Almost everyone running a nursing home knows what causes the problems that lead to illness, death and lawsuits over bad care. Dr. John Morley, a nationally renowned gerontologist at St. Louis University, knows how to solve them. 

Eight nursing homes in the St. Louis area pay the university "embarrassingly big bucks" for Morley's expertise, he says. 

It began in 1992, when the new administrator of a nursing home in Maryland Heights approached SLU officials for help. National Health Care had just reopened the former Villa Capri Nursing Home. 

The history was not good. State regulators had ordered Villa Capri closed, and prosecutors had sought felony neglect charges against several employees and the former owner, Beverly Enterprises. Beverly later sold the home and paid a $1 million settlement to avoid criminal prosecution. None of the employees was convicted. 

The new administrator, struggling to overcome the reputation and various new problems, agreed to pay the university $60,000 a year in return for help caring for the home's 130 residents. 

The university turned to Morley, who arrived at SLU in 1989 with three others from the geriatrics faculty at the University of California at Los Angeles. He became the nursing home's medical director, a position he now assumes at all the troubled homes he helps. 

This summer, Morley walked with a visitor through the tree-shaded home, now named NHC Healthcare of Maryland Heights, and drew a deep breath to emphasize how far the once-troubled facility has come. 

"It used to stink of urine," said Morley, a bearded, burly South African with a booming laugh. 

Today, company officials say the home serves as a model for quality in the National Health Care chain. 

Morley's cure consists of a mix of basic management principles and sound medical practices administered in digestible doses. 

He and other experts cite several keys for turning around a troubled home. They include a recognition by owners and administrators that problems exist, that the problems will take time to fix and that everyone on the staff must be committed, enthusiastic and constantly focused on improvement. And there must be some Medicare or private pay residents to generate enough money to make the necessary fixes. 

It is those attributes that can commonly be found in well-run homes that provide high-quality care. 

"Continuous quality improvement" 

During a two-hour "quality control" meeting that Morley holds every month at the Maryland Heights home, each of about 20 staff members reports on the staffer's latest effort to improve things. They talk in detail about record keeping, staff development, family outreach, wound treatment, pharmacy operations, room temperatures and urinary tract infections. 

At one such meeting this summer, Morley sat, chin in hand, and listened before frequently breaking in with a question, a suggestion or comment. He offered generous praise and the occasional wisecrack. 

The constant collection and review of data is a hallmark of Morley's management philosophy. Morley uses the information to spot trends and set goals. 

"All we do is continuous quality improvement," Morley said. 

But that improvement isn't always immediate. Many of the homes he works with are not nearly as far along as the Maryland Heights facility. 

"The places that really need fixing need a lot of time, and they need a lot of individual attention," Morley said. 

In 1992, Morley and his team spent their first month at the Maryland Heights home wandering the halls, talking to patients and staff and quietly observing. 

"You just try to work out what's good and what's bad," Morley said. "Once you do that, you look at what's very bad." 

He found the home's residents malnourished and dehydrated, a third of them suffering from bedsores. The home used physical restraints on half the residents, keeping them tied down in bed or strapped into wheelchairs. 

Morley set priorities to cut restraint use, curb weight loss and heal bedsores. His most important allies would be nurse's aides who serve as the frontline caregivers. "One of the keys is to create an ethic where everyone feels they are part of the team and they're going to make a difference," Morley said. 

"Perhaps the hardest part of fixing any place is convincing the administrator that they should allow people who are not always well-enough trained or have enough knowledge to actually take over and make their own decisions and support them in those decisions. When you take control away from people, they stop trying to fix things. They stop working hard." 

Let employees find the solution 

Morley said he asked the employees their suggestions for improvement. 

"Let the people who are going to do it every day come up with the solution," he said. "A lot of the problems in nursing homes are fixable purely by people paying attention." 

He then set modest goals for improvement, such as cutting the number of residents with bedsores by 5 percent over two or three months. 

"You're looking for things where you can give positive reward for small improvement," Morley said. "You don't fix it all today." 

Another important step is to identify the best employees. In some cases, even those employees may not fit into long-term plans for improvement. 

"It's just that they're more functional than anybody else you have," Morley said. "In the end, you're going to have huge turnover, but you can't get rid of everybody today. What you want in the end is the system to run without us going in and telling people what to do. Otherwise we're totally useless." 

Over time, the staff nearly eliminated restraint use and weights stabilized. Bedsores are now infrequent. 

Educating the doctors 

As medical director, Morley said, he tries to work closely with fellow physicians who have patients in the home, reviewing charts, offering suggestions or teaching state-of-the-art care. 

Many doctors serve only a few nursing home patients and are not experts in geriatrics, he said. 

"Whenever you get a facility that is struggling, you're going to have physicians who are struggling," Morley said. "They tend to do things to people that might be very good if they are fairly healthy and out in the community and terrible for them in a nursing home." 

That may include prescribing too many medications or an inappropriate diet. 

Even minor changes in treatment can lead to significant improvement for a nursing home resident. 

After taking over at Maryland Heights, for example, Morley found many of the residents overmedicated and on improper low-salt diets. 

"If we can cut medication by a third, that means we save a nurse time to go and deal with other things," Morley said. "If we can get rid of the therapeutic diets, that means people can spend more time feeding rather than trying to figure out a diabetic diet or low-salt diet or this diet or that diet." 

Morley said physicians are poorly educated in nutrition care and pressure ulcers. 

"Most of the time physicians don't even notice that there's malnutrition," Morley said. "Malnutrition has been called the skeleton in the hospitals' cupboard because physicians don't even see it." 

Morley said many homes don't pay enough to attract quality medical directors. 

"What you finish up with is often paying the person to show up for one one-hour meeting a month and they want the meeting to get over with as quickly as possible, because they get paid for being at the meeting," Morley said. "That's not good management." 

Regulators complain about "doorway doctors" who do little more than poke their heads into a room and then bill for a visit. 

The dumping grounds 

Many of the worst homes struggle to fill beds, and they become dumping grounds for some of the most difficult patients, Morley said. 

"When a place is struggling, they get every single pressure ulcer, they get everything that nobody else wants, because they need to take people to stay alive," Morley said. "All the nursing homes cherry pick. Very few top-class nursing homes take difficult-to-manage people. So you've got to improve and not take every difficult-to-manage person or you're never going to survive." 

Morley said the ability to attract private pay residents is critical to turning around a poor home. 

Government Medicaid reimbursements are so low that it leaves little left over to improve patient care, he said. 

"You've got to get the facility to the point where you can sell it to people," Morley said. "If you're three-quarters full, you can't staff appropriately and you're not going to make enough money to be able to really do all the things you need to do." 

At Maryland Heights, the percentage of private pay residents increased from 5 percent to nearly 40 percent during the last decade, he said. 

"A totally Medicaid home, with no other support, is going to struggle," he said. "They're not going to be able to do all the things we did at Maryland Heights, which is a totally different facility at this stage, certainly a facility that anyone would be happy to be in." 
 

After more than 50 years as man and wife, living together in the same house, bearing a son and raising him, Lawrence and Virgie Carroll all but shared each breath. They walked together in Handy Park, read Scripture and attended church regularly, listened to their favorite old jazz recordings and entertained 
musician friends around their kitchen table. Despite Lawrence's love and best efforts, however, Virgie's health was failing. He could barely face the inevitable — that he wasn't strong enough and couldn't be attentive enough to keep his frail wife from danger. It was clear to their only child, Mark, that he had to do something to help his mother, his father — and himself. 

Mark Carroll first noticed that something didn't seem quite right with his mother on the day he wed Lisa Holten in late spring 1997. At the outdoor reception, Virgie, dressed in a simple beige frock, sipped lemonade beneath a shade tree. 

"I noticed that she was there but wasn't there. It was like she was in a fog," Mark said. "I remember Lisa saying 'Is your mother OK?' " 

What started as confusion led to the occasional inability to complete sentences. After about two months of wondering whether something was wrong with his wife, Lawrence took Virgie to the doctor. 

The diagnosis: dementia. Three years later, a new diagnosis: Alzheimer's. Last year, another disease was added: Parkinson's. 

Over the past few months, the Alzheimer's has stolen her mind. The Parkinson's has ravaged her body. 

