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“They even arrive with human scabies”: cases of elderly people abandoned in hospitals multiply

Long-term care homes in Puerto Rico can hardly cope with this problem, which also faces budgetary challenges and invisibility

June 17, 2024 - 11:34 AM

Act 121 of 2019 protects persons 60 years of age or older, with responsibilities and duties to family members for their care. (Vanessa Serra Díaz)
Editor's note
First of four stories in the series "Pliegues en su piel, vacío en su corazón" (Folds in your skin, emptiness in your heart), which analyzes the increasing number of lonely older adults in hospital facilities in Puerto Rico. This work received the support of the Journalists in Aging Fellowship, awarded by the Gerontological Society of America, along with the Journalists Network on Generations and the Silver Century Foundation.

Reina, a 74-year-old woman who does not remember her name or family background, had been living under a bridge in Río Piedras for several weeks until a neighbor in the area alerted the authorities.


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The woman - whom El Nuevo Día identifies with a pseudonym - only remembers that “someone” in a bus took her there, perhaps a relative or neighbor. Under the Ley de Salud Mental 408 (Mental Health Law 408), she was admitted to the Hospital de Psiquiatría General Dr. Ramón Fernández Marina (General Psychiatric Hospital), also in Río Piedras. The hospital administration took the case to court and, with no relatives to identify, the Puerto Rico Department of the Family (DF) took physical custody of her.

Reina was hospitalized for 11 months until the DF found a long-term care facility that could receive her. For the past four years, she has been living in Hogar Semilla de Amor, a long term care facility in San Juan, along with 29 other women, nine of them also homeless in hospitals, with no family or relatives responsible for their care.

Among them is Gladys (pseudonym), 82 years old. A resident of the metropolitan area, she was taken by her daughter to the hospital for the treatment of a urinary infection. The daughter never returned for her mother and, after six months, the DF took temporary custody of her and placed her in this Home.

Also residing with them is Marta (pseudonym), a 64 years old woman native of the town of Ponce, who had been living in subhuman conditions since a sister who cared for her died. Disoriented, four months after her death, she took to the streets. Another sister -who lives outside the country and is unable to care for her- put her in a hospital and disengaged. After eight months, the DF took responsibility for her and she arrived at Semilla de Amor.

“The bureaucracy is long in these cases. First (in the absence of family members), the hospital has custody, but then they go to court so that the DF can take it over and place them,” said Jonathan Morales Adorno, owner of Hogar Semilla de Amor, as he recounted some details about the residents of this facility.

“There are few Homes that accept these cases. Once the DF subsidizes that case, the social worker has to look for a Home that meets that adult’s criteria,” he added.

According to Morales Adorno, the profile of these cases is quite similar. In general, they are low-income people who did not work, or worked informally, and did not contribute to Social Security. Most of them, he added, did not prepare for their retirement or, with the increase in the cost of living, their income is insufficient for their expenses.

Many were left alone when their children or relatives migrated, especially after Hurricane María (2017) and the COVID-19 pandemic (2020). Some older adults simply did not want to leave the country, preferring to spend their old age in their homeland, Puerto Rico.

“Many have Alzheimer’s or suffer from some mental illness, usually because of a trigger, such as the loss of their parents, children or a divorce,” he added.

Reina, for example, still does not know her true identity. “She doesn’t remember her name or if she had children. She has no one. The DF identified a name, but her Social Security number does not appear,” said Morales Adorno. The president of the Federación de Instituciones de Cuidado Prolongado de Puerto Rico (Federation of Long-term Care Institutions of Puerto Rico) said that one theory is that the woman lived in another town, from where she was transferred and abandoned.

Warning flags

“Many arrive at the hospital disoriented and without family members. When no one looks out for them, they are still in the same clothes and no family member asks for the doctor, the social work team of the hospital and the DF staff intervenes,” said Annie Rodríguez Laboy, administrator of the Hogar Sueños de Esperanza in Arroyo, about possible warnings.

Another red flag, she said, is when medical personnel need to explain and obtain consent from a family member before performing a procedure, especially if the person is not capable of making decisions.

“That’s when you usually identify whether a third party brought you in, whether you came in alone or by ambulance. If no family member is available and there are no other telephone numbers other than the one given at admission, the protocol is activated, the DF is called and the situation is explained,” said Rodríguez Laboy.

These cases are taken to court, where the hospital requests that the DF assume custody of the patient. The person must then be relocated, a process that can take months.

For the Puerto Rico Department of the Family, the greatest challenge in dealing with cases of abandonment of older adults is budgetary.
For the Puerto Rico Department of the Family, the greatest challenge in dealing with cases of abandonment of older adults is budgetary. (David Villafañe)

“In the southern area, the peculiarity we have is that many of our elders did not contribute to a rewarding Social Security benefit. Many worked in the sugarcane (industry) and, since they couldn’t read, they were extorted by their employers. What they get is $200 to $600 (a month) Social Security payment, if anything. That is why these cases are more difficult to locate than others with economic solvency,” he said, noting that there are people who arrive without clothes or belongings, and even without basic documents, such as a birth certificate.

“Of the 22 residents we have (in the Home), 80% come from hospitals, 40% of them without family,” he said.

One of her current residents, she said, is 98 years old and arrived at the home four years ago. With no children, husband or siblings, no one visits her. Another, 78 years old, was admitted to the hospital in subhuman conditions and, after four months hospitalized, has been living in this Home for two and a half years. He does not receive visitors either.

“My home’s mission is to take on, perhaps, the cases that others cannot, to serve those who have no one,” said Rodríguez Laboy, who advocated for a culture of greater respect and empathy for the elderly to be fostered from childhood.

Despite the magnitude of these cases, according to data from the Oficina de Administración de los Tribunales (Court Administration Office), in the last two fiscal years (2022-23 and 2023-24, as of May 23), only seven cases of “abandonment of elderly and disabled persons” had been filed under the “crimes against the family” classification in Puerto Rico. Six were resolved with convictions and one was filed. In that period, 12,750 protection orders were requested under the Carta de Derechos de los Adultos Mayores (Bill of Rights of the Elderly or Law 121 of 2019) to protect them from mistreatment. Of those, 59% (7,471) were issued.

Biggest challenge: budget

“There are challenges with the special placement of these cases, especially if they leave the hospital with a condition. We have to find them a special Home for their care, for example, if they need ventilators, feