Even Grave Errors at Rehab Hospitals Go Unpenalized and Undisclosed

Rehab hospitals that assist folks recuperate from main surgical procedures and accidents have change into a extremely profitable slice of the well being care enterprise. However federal knowledge and inspection experiences present that some run by the dominant firm, Embody Well being Corp., and different for-profit firms have had uncommon however severe incidents of affected person hurt and carry out beneath common on two key security measures tracked by Medicare.

But even when inspections reveal grave instances of damage, federal well being officers don’t inform customers or impose fines the way in which they do for nursing houses. And Medicare doesn’t present easy-to-understand five-star rankings because it does for normal hospitals.

In probably the most severe issues documented by regulators, rehab hospital errors concerned affected person deaths.

In Embody Well being’s hospital in Huntington, West Virginia, Elizabeth VanBibber, 73, was fatally poisoned by a carbon monoxide leak throughout building on the facility.

At its hospital in Jackson, Tennessee, a affected person, 68, was discovered useless in a single day, mendacity on the ground in a “pool of blood” after an alarm that was purported to alert nurses that he had gotten off the bed had been turned off.

In its hospital in Sioux Falls, South Dakota, a nurse gave Frederick Roufs, 73, the flawed drug, certainly one of 26 medicine errors the hospital revamped six months. He died two days later at one other hospital.

“I can nonetheless see Fred laying within the mattress as they shut every little machine off,” mentioned his widow, Susan Roufs. “They clicked 4 of them, after which the love of my life was gone.”

Embody, which owns 168 hospitals and admitted 248,000 sufferers final 12 months, has led the transformation of this area of interest business. In 2023, stand-alone for-profit medical rehabilitation hospitals overtook nonprofits because the locations the place the vast majority of annual affected person admissions happen, a KFF Well being Information and New York Occasions evaluation discovered. A 3rd of all admissions had been to Embody hospitals. Such services are required to supply three hours of remedy a day, 5 days per week.

Throughout the nation, there at the moment are practically 400 stand-alone rehab hospitals, the majority of that are for-profit. These hospitals collectively generate income of 10%, greater than normal hospitals, which earn about 6%, and way over expert nursing houses, which make lower than 0.5%, in response to the newest knowledge from the Medicare Cost Advisory Fee, an impartial congressional company.

On the similar time, the variety of small, specialised models inside acute care hospitals — the place most rehab was supplied — has dwindled. There at the moment are round 800 of these, and most are nonprofits.

In its newest annual report, Embody, which is publicly traded, reported an 11% internet revenue in 2024, incomes $597 million final 12 months on revenues of $5.4 billion.

Federal knowledge on the efficiency of about 1,100 of the rehab services present Embody tends to be higher at serving to most sufferers return dwelling and stay there. In a two-year interval ending in September 2023, Medicare rated 233 rehab services as performing higher than the nationwide charge for this main metric, known as “discharge to group.” Most rehabs with higher group discharge charges are for-profit, and Embody owns 79 of them.

However knowledge from Medicare additionally reveals Embody owns most of the rehabs with worse charges of probably preventable, unplanned readmissions to normal hospitals. Medicare evaluates how typically sufferers are rehospitalized for situations which may have been averted with correct care, together with infections, bedsores, dehydration, and kidney failures.

Embody accounts for about 1 in 7 rehab services nationally, however owned 34 of the 41 inpatient rehab services that Medicare rated as having statistically considerably worse charges of probably preventable readmissions for discharged sufferers. (Total, charges of readmission after discharge ranged from 7% to 12%, with a median of 9%.)

And it owned 28 of the 87 rehab services — 65 of which had been for-profit — that had worse charges of probably preventable readmissions to normal hospitals throughout affected person stays. (The median for these sorts of readmissions was 5%, and charges for particular person rehabs ranged from 3% to 9%.)

Patrick Darby, the manager vp and normal counsel of Embody, strongly defended the corporate’s file in written responses to questions. He dismissed Medicare’s readmissions rankings of “higher,” “worse,” and “no completely different than the nationwide charge” as “a crude scoring measure” and mentioned “efficiency is so related throughout the board.” He known as the violations discovered throughout well being inspections “uncommon occurrences” that “don’t assist an inference of widespread high quality issues.”

“The only and most correct motive for EHC’s success is that our hospitals present superior care to sufferers,” he mentioned, referring to Embody by its company initials.

Chih-Ying Li, an affiliate professor of occupational remedy on the College of Texas Medical Department at Galveston Faculty of Well being Professions, mentioned in an interview {that a} analysis research she performed discovered the revenue standing of a rehab facility was the one attribute related to greater unplanned readmissions.

“The discovering is fairly sturdy,” she mentioned. “It’s not like enormous, enormous variations, however there are variations.”

Alarming Errors

Since 2021, the federal Facilities for Medicare and Medicaid Companies, or CMS, which oversees well being inspections, has discovered that 10 Embody hospitals, together with the one which cared for VanBibber, had instant jeopardy violations, federal data present. Such violations — like those that Medicare additionally present in reference to the deaths of Roufs and the affected person who fell after leaving his mattress — imply a hospital’s failure to adjust to federal guidelines has put sufferers in danger for severe damage, severe hurt, severe impairment, or demise.

Darby, the overall counsel for Embody, mentioned the corporate regretted any scientific issues and had promptly addressed all such findings to the satisfaction of inspectors. He mentioned Embody that has an “wonderful compliance file,” together with superior outcomes from its accreditation company, and that its general variety of well being citations was tiny given what number of hospitals Embody owns and what number of sufferers it treats.

Six different corporate-operated for-profit hospitals had been additionally cited, whereas not one of the 31 stand-alone nonprofit rehab hospitals obtained such violations from 2021 to 2024. (Inspection experiences for normal hospitals don’t systematically specify during which a part of the constructing a violation occurred, so rehab unit violations can’t be recognized.)

An alert known as a mattress alarm was on the root of instant jeopardies at Embody hospitals in Morgantown, West Virginia, and Jackson, Tennessee. The gadgets are pressure- and motion-sensitive and emit a sound and show a lightweight to alert workers members that somebody at a excessive danger of falls has left his or her mattress.

In its Morgantown hospital, a nurse technician found a affected person face down on the ground with a big gash on her head after a faulty alarm didn’t go off, an inspection report mentioned. After she died, the nurse informed inspectors: “We’re having a whole lot of issues with the mattress alarms.”

Medicare shouldn’t be approved by legislation to nice rehab hospitals for security rule violations, even ones involving deaths uncovered throughout inspections, because it has carried out with practically 8,000 nursing houses over the past three years, imposing common fines of about $28,000.

The one choice is to thoroughly minimize off a rehab hospital’s reimbursement for all companies by Medicare and Medicaid, which cowl most sufferers. That step would most certainly put it out of enterprise and is sort of by no means used due to its draconian penalties.

“Termination is often a final resort after working with the supplier to return again into compliance,” Catherine Howden, a CMS spokesperson, mentioned in an e-mail.

In consequence, as a result of there’s no graduated penalty, even probably the most severe — and uncommon — instant jeopardy violations successfully carry no punishments as long as the hospital places steps in place to avert future issues.

“Solely having a nuclear weapon has actually damage affected person security,” mentioned Michael Millenson, a medical high quality advocate.

One instant jeopardy incident did end in a punishment, however solely as a result of the hospital was in California, which permits its well being division to subject penalties. Embody’ Bakersfield hospital paid a $75,000 nice final 12 months for failing to regulate the blood sugar of a affected person who died after her coronary heart stopped.

Speedy Development and a Troubled Historical past

Embody has accelerated its growth in recent times and now operates in 38 states and Puerto Rico. It plans to open 17 extra hospitals in Arizona, Connecticut, Florida, Georgia, Maine, Pennsylvania, South Carolina, Texas, and Utah by the top of 2027, in response to its newest report.