"Stand up, baby. Come on with daddy," coaxes Lawrence, 77, his arm around Virgie's shoulder as he tries to get her down the stairs to start their day. Virgie, 75, moves slowly. Her 115-pound body hangs on to her husband, just 20 pounds heavier, for balance. 

Her husband clings to the hope that a new drug from Germany might slow the progression. He wants his spirited wife back, the one he affectionately called "Ironsides." 

Lawrence remembers his "girl" as the woman who water-skied at their summer home at Lake of the Ozarks, who was one solo flight short of getting her private pilot's license, who taught kindergarten for 38 years, who played the piano at church and who loved the old Negro spirituals. 

And he prays for her return. 

But her son is eyeing a different version of the future. He has already been exploring alternatives. 

On a friend's recommendation, Mark tours a nursing home near Tower Grove Park. At 43, Mark is uneasy becoming the parent to his parents, but he takes comfort in the planning. 

"Mother talked to me all the time about aging," Mark says. "She would say that 'if I get ill and you need to put me in a home, you do what's best.' She was very comfortable with her mortality." 

Mark knows it is only a matter of time before calamity will strike. 

It hits first on a morning last spring. Virgie falls. Two days later, when Lawrence brings her to the adult day-care center she normally attends, staff members notice that she seems lethargic. They dial 911. An ambulance picks up Virgie and carries her to the emergency room, where doctors conclude that her new medicine needs adjustment.

Since she is weak and can't walk, an ambulance also takes her home. Paramedics carry her upstairs to her bed. Lawrence hovers. 

"If Mother (Virgie) and God decided today is her last day, I'm OK with that," he says, watching the ambulance leave his driveway. "I'm trying to do the right thing. All I can ask is for the Lord to help me." 

Two weeks later, on a Friday, Virgie falls down the stairs. And — if a few bruises are any indication — Lawrence tumbles down a couple with her. Not one to complain, he picks her up, brushes her off, and takes Virgie to day-care as usual. 

This time, staff members notice a bump on Virgie's head. They call Mark, who picks her up at day care and takes her to the hospital. This was it as far as he was concerned. 

With his mother in the hospital for observation, Mark spends the next three days lining up her future at Beauvais Manor on the Park, a nursing home at South Grand Boulevard and Magnolia Avenue. 

On Tuesday, Mark tells a social worker to have an ambulance take Virgie to her new home. 

"We're giving her the best care she deserves," says a weary Mark after spending the long weekend bouncing between Virgie's hospital room and taking care of his newborn son, Julian. 

Nearby, Lawrence sits silently in his son's office, head and shoulders bent forward, fingers clasped. Mark glances at his father and back at his computer screen as he works to finish a project. 

Then he looks back at his father again, remembering how carefully Lawrence had put Virgie's hat on her head, purse on her arm, earrings on her earlobes and lipstick on her lips. 

"There are a lot of folks out there that say they love their loved ones, but not many who go as far as Daddy's gone," Mark says. 

While Lawrence is missing Virgie on the first Sunday that he attends the Westminster Presbyterian Church without her, he has something to look forward to. 
He is singing a solo with the choir. 

Lawrence's remarkable tenor is strong and steady as he sings, "His Eye is on the Sparrow." The words of the old hymn seem today to have a special meaning: "Whenever clouds arise . . . When hope within me dies . . . I draw closer to Him . . . His eye is on the sparrow . . . And I know He cares for me." 

The service ends. Lawrence walks down the stairs from the choir loft into the warm embrace of congratulations from friends. 

Conversation quickly turns to Virgie. 

Lawrence explains that she went into the nursing home last week. "She's doing as well as can be expected," he says. Perhaps one Sunday, he'll pick her up and bring her back to church, to the place where his son walked down the aisle five years earlier. 

He is hopeful. 

But now he paces uneasily at a coffee and cake reception after the morning service. He obviously wants to be somewhere else. He does not stay long. 

A quick ride home is followed by an equally brisk change of clothes. His suit and tie give way to shorts, shirt and his ever-present ball cap. He points his Honda to the east and heads for Beauvais Manor, where he's wanted to be all day. 

Lawrence is going to see his bride.