee at the time of injury, but denied spilling coffee on the Plaintiff. Plaintiff suffered a fractured distal femur and first and second degree burns. Verdict was $378,990, with medical expenses totaling $128,000.
2. Wiggins v. St. John’s Terrace Homes, Inc. Docket No. 96-2705-CA; FJVR reference No. 98:7-55 (July 1998) Plaintiff, an assisted living resident, was seated at a dining table when a coffee pot burst open, pouring scalding coffee down Plaintiff’s leg. Verdict of $223,893.
3. Weiland, as Personal Representative of Louise Debenack, v. Alexandra & Co. of Boca Raton, Inc., d/b/a/ The Colonnade at Haverhill, Docket NO. CL 99-00066 AE; FJVR reference No. 01:6-54 Pub.(June 2001). Plaintiff found dead after she developed a UTI that became septic. Upon admission to hospital, plaintiff had a large hematoma which was not explained by the defendant. Settlement for plaintiff for $1 million.
4. Estate of John Doe v. Anonymous Assisted Living Facility. (Reported from the Michigan Trial Reporter, JAS Publication) Settlement of $1,350,000 for an elderly assisted living resident who died from burn injuries sustained while showering. Plaintiff’s theory of negligence alleged that defendant was negligent in not having proper temperature controlling devices for their residents.
5. Davis v. Premium Health Care, Inc. Docket No. 98-20263, Reference No. 01:8-12 (August 2001). Settlement of $300,000 for decedent who developed multiple pressures sores (including a stage IV) while in the facility.
6. Casaletto v. Helen Homes Corp., d/b/a The Palace Gardens, Docket NO.: 01-12468 BA 20; FJVR Ference No. 02:9-44 (Miami, September 2002) Defense verdict involving an 86 year old male who was admitted to an assisted living facility in May and suffered a fall in August of the same year. Plaintiff alleged improper admission and failure to properly supervise. Defendant contended that the decedent was a proper admission and that the level of supervision was appropriate in he ambulated independently. Both parties relied on experts in the area of assisted living administration.
7. Pollock v. CCC Investments I. LLC d/b/a Tiffany House by Marriot, Docket No. 01-16746, Ref. No. 05:3-9 (Florida 2005). Defense verdict involving a resident who was murdered by another resident. Defendant’s argued they had no notice of the other resident’s potential violent conduct. The jury found there was no negligence on the part of defendants that caused plaintiff’s death. They also found there was no violation of the assisted living facility’s resident’s rights under Florida statutory law. Defendant’s highest offer was $750,000 with lowest demand at $9,900,000.
II. Conclusion
As this is a new and evolving area of the law, attorneys who litigate these cases should strive to establish favorable precedents for those who follow. If the recent explosion in nursing home litigation is any indication, assisted living facilities could be the nursing homes of the future. As with nursing home litigation, the civil prosecution of these cases provides an important safeguard in protecting the rights of our elderly and assuring that proper standards are followed in the industry.
[1] Mollica, Robert L. State Assisted Living Policy: 2000. Portland: National Academy for State Health Policy, 2000, Executive Summary.
[2] Issue Brief, Health Policy Tracking Service, National Conference of State Legislatures, October 1, 2002.
[3] Based on a study done by AARP that randomly shopped some 80 assisted living facilities, a pattern of discrepancies was found between what representations were made in the marketing materials versus promises made in the admission’s contract. Two previous surveys that compared marketing materials and assisted living contracts, one by the American Bar Association’s Commission on Legal Problems of the Elderly Consumer Reports, and the other by the U.S. General Accounting Office, revealed similar problems. Adrienne Oleck & Bruce Vignery, Nurture or Neglect? Challenging Deceptive Practices in Assisted Living Facilities, CONSUMER ADVOC., Jan. 2001, 7(1).
[4] See, 42 C.F.R. 483.10 et seq.
[5] Montana law prohibits assisted living facilities from admitting patients who, inter alia, are non-ambulatory, in need of physical/chemical restraints, or unable to self-medicate. MONT. CODE ANN. § 50-5-226 (2002); Florida law prohibits admission of residents who are bedridden, those who have stage III or stage IV pressure sores and those residents who may require 24 hour nursing care. FLA. STAT. Ch. 400.407 (2005).
[6] In Walker, there was evidence that a patient had a history of falls and further that the patient’s doctor had instructed the nurse to leave the bed rails up at all times. A nurse lowered the bed rails and the patient fell. The court held that the plaintiffs were not required to present expert testimony because the breach of care alleged by the plaintiffs, leaving the bed rail down contrary to doctor’s orders, was so apparent as to be understood by a layman.
[7] Risk factors for falling could include dementia, confusion, unstable gait, prior stroke, arthritis, medications usage, history of falls, history of agitated behaviors, vision problems, and weakness or muscle atrophy.
[8] Dorn v. McTigue, 157 F. Supp. 2d 37 (D.D.C. 2001) (holding that District of Columbia Consumer Protection Act applied to the medical profession); Chalfin v. Beverly Enters., Inc., 741 F.Supp. 1162 (E.D. Pa. 1989), reconsideration den., 745 F.Supp. 1117 (E.D. Pa. 1990) (health care services provided by a nursing home were within the scope of “trade or commerce” provisions of Pennsylvania consumer protection laws); Winkler v. Interim Servs., Inc., 36 F. Supp. 2d 1026 (M.D. Tenn. 1999) (Disabled Medicare beneficiaries’ claims against home health care provider for violation of Tennessee Consumer Protection Act were not exempt on the grounds that the provider’s termination of services was regulated by the Medicare Act, given the alleged claims did not arise under the Medicare Act).
[9] According to the National Center of Elder Abuse, www.Elderabusecenter.org/laws, all fifty states and the District of Columbia have enacted legislation authorizing the provision of adult protection services in cases of elder abuse. The statutes vary widely on definitions of abuse, investigation responsibility, and remedies for such abuse.
[10] The Tennessee Adult Protection Act, TENN. CODE ANN. § 71-6-101 et. seq. (2002) does not apply to actions against “health care providers,” as defined in the TENN. CODE ANN. § 63-6-228 et. seq. Alternatively, Tennessee’s Medical Malpractice Act provides the statutory authority to suits against health care providers.
[11] See, Texas Health Enters. V. Geisler, 9 S.W.3d 163 (Tex. App. Fort Worth 1999) (repeated shortages of staffing and other acts of negligence supported punitive damage award against defendant); Estate of McIntyer by & Through Ex’r v. Transitional Health Servs., 1998 U.S. Dist. LEXIS 13965 (M.D.N.C. May 1998) (holding that defendant’s knowledge that it was operating in serious violation of several health codes and that it took very little, if any, action to remedy those violations might reasonably be found to constitute reckless indifference to the rights of their elderly residents with varying medical and non-medical needs); Beverly Enters. – Florida v. Spilman, 661 So. 2d 867 (Fla. Dist. Ct. App. 5th Dist. 1995) (testimony that expert was “outraged” at poor level of care of resident who developed and died from an infected decubitus ulcer supported punitive damage award against corporation and management company). See also, Christopher Vaeth, Allowance of Punitive Damages in Medical Malpractice Action, 35 A.L.R. 5th 145 (1996).
[12] Fair Housing Amendments Act, 42 U.S.C. § 3601 et. seq. (2000).
[13] Americans with Disabilities Act, 42 U.S.C. § 12101 et. seq. (2000).
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