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DON GONYEA, HOST:

And now, nurse assistants and home health aides provide intimate care - bathing, feeding and dressing the elderly, disabled or ill. So what happens when a caregiver abuses or hurts a patient? Well, public health regulators in California have been letting many complaints sit for years, even when they involve severe injuries or deaths. Mina Kim reports from member station KQED, in San Francisco.

MINA KIM, BYLINE: Elsie Fossum's nieces and nephews say she was the aunt you wanted to have.

JANET FLYNN: She gave us our first car.

JIM FOSSUM: It was a '59 Ford Galaxy 500, with massive fins on it.

KIM: Jim Fossum and his sister, Janet Flynn, remember their aunt, a librarian and teacher who never married or had kids.

FLYNN: She would come for the summer with this tiny Samsonite suitcase. And she would be impeccably dressed, mixing and matching; and her hair was always done; always looked wonderful.

KIM: But on the morning of July 3rd, 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.

BEVERLEE MCPHERSON: She looked like she went four or five rounds with Muhammad Ali.

KIM: Beverlee McPherson is a registered nurse who supervised nurse assistants at Claremont Place. The lone caregiver on Fossum's floor that night said Fossum fell. But McPherson suspected abuse. 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.

MCPHERSON: Oh, I'm 100 percent convinced she didn't fall out of bed, 100 percent. If you saw this woman's face - I mean, her entire face was beaten to a pulp.

KIM: 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.

RON CHAPMAN: So there was a backlog.

KIM: Ron Chapman heads the California Department of Public Health. He blames the delays in handling complaints on a stack of more than 900 cases, cases that piled up between 2004 and 2008.

CHAPMAN: There were a number of reasons for that backlog, including poor management decisions during that time.

KIM: Chapman says a plan was implemented in 2009 to address the backlog, before he came to head the department in 2011.

CHAPMAN: 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.

KIM: But the number of nurse assistants facing disciplinary action after complaints has dropped recently; 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 current work. But Marc Parker, who headed the investigations section for nine years, says he was forced to cut corners.

MARC PARKER: Hundreds of cases were closed - hundreds - with nothing but a phone call.

KIM: 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.

PARKER: I could not protect the public any longer. There was just a failure to protect the most vulnerable people in our state from abuse and neglect.

KIM: Public health regulators are required to report all suspected crimes to the state attorney general. And in the seven years before addressing the backlog, the department referred, on average, 37 deaths a year. Last year, they referred three; the year before that, two.

CHAPMAN: We don't understand that decline in numbers. It's very concerning to me, and we'ree looking into it.

KIM: Public Health Director Ron Chapman 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. Chapman now says he's willing to review Fossum's case.

FLYNN: Oh, yes...

FOSSUM: Grandma.

FLYNN: Grandma looks like Dad. Maybe Elsie looked like Grandpa's side of the family.

KIM: Back at Jim Fossum's home, nephews and nieces look at photos of their aunt. Janet Flynn says to this day, their calls and emails to state agencies and local police have turned up little information. They say they never heard from the Department of Public Health.

FLYNN: I would think this would be very chilling to anyone who has loved ones in a facility - especially if you think the safeguards are in place, and you think that staff are qualified, and that this is being regulated. And this, I find chilling.

KIM: This year, the Los Angeles County Sheriff's Department opened a homicide investigation into Elsie Fossum's death. Her caregiver is the sole person of interest.

For NPR News, I'm Mina Kim in San Francisco.

GONYEA: This story was co-reported by Ryan Gabrielson at the Center for Investigative Reporting. Tomorrow on WEEKEND EDITION, the story of Angela Gwanzon(ph). In 2005, she came to the U.S. from the Philippines, to work in a nursing home. But not long after she arrived, Angela Gwanzon realized she wasn't working a normal job. She was actually being held against her will as a modern-day slave. Her story, and how she escaped and rebuilt her life, tomorrow on WEEKEND EDITION.

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