It regularly strikes into new markets by persuading native nonprofit hospitals to shutter their rehab models in trade for an fairness stake in a newly constructed Embody hospital, firm executives have informed traders.

The president of Embody, Mark Tarr, calls it a “win-win proposition”: The native hospitals can use their emptied area for a extra profitable line of service and Embody will get a “bounce begin” into a brand new market, with companion hospitals typically referring sufferers.

Tarr, who was paid $9.3 million in compensation final 12 months, informed traders that Embody requires that the prevailing hospitals signal a noncompete deal. Sixty-seven Embody hospitals are joint ventures, largely with nonprofit hospitals as traders, in response to the corporate’s June monetary submitting, the newest out there.

Darby mentioned the corporate’s income permit it to construct hospitals in areas that lack intensive inpatient rehabilitation and enhance present hospitals. “Excessive-quality affected person care shouldn’t be solely in line with shareholder return, however high quality and shareholder return are in reality vital to at least one one other,” he mentioned.

The success of Embody is especially notable provided that it barely survived what consultants mentioned was one of many largest trendy accounting scandals in 2003.

The Securities and Change Fee charged that the corporate, then referred to as HealthSouth, overstated earnings by $2.7 billion to fulfill Wall Avenue analyst quarterly expectations, resulting in the ouster of its founder and administrators. In 2004, the corporate agreed to pay the federal government $325 million to settle Medicare fraud allegations with out admitting wrongdoing. Darby credited the corporate’s new leaders for acquiring a $2.9 billion judgment on behalf of shareholders towards the corporate’s founder.

The corporate modified its identify to Embody in 2018 after buying Embody House Well being and Hospice. In 2019, the Justice Division introduced the corporate had agreed to pay $48 million to settle whistleblower lawsuit claims that it misdiagnosed sufferers to get greater Medicare reimbursements, and admitted sufferers who had been too sick to learn from remedy. The corporate denied any wrongdoing, blaming impartial physicians who labored at its hospitals. Darby mentioned Embody settled the case solely to “keep away from extra years of expense and disruption.” He mentioned the Justice Division by no means filed a lawsuit regardless of years of investigation.

Remedy Harms

Rehab hospital inspection experiences are usually not posted on Care Evaluate, Medicare’s on-line search device for customers. KFF Well being Information needed to sue CMS below the Freedom of Info Act to acquire all its inspection experiences for rehab hospitals. In distinction, Care Evaluate publishes all nursing dwelling inspection experiences and assigns every facility a star score for its adherence to well being and security guidelines.

So folks now selecting a rehab hospital wouldn’t know that on the Embody hospital in Sioux Falls, South Dakota, in 2021, a nurse by accident gave Roufs a blood strain drug known as hydralazine as an alternative of hydroxyzine, his prescribed anti-anxiety medicine, in response to an inspection report. Roufs went into cardiac arrest. The sort of error, known as a “look-alike/sound-alike,” is one hospitals and workers members are purported to be particularly alert to.

Months earlier than, an inner security committee had recognized a pattern of medicine errors, together with when a nurse by accident gave a affected person 10 instances the prescribed quantity of insulin, sending him to the hospital, the inspection report mentioned. The nurse had misinterpret 4 models as 40. Since Roufs’s demise, inspectors have faulted the hospital six instances for numerous lapses, most not too long ago in April 2024 for improper wound care.

An Embody hospital in Texarkana, Texas, misused antipsychotic drugs to pacify sufferers, leading to a right away jeopardy discovering from CMS, the report mentioned. And the corporate’s hospital in Erie, Pennsylvania, was issued a right away jeopardy violation for not preserving monitor of medicine orders in 2023, when a affected person had a cardiac arrest after not receiving all of his medicine, in response to the inspection report.

The federal authorities’s general high quality oversight efforts are restricted. Medicare docks fee to rehab services for sufferers readmitted to a normal hospital throughout shorter-than-average rehab stays, however not like at normal hospitals, there are not any monetary penalties when not too long ago discharged rehab sufferers are hospitalized for vital well being points.

