Relocating Nursing Home Residents Can Be Fatal. Is a Wave of ‘Transfer Trauma’ Coming?

Betty Jo Artrip's favorite spot in Mountain View Regional Hospital, her nursing home of more than seven years, was the window at the end of her corridor. She affectionately called the spot the ridge, for its view of an Appalachian mountain. It wasn't the most spectacular vista — more of a hillside than a hilltop — but she loved it, nonetheless.

Most days, after breakfast and a bath, Betty would roll down to the ridge in her wheelchair to meet her friend Amanda. Dementia hindered their ability to communicate much, but they enjoyed each other's company as they peered out from the fourth floor together.

The view from the ridge

In July 2022, Ballad Health — a large nonprofit health care chain serving mainly northeast Tennessee and southwest Virginia — announced it was closing Mountain View. The 44-bed nursing home in the small town of Norton, Virginia, was fueling “excess capacity” in the region, according to a letter from Ballad Health to its employees. In other words, too many nursing home beds were going unused. The 20 long-term care residents who lived there, including Betty, would have to find new homes.

The residents were formally given until April 2023 to relocate. But several staff and family members of residents claim they felt pressure from Mountain View's management to relocate residents as quickly as possible. By mid-September 2022, all the residents were out.

Betty struggled to adjust to her new 97-bed nursing home. She became confused, anxious and fearful, according to Jerry Artrip, Betty's youngest son. Then, “it was almost like a depression came over her,” Jerry recalls. After roughly five weeks in the new facility, Betty died. She was 93.

The deaths kept coming. Seven Mountain View residents died less than three months after their moves. Of the 18 residents who were relocated (two residents died before their transfers), only seven survive today. Though death rates among nursing home residents are typically high, Mountain View staff and families say the losses were excessive.

“If we had one or two [residents] pass away a year, that was a lot to us,” says Misty Mullins, who worked as a certified nursing assistant at Mountain View for almost a decade. “The move was killing people.”

Ballad Health declined AARP's requests for interviews.

Negative impacts from relocating fragile residents — often labeled transfer traumas — have long been a problem for U.S. nursing homes. For decades, resident advocates have warned of the harmful effects of involuntary moves and fought to increase protections against them. They say a chronic lack of oversight and accountability in the industry has allowed the problem to persist, often unnoticed.

That problem, with tragic consequences, may be about to grow. The COVID-19 pandemic threw the U.S. nursing home industry into turmoil, exposing an array of long-standing industry shortfalls from understaffing to overcrowding. The chaos pushed a growing number of facilities toward closure or consolidation, putting their residents at risk of displacement. Earlier this week, a St. Louis nursing home quickly shuttered its doors, making headlines as 170 residents were transferred elsewhere, some without their belongings or the knowledge of their families, The New York Times and other outlets reported.

Operating pressures and demands for improved performance have continued to mount. A proposed federal law designed to boost safety in these facilities by increasing staffing will likely add to the pressure. Roughly a quarter of nursing home residents nationwide may need to relocate once the rule takes effect, according to a recent analysis commissioned by the American Health Care Association (AHCA), the nation's largest lobbying group for nursing homes.

Without better uptake and enforcement of safeguards that allow for smooth transfers, many residents may be vulnerable to the trauma of upheaval, just like those at Mountain View.

Residents were ‘dwindling away’

“They treated their staff and patients as family,” says Haynes, who began visiting St. Mary's as a three-year-old in 1966 when her mother became the facility's director of medical records. When Haynes, now 60, was in her early 20s, she became a nursing assistant at what had by then become Mountain View. She left for a time but returned in 2015 and stayed on through the closure. “All of us that have worked there carried on the sisters' level of care,” she says.

That's what attracted Mullins, the certified nursing assistant, to Mountain View more than a decade ago. As the nursing home industry moved toward large, for-profit models with high patient-to-staff ratios, Mullins recognized that Mountain View's small size and intimate culture was rare. She was able to spend extra time with residents, letting them choose their clothes for the day and singing along as she played their favorite tunes. She made sure they always got a long soak: “I'd give 'em a bath like I would want to be bathed,” she says.

Amid the transfers at Mountain View, Mullins tried her best to uphold the sisters' legacy. She picked up shifts at the facility where most residents moved to try to help them adjust. There, she was required to care for about 12 residents per shift instead of eight. Still, she worked hard to provide her longtime patients with their normal standard of care. She even coordinated with other nurses to cluster them together on the same ward, so they would see familiar faces. When she worked the morning shift, she made sure they still got a good bath, even if it was shorter than usual.

Lucille (Lucy) Trent was one of those residents. At Mountain View, where she lived for roughly four years, she did “exceptionally well,” says her youngest daughter, Kim Meade. Despite having dementia, Trent was almost always calm and content. The workers knew what she liked: being called “mommy,” sitting by the communal television, and bottles of Coca-Cola. “All she had to do was call out ‘Hello?’ and it didn't matter who was walking by, they would go and get her a Coke,” Meade says. “It was her thing.”

