Nurse assistants and home health aides provide intimate care, bathing, feeding and dressing the elderly, disabled or ill. So what happens when an abusive caregiver hurts a patient?
Public health regulators in California have been letting many complaints sit for years even when they involve severe injuries or deaths.
'Beaten To A Pulp'
Elsie Fossum's nieces and nephews say she was the aunt you wanted to have.
"She gave us our first car," Janet Flynn remembers. Her brother, Jim Fossum, chimes in: "A '59 Ford Galaxie 500, with massive fins on it."
Flynn says their aunt, a librarian and teacher who never married or had kids, always looked chic.
"She would come for the summer with this tiny Samsonite suitcase," Flynn says. "And she would be impeccably dressed, mixing and matching, and her hair was always done. Always looked wonderful."
But on the morning of July 3, 2006, Elsie Fossum lay in a pool of blood on the floor of her bedroom at Claremont Place, a Los Angeles-area assisted living facility. The 95-year-old Fossum had lived there for two years.
Her eyes were bruising black, her lip was badly cut, and her right arm was broken. But she was alive.
The lone caregiver on Fossum's floor that night said Fossum fell, but Beverlee McPherson, a registered nurse who supervised nurse assistants at Claremont Place, suspected abuse.
"She looked like she went four or five rounds with Muhammad Ali," McPherson says.
Unable to take much food or water through her swollen mouth, Fossum died of dehydration less than three weeks later. A Los Angeles County coroner could not rule out assault and called the manner of death undetermined.
McPherson is resolute.
"Oh, I'm 100-percent convinced she didn't fall out of bed, 100 percent," she says. "If you saw this woman's face, I mean, her entire face was beaten to a pulp."
'Staying On Top Of Complaints'
Emergency room nurses who treated Fossum at a nearby hospital also suspected abuse. The hospital quickly notified the California Department of Public Health, the agency responsible for decertifying nurse assistants who violate standards of care.
But internal documents obtained by the Center for Investigative Reporting show department investigators shelved Fossum's case for six and a half years.
CDPH Director Ron Chapman blames the delays in handling complaints on a backlog of more than 900 cases that piled up between 2004 and 2008.
"There were a number of reasons for that backlog, including poor management decisions during that time," Chapman says.
The department implemented a plan in 2009 to address the backlog, says Chapman, who was sworn in to his position in 2011.
"In the two years that I've been in the job, there's now new management from top to bottom, and we're staying on top of all the complaints as they come in," he says.
Yet the number of nurse assistants facing disciplinary action following complaints has dropped, from 27 percent a few years ago to 9 percent last year.
Chapman says he sees no evidence that addressing the backlog has undermined the quality of the department's current work, but Marc Parker, who headed the investigations section for nine years, says he was forced to cut corners.
"Hundreds of cases were closed, hundreds, with nothing but a phone call," he says.
'A Failure To Protect'
Parker says without visits to facilities, investigators are unable to see the layout of a room, conduct impromptu interviews, or assess a person's body language. Parker retired in December of 2011, earlier than planned.
"I could not protect the public any longer," he says. "There was just a failure to protect the most vulnerable people in our state from abuse and neglect."
Public health regulators are required to report all suspected crimes to the state attorney general. In the seven years before addressing the backlog, the department referred an average of 37 deaths a year. Last year, they referred three. The year before that, two.
"We don't understand that decline in numbers," Chapman says. "It's very concerning to me and we are looking into it." He says his staff is drafting agreements with the attorney general's office to improve communication.
As for Elsie Fossum's suspicious death, department investigators closed her case this year, and decided no action was warranted against her caregiver.
Also this year, however, the Los Angeles County Sheriff's Department opened a homicide investigation into Elsie Fossum's death. Her caregiver is the sole person of interest. Chapman now says he's willing to review the case.
Elsie Fossum's nephews and niece say they never heard from the Department of Public Health. Flynn says their calls and emails to state agencies and local police have turned up little information.
"I would think that this would be very chilling to anyone who has loved ones in a facility, especially if you think safeguards are in place and you think that staff are qualified and that this is being regulated, and this I find chilling," Flynn says.
This story was co-reported by Ryan Gabrielson at the Center for Investigative Reporting.