Case: CRIPA Investigation of the W.F. Green State Veterans’ Home in Bay Minette, Alabama

On November 8, 2007, pursuant to the Civil Rights of Institutionalized Persons Act ("CRIPA"), 42 U.S.C. §§ 1997 et seq., the Civil Rights Division of the U.S. Department of Justice ("DOJ") conducted an investigation of conditions at the William F. Green State Veterans’ Home (W.F. Green), a state-operated nursing home/facility in Bay Minette, Alabama. W.F. Green served about 150 veterans of the armed forces and their family members.

On December 18, 2008, the DOJ issued a findings letter regarding the inadequate conditions of W.F. Green. First, the DOJ found that W.F. Green inadequately assessed and cared for its residents’ health care needs. Generally, nursing homes are expected to develop and implement care plans that address each resident’s needs. W.F. Green failed to assess residents’ conditions as they changed, which, in some cases, resulted in serious injury. An example of such a situation was the case of Mr. R, who, before arriving at W.F. Green, had a history of falling. He had four serious falls before the staff of W.F. Green even thought about addressing his multiple risk factors for falling. The falls resulted in neurological damage. Additionally, the DOJ found that the training that the staff received also resulted in an unacceptable risk of the transfer of communicable diseases.

Second, the residents received inadequate nutritional and hydration care. Of particular concern to the DOJ was that there were very few protocols in place to address resident loss, and the nursing staff consistently failed to investigate significant, unplanned resident weight loss. When weight loss was addressed, it was usually addressed ineffectually; for example, W.F. Green often provided supplements in response to weight loss, but they were not enough to meet a residents’ needs. Additionally, the hydration measures were unsatisfactory as well. Nursing staff often ignored fluid orders, and water was nowhere to be found by residents’ besides.

Third, W.F. Green used psychotropic medications dangerously and inappropriately. Typically, psychotropic medications are only acceptable if they are necessary. Unnecessary medication is defined in federal law as any medication that is excessive in dose or duration, that is prescribed without adequate monitoring, or that is prescribed without a specific target symptom. W.F. Green would use psychotropic medicine in the absence of target symptoms and for indefinite durations, but most egregiously, it had practically no oversight of the psychotropic medicine use.

Fourth, nurses were inadequately trained in how to spot and prevent pressure sores and skin issues, which are common in nursing homes.

Fifth, the rehabilitative care at W.F. Green was unusually sparse. W.F. Green additionally lacked the space and facilities to provide more rehabilitative services. The lack of facilities also extended to lack of other rehabilitative tools, like wheelchairs. Wheelchairs at W.F. Green were ill-fitting, which resulted in a higher risk of falls and injuries resulting from poor circulation.

In its findings letter, the DOJ set out some necessary remedial steps, including providing adequate medical care, adequately supervising all clinical disciplines, providing residents with adequate nutrition and hydration, bringing pharmacological practices within generally accepted standards, increasing activities for residents, instituting measures for preventing bed sores, instituting polices to prevent falls and patient abuse, and reducing the uses of restraints. In addition, the findings letter briefly mentioned the obligation under the Americans with Disabilities Act, as interpreted in Olmstead v. L.C., 527 U.S. 581 (1999), to provide services in the most integrated setting practicable for eligible patients.

According to several annual congressional reports beginning Fiscal Year 2008, the Civil Rights Division also considered this matter part of its "New Freedom Initiative," an effort to enforce the ADA's integration mandate. The reports explained that the Division was working with W.F. Green to increase integration with respect to residential, day, and vocational services for its residents. In particular, as a state-run facility, W.F. Green had an obligation to discharge eligible residents to the most integrated setting appropriate for their needs. W.F. Green, in violation of this mandate, left its residents adrift when it discharged them, and it did not tailor the discharge to each resident’s individual needs.

On January 11, 2011, the DOJ and Alabama agreed to an out-of-court Memorandum of Understanding. Within nine months, W.F. Green was expected to increase the supervision and training of its staff, to provide individualized care plans for its residents, to develop policies that ensure that residents get adequate nutritional and hydration care, including engaging a dedicated dietitian who receives regular training, to use psychotropic drugs only in accordance with individualized resident care plans, to develop and institute a pressure sore program to prevent sores, to provide a screening program to identify patients who need rehabilitation and to provide that rehabilitation.

Additionally, W.F. Green was expected to take all steps necessary to prevent falls and to prevent abuse, be it from other residents or neglect and mistreatment by staff.

Finally, the agreement outlined what was expected of W.F. Green with regards to integrating its residents into the community. Upon admission, residents were to be screened to see if they truly needed a nursing home environment. Initial comprehensive assessments needed to evaluate whether a patient desired to be discharged into the community. Quarterly, annually, and upon significant change, W.F. Green was to analyze whether the resident could be served in an integrated community setting. If the resident could be served in a less restrictive setting, professionals were to evaluate what services would be necessary to help the resident’s transition.

In 2013, the DOJ closed this matter, noting in that year's congressional report that W.F. Green had “fully complied” with the Memorandum of Understanding, that health of the residents had improved, and that residents were better able to be served in more integrated settings.