But after her transfer, getting Trent to eat or drink became increasingly difficult. After just a month in her new facility, her bottles of Coke remained full. “It got to a point where she wouldn't eat anything at all,” Meade says. “She just started to look through me.”

Trent died just shy of three months after her transfer at age 94. Chronic obstructive pulmonary disease was listed as Trent’s official cause of death. Meade says the move was at the heart of her decline.

Although there's risk of transfer trauma for displaced nursing home residents, their advocates argue there's also risk in keeping them in facilities without the workforce to support their needs. “Inadequate staffing can have dangerous — even deadly — consequences,” says Megan O'Reilly, AARP vice president for health and family issues. AARP supports the introduction of staffing minimums. “This is one critical way to ensure quality of care,” O'Reilly says.

If some nursing homes fold under the mounting regulatory pressures, maybe that's “for the best,” argues Charlene Harrington, a professor emeritus at the University of California, San Francisco (UCSF), who has documented widespread care deficiencies in her research on nursing homes. “Nursing homes are, generally, not of sufficient quality ... and there are a lot of people in nursing homes that don't need to be in there.” Continued industry contraction, in tandem with more long-term care alternatives, including home health services, will benefit America's aging population, she says.

But nursing homes will still be needed. So exactly which nursing homes close and in which communities is important, Harrington says. Large, for-profit chain facilities are more likely to stay in business, she says, while smaller, nonprofit operations, which tend to provide better care, go under. In rural areas, such as Norton, Virginia, where Mountain View was located, quality care alternatives are limited, so these closures are particularly worrying.

When shutdowns are necessary, some strategies can reduce the risks of transfer trauma, resident advocates say. Relocation is “not ideal” among this fragile population, says Elizabeth Halifax, an assistant professor of social behavioral sciences and nursing home researcher at UCSF, “but you can make it as painless as possible.”

Safeguards are written into federal nursing home regulations, including notifications at least 60 days before closing, state approval of a facility's closure plan and assurances that residents are “transferred to the most appropriate facility or other setting” that considers their needs and best interests. Essential care documents and information must be given to the receiving health care provider.

But amid complex medical cases and needs, things can easily fall through the cracks, says Joseph G. Ouslander, a professor of geriatric medicine at Florida Atlantic University. No shared system of electronic health records exists for nursing homes, making the transfer process ripe for medical errors. “They happen all the time,” he says.

For dementia patient Georgia Durham, the tipping point of her transfer may have been the loss of her hearing aids, which disappeared in the flurry of activity before her move out of Mountain View, says her youngest son, Jerry. “She really relied on those,” he says.

Without hearing aids, Georgia struggled to acclimate to her new home. Unable to listen to the Christian music she loved, her regular programs on Fox News or the familiar voices of her sons, she became less engaged and seemed depressed, Jerry says. Ten weeks after her relocation, Georgia, 88, contracted COVID-19 and died less than 24 hours after testing positive for the virus. Amid the move, she'd “maybe lost her will to live,” Jerry says.

Though the list of regulations to safeguard against transfer trauma is long, proper adoption of them has historically been weak, says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. Complaints regarding improper discharge or transfer have consistently been among the most common types of grievances reported to the States' Long-Term Care Ombudsman Programs for roughly a decade.

At the same time, the government doesn't collect national-level data on resident transfers or discharges occurring in nursing homes. The Centers for Medicare & Medicaid Services (CMS), the government agency responsible for regulating the vast majority of U.S. nursing homes, says it provides oversight through surveys and other means to make sure institutions comply with federal requirements, according to a CMS spokesperson. But CMS data shows that roughly 30 percent of the nation's nursing homes are overdue on these surveys, which by law should occur at least once every 15 months.

Both were culpable, argues Patricia McGinnis, executive director of California Advocates for Nursing Home Reform. Government regulators played a lead role in endangering the residents by pressuring Laguna Honda to evict residents quickly, knowing it had no safe places to send them, she wrote in a January public statement. The fines handed down to the facility were a mere slap on the wrist for repeated and lethal acts of elder abuse.

Under an intense media spotlight, the federal government extended Laguna Honda's funding to allow for better closure planning and an opportunity to win back its Medicaid certification. In August 2023, recertification was granted, meaning the facility could keep operating.

Jerry Artrip has struggled to process his feelings about the experience, even turning to poetry to try to find the right words. Since his mother's death, he's spent months searching for explanations for Mountain View's closure, but responses from Ballad have been brief. “They've said it's just a business decision,” he says. “In the end, it's all about money, not care and love.”

Jerry Durham admits more time probably wouldn't have changed the outcome. “I think the move was always going to be too much for her,” he says of his mother. But he believes a pause on transfers would have at least allowed him a few extra months with her. “I would give anything for that.”