Prolonged Hospital Stays for Disabled Are Criticized in D.C.

Sheila J., a ward of the District with mental and physical disabilities, was admitted to Washington Hospital Center in October with internal bleeding and pneumonia and was deemed ready for release a few weeks later.

But the 54-year-old patient didn't leave her hospital bed until Feb. 9 -- 91 days after doctors gave the okay. The hospital had to go to court to force the city to find another place for her.

Sheila J.'s case, lawyers and D.C. officials say, is a glaring and costly example of an increasingly common problem: needlessly prolonged hospital stays for the city's most vulnerable residents.

Some of the District's mentally retarded and mentally ill are spending extra weeks and sometimes months in hospitals because of a shortage of group homes and nursing facilities that care for them after hospitalizations. Stays also are drawn out because of delays in appointing guardians who can authorize transferring them from the hospitals.

"For too many of these patients, we're being used as a hotel because the D.C. bureaucracy can't get itself together," Kenneth H. Rosenau, an attorney for Washington Hospital Center, said in an interview. "We're a very expensive hotel."

Details of Sheila J.'s case and others were drawn from court records. The Washington Post is not using the full names of patients to protect their privacy.

Overly long hospital stays were one of many problems cited last week by a federal court monitor in a report that assessed the District's services for about 2,000 mentally and physically disabled residents. The monitor expressed concern about the case of a man, identified as C.P., who has spent more than three months in a hospital while waiting to move to a nursing home.

Rosenau has represented Washington Hospital Center and Georgetown University Medical Center in court battles with the city's Mental Retardation and Developmental Disabilities Administration and helps handle cases involving hospital stays and guardianships.

D.C. officials were unable to provide overall figures to help gauge how often these prolonged hospitalizations occur or how much they cost. Rosenau said that the eight or nine cases he had last year involved about $3 million to $4 million in costs.

"It adds up very quickly, and that's just the problem cases that make it to my desk," he said. "I usually don't get called in until a patient has been there 60 days or more beyond their discharge date."

Rosenau stressed that money is not the issue for his clients because Medicaid picks up 90 percent of the bill. Instead, hospitals often resort to legal action to keep patients from picking up infections -- and to free up bed space.

"It's not good medicine to keep a patient in the hospital a long time," he said.

Washington Hospital Center went to court in December to get expedited action in the case of Donald B., a 64-year-old pneumonia patient who had been ready for discharge for more than a month.

"The hospital is in dire need of this bed," Rosenau argued in his petition, noting that it had temporarily closed its emergency room to ambulances because there was no room for new patients.

Sheila J.'s and Donald B.'s hospital stays were lengthy because of complicated issues that involved naming guardians and finding facilities that could provide for their special needs, court documents show. Her nursing home refused to take her back because she needed assistance with a breathing device after a tracheotomy. His group home refused to take him back because the hospital had fitted him with a feeding tube in his stomach -- so he wouldn't choke while eating -- and no one at the home was trained to use it. Both were eventually moved.

Marsha Thompson, interim director of the city's mental retardation agency, said securing guardianships and appropriate, quality placements are "two huge issues" that lengthen hospital stays.

"I do not have providers on board today who can take these very, very fragile people and support them safely," she said. "I'm doing outreach to other states to see if providers will come in."

Except in life-threatening emergencies, the District requires family members or designated guardians to give consent for medical treatment or to move someone from a hospital to a long-term acute care facility.

Even those who aren't hospitalized suffer. Routine but no less urgent medical procedures are often held up while guardians are named by the court, which can take one to three months or more.

"I have people waiting with a painful toothache, waiting for biopsies, waiting for a colonoscopy," said Sandy Bernstein of University Legal Services, which represents hundreds of former residents of Forest Haven, the District's former institution for the mentally retarded.

The mental retardation administration used to be able to authorize medical procedures. The D.C. Council, concerned that the agency might have a budgetary conflict of interest, recently removed it as a decision-maker and set up a system using other surrogates. "We wanted it to be someone who has a relationship with the person," said council member Vincent C. Gray (D-Ward 7), who sponsored the legislation. "The downside is that not everyone has someone like that in their life."

In those situations, the court appoints temporary guardians.

Tina Campanella, executive director of the advocacy group Quality Trust, argues that just because people are wards of the city doesn't mean they are incompetent or incapable of being involved in decisions about their health care.

But whatever the circumstances, people "should make health care plans in advance," she said. "It's a whole lot easier if you plan ahead for the supports you need than if you try to figure it out on the fly."