By the time Florentina Lazo's private caregiver brought her to a hospital emergency room, the 81-year-old Waialua woman suffered from pneumonia, malnutrition, gangrene and severe pressure sores, including one that penetrated so deeply it exposed bone.

Until she was taken to the ER, Lazo hadn't been seen by a doctor for eight months.

She eventually lapsed into a diabetic coma, and hospital physicians decided the gangrene was so severe they amputated her left leg above the knee. She died several days later in May 2003 from a heart attack.

An autopsy determined that elder neglect was a contributing factor in Lazo's death.

The state prosecuted Merlina Oamil, Lazo's live-in caregiver, for failing to properly care for the elderly woman and for accepting $1,000 a month and living accommodations in exchange for services that weren't delivered. In 2005, Oamil pleaded guilty to second-degree assault and theft.

Pablo Lazo, the elder Lazo's adopted son, said the family hired Oamil, a nurse aide, based on a recommendation from a friend. "In the beginning, she was all right," he said.

The Oamil case underscores the potential risks families face when hiring strangers to come into their homes to provide care for loved ones. If the caregiver is hired without sufficient screening, such as criminal background and reference checks, the risks are considered greater.

Yet many Hawai'i families turn to unregulated, unsupervised caregivers, usually to try to save money. Hourly rates for basic home workers can vary widely, from roughly $12 to $25, sometimes higher. Because unregulated caregivers aren't required to adhere to minimum standards or abide by other requirements, they often charge rates substantially lower than their regulated counterparts. But the reduced costs come at the expense of outside oversight.

"There's a lot more risk involved," said James Pietsch, who heads the University of Hawai'i's elder law program. "We hear credible stories of caregivers who come (into the home) and basically take over and isolate the person."

UNKNOWN NUMBER

No one knows how many Hawai'i families hire unregulated caregivers, but senior advocates and others believe the number is substantial. While most home workers are believed to provide good service, anecdotal evidence suggests that quality problems are not uncommon, though they don't often come to light.

Advocates say abuse or neglect in the home is vastly underreported for a variety of reasons. The victims tend to be very vulnerable, they often are unable or unwilling to speak up and the abuse or neglect largely occurs behind closed doors, typically when no one else is around to witness it.

Several families told The Advertiser they discovered problems only after showing up unannounced to check on their loved ones. The caregivers had left their elder clients home alone to go run errands, or they were so busy with other jobs that the clients were all but neglected.

One woman found her mother's caregiver essentially running a laundry business from the home, doing large quantities of other people's laundry. Another family said the caregiver, unbeknownst to the family, was running a mini-day care operation, taking in other people's kids for a few hours each day while she was supposed to be tending to her elder client.

In the Lazo case, the neglect came to light only after the elderly woman was admitted to the hospital.

Pablo Lazo, a Waimānalo resident who lived about an hour from his mother's home, said he checked on her regularly by phone and through periodic visits. Oamil would assure him that his mother was doing fine, he added. Once she was hired, Oamil moved into the Waialua home with her husband and two children, Pablo Lazo said.

That arrangement lasted about two years — until Lazo got a phone call in 2003 from a doctor who told him his mother was hospitalized and gravely ill.

Lazo said he was angered by what Oamil did but never got even an apology from her. "I felt bad about that."

For the assault and theft charges, the former nurse aide was sentenced in 2005 to five years' probation and ordered to pay a $2,000 fine. Oamil's name also was added to a federal blacklist designed to keep unfit healthcare workers from getting hired at federally funded programs. Her name remains on the list today. She could not be reached for comment.

FINANCIAL FRAUD

In the case of Hong Chow Chock, a Big Island resident who hired a live-in caregiver in 2000 through a classified ad, the abuse — this time financial — came to light only after Chock's friends became suspicious and reported their concerns to authorities. The friends told investigators that Chock, then in his mid-80s, would be dropped off at the mall to meet them for nearly daily outings, but he often looked unhappy, tired and was sometimes inappropriately dressed.

Chock, a widower, frequently had no money, even though he was left at the mall for nearly the entire day, the friends said. They often had to pay for his lunch.

Less than a year after the caregiver, Laura Kauwe, and her husband, Abraham, moved into Chock's home, his savings account of $47,000 was emptied, according to court records. Chock also transferred the deeds to his Hilo home and a vacant lot he owned to Laura Kauwe.

"He was so taken in by that wahine," said Chock's nephew, Rex Auna.

The Kauwes in 2005 were found guilty of multiple counts of theft. Laura Kauwe, who unsuccessfully appealed the verdict, was sentenced to 10 years in prison but died in 2007 without serving the time. Abraham Kauwe was sentenced to 180 days behind bars and five years' probation.

While Chock's property was returned to him, only $30 of the $28,000 in court-ordered restitution was repaid by the Kauwes, according to Chock's niece. Chock died last year from natural causes.

To guard against potential problems, industry officials recommend that families deal only with caregivers employed by licensed or nationally accredited home-health or home-care agencies. Home-health agencies provide medical-related services, such as physical or speech therapy, that are ordered by physicians; home-care agencies provide non-medical services, such as housekeeping, meal preparation and bathing help, that are arranged by the clients or their families.

Jean St. John, 87, has had caregivers from Wilson Homecare, a licensed home-health agency, tend to her at her Pearl City residence for the past year. They prepare meals, drive her to appointments, take her shopping.

"I depend upon them for everything," St. John said. "I'm lucky. I can't imagine having anyone nicer around."

CHECK LICENSES

To be licensed or accredited, agencies typically must screen their caregivers, including performing criminal background checks, competency evaluations and health screenings, and provide on-going training. Also, the caregivers usually are bonded or insured. Medicare-certified agencies similarly must meet a host of federal requirements, including developing written care plans for each client and monitoring compliance.

They are regularly monitored by the licensing body.

"Unlicensed caregivers have no such minimum standards," said deputy attorney general Michael Parrish, whose Medicaid Fraud Control Unit prosecuted Oamil and the Kauwes.

Beth Hoban, president of PrimeCare Services Hawai'i, a licensed home-health agency, said many families hire caregivers while in the midst of a medical crisis, so they often have little time to do quality-of-care research.

"Most consumers don't really know (about that), especially because they're desperate and need care right away," Hoban said.

While home-health agencies here must be licensed, that isn't the case with home-care agencies, the ones that provide basic non-medical assistance.

Hawai'i is among the minority of states that currently do not require home-care agencies to be licensed, though that is scheduled to change once administrative rules are adopted by the Department of Health to implement a new licensure law.

The Legislature last year passed the licensing bill as a way to enhance consumer protections and plug a gap in Hawai'i's long-term-care system. Industry officials are hoping the rules are in place in about a year.

Until they are, anyone with a general excise-tax license can open a home-care business in Hawai'i. You don't need any previous experience or formal training, reflecting what is truly a "buyer beware" market.

"Home care is where you have to be very consumer savvy," said Joel Nakamura, an assistant caregiver specialist with the city's Elderly Affairs Division. "You're in the driver's seat. No one else is accountable."