The Biden administration introduced final 12 months it meant to develop a score scale of 1 to five stars for rehab services. The business’s commerce affiliation, the American Medical Rehabilitation Suppliers Affiliation, requested a delay within the creation of star rankings till the present high quality measures had been refined. The Trump administration has not decided whether or not it can proceed the hassle to charge rehab services, in response to a CMS spokesperson.

Lethal Bedsores

The household of Paul Webb Jr., 74, claimed in a lawsuit that the Embody hospital in Erie left Webb unattended in a wheelchair for hours at a time, placing strain on his tailbone, in 2021. His medical data, supplied to reporters by the household, checklist a sitting tolerance of 1 hour.

Webb — who had been initially hospitalized after a mind bleed, a kind of stroke — developed pores and skin injury referred to as a strain sore, or bedsore, on his backside, the lawsuit mentioned. The swimsuit mentioned the sore worsened after he was despatched to a nursing dwelling, which the household can be suing, then dwelling, and he died later that 12 months. In his remaining weeks, Webb was unable to face, sit, or transfer a lot due to the damage, the lawsuit mentioned.

In courtroom papers, Embody and the nursing dwelling denied negligence, as Embody has in another pending and closed lawsuits that accused it of failing to forestall strain sores as a result of nurses and aides did not recurrently reposition sufferers, or discover and deal with rising sores. Darby mentioned Webb’s demise occurred three months after his Embody keep and was not associated to his care at Embody. He mentioned no hospital with long-term sufferers may forestall each new or worsening strain sore, however that Embody’ charges had been just like the 1% nationwide common.

One among Webb’s sons, Darel Webb, recalled a warning given to the household as they left an appointment their father had with wound specialists: A health care provider introduced up Christopher Reeve, the actor who performed Superman in films within the Seventies and Nineteen Eighties.

“He goes, ‘Bear in mind, Superman was paralyzed from falling off the horse, however he died from a bedsore,’” he mentioned.

Jordan Rau has been writing about hospital security since 2008. Irena Hwang is a New York Occasions knowledge reporter who makes use of computational instruments to uncover hidden tales and illuminate the information.

METHODOLOGY

To look at the medical rehabilitation hospital business, we obtained and analyzed a database of inspection experiences of freestanding rehabilitation hospitals from the federal Facilities for Medicare & Medicaid Companies, or CMS. We additionally obtained inspection experiences from a number of states by way of public data requests.

We analyzed inpatient rehabilitation facility traits and affected person quantity knowledge contained in hospital knowledge information from the Rand Corp., a nonprofit analysis group. This dataset compiles value experiences all hospitals submit annually to CMS. For every facility for the years 2012 to 2023, we categorized annual discharges by facility kind (freestanding rehabilitation hospital or unit inside an acute care hospital); facility possession standing (for-profit, nonprofit, or authorities); and which hospitals had been owned by Embody Well being below its present or prior identify, HealthSouth.

Monetary details about Embody Well being was obtained from the corporate’s Securities and Change Fee disclosure filings.

We examined the readmission charges for all inpatient rehabilitation services that CMS publishes in its high quality knowledge. CMS evaluates the frequency with which Medicare sufferers had been readmitted for probably preventable causes to an acute care hospital throughout their rehab keep. Individually, CMS additionally evaluates the frequency of probably preventable readmissions to an acute care hospital inside 30 days of discharge from rehab. We additionally examined the speed of profitable return to dwelling or group. Figures for all three metrics had been out there for about 1,100 of the roughly 1,200 rehab services within the CMS knowledge. The newest readmission knowledge lined Medicare discharges from October 2021 by way of September 2023.

We examined nursing dwelling penalties from the final three years from CMS’ knowledge on nursing houses.

KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is among the core working packages at KFF—an impartial supply of well being coverage analysis, polling, and journalism. Be taught extra about KFF.

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