The federal government has fined a Nu'uanu nursing home $3,000 for "abandoning" an elderly resident at a hospital emergency room last year just days before Christmas.

The fine underscores what some hospital and social workers say is a persistent, although infrequent, problem: Elderly are being left at emergency rooms — even if they don't need hospitalization — because caregivers are unable or unwilling to continue caring for them.

When it does occur, it adds to the problem of crowded ERs and lack of space for acute-care patients.

"Access to both emergency rooms and hospital beds for those who require acute level of care becomes compromised," said Claire Tong, a spokeswoman for Hawaii Pacific Health, which operates several hospitals statewide.

In the case of Florence Ko, a former Nu'uanu Hale resident, a hefty unpaid bill contributed to her pre-Christmas discharge from the nursing home. A daughter months earlier had stopped helping with her mother's payments to the facility.

By the time Ko was left at Straub Clinic & Hospital's ER on Dec. 17, her Nu'uanu Hale tab had climbed to more than $30,000.

Nu'uanu Hale dropped off Ko, then 81 and confined to a wheelchair, even though the facility had no assurance she would be admitted to the hospital and no prior arrangements had been made for her transfer to another care facility.

Ko was wearing only a hospital gown and had less than $3 in her purse when she was dropped at the ER around 10:30 a.m. She also had her cell phone — minus the charger — but did not have any of her medications. Ko previously told The Advertiser she had no idea what was happening to her on the morning of her discharge.

Even though Ko's doctor directed her to be sent to the ER for an acute anxiety problem, the hospital determined that Ko did not need to be admitted, according to state inspection documents detailing what happened. But when Straub contacted Nu'uanu Hale shortly after 2 p.m. about taking her back, the nursing home already had placed another resident in Ko's bed and had no room for her, the report said.

Ko ended up staying at Straub for roughly 12 hours before the hospital found her a temporary spot that evening in an 'Aiea care home.

"The resident was abandoned at the hospital emergency room, she had no place to live or knowledge of what would happen to her," the inspection report said.

BED SOON FILLED

The $3,000 fine for violating federal discharge regulations was disclosed in a June 29 letter that the Centers for Medicare & Medicaid Services, which regulates federally certified nursing homes, sent to Gayle Lau, Nu'uanu Hale's administrator, as a follow-up to the state's inspection findings. The Advertiser obtained the letter last week through a government records request.

Details disclosed in the state inspection report, which doesn't mention Ko by name, largely match what the newspaper reported in early January. But it also includes new information from Nu'uanu Hale, which had declined to discuss the case with the newspaper but was required to respond to the state's inquiry.

The inspectors noted, for instance, that Nu'uanu Hale didn't follow its own normal practice of checking whether a resident taken to a hospital would be admitted before making that person's bed available to someone else. The bed Ko was using was filled at 1:45 p.m., more than three hours after she was taken to the hospital. Lau acknowledged that the nursing home released Ko's bed without knowing whether the woman would return or be admitted, according to the inspectors' report.

About a week before Ko was sent to the hospital, she had been told she would be transferred to her son's residence because of her lack of funding — a plan Ko balked at, the report said. She subsequently developed what nursing home records described as "acute anxiety and mental changes related to pending discharge from the facility to her son's home." Ko was then taken to the emergency room, but Straub found no medical reason to admit her.

The inspection report quotes Nu'uanu Hale's administrator as saying Ko's inability to pay her nursing-home bill was a factor in the discharge.

Ko's daughter in May 2008 stopped paying the portion of the monthly tab not covered by her mother's $1,400 Social Security check, according to the report. By early February, Ko's outstanding balance was nearly $33,500.

Kathryn Ko, a New York neurosurgeon, previously told The Advertiser in a statement that she had helped her mother financially for many years. But because of a life-threatening illness in her own family, she had to stop assisting with the nursing-home bill and redirect her resources, the daughter said.

Kathryn Ko could not be reached for comment.

DIFFERING ACCOUNTS

The nursing home assumed the elder Ko would qualify for Medicaid, a health benefits program for low-income residents, but she subsequently was deemed ineligible, according to the inspection report.

At the time Ko was taken to Straub, Lau was under the impression Ko would be admitted, the report said. Lau also told the inspectors that Ko's son was notified about the transfer and that the hospital offered to find a placement for the elder woman, according to the document.

But a Straub case manager told inspectors that the hospital did not make such an offer, and no records were produced to support such an agreement between the two facilities, according to the report. After the hospital learned Nu'uanu Hale would not take the patient back, it referred the matter to a Straub social worker, who found Ko a temporary place to stay.

In its written response to the state's inspection findings, Nu'uanu Hale said it was committed to respecting residents' discharge and transfer rights and would make certain a similar incident would not be repeated.

The institution also noted that it has since revised its discharge policy.

Among other things, the new policy stipulates that if a discharge or transfer is due to failure to pay a bill, a written notice would be issued to the resident or an authorized representative at least 30 days before the discharge or as soon as practical. Ko received no such notice.

Lau, the Nu'uanu Hale administrator, declined comment for this story.

Ko, in a brief phone interview, said she was hopeful news of the $3,000 fine would serve as a deterrent so other elderly residents wouldn't be abandoned at emergency rooms.

"I certainly had kind of a bad experience," said Ko, who now lives with a caretaker in a Honolulu apartment complex.

'NOT APPROPRIATE'

John McDermott, the state's long-term-care ombudsman, said social workers have been telling him about local dumping cases for years. Even though the numbers may be small, the practice is wrong, he said.

"It's totally inappropriate for nursing homes or any long-term care facility to use our emergency rooms for dumping residents for whatever reasons," McDermott said. "That's not an appropriate discharge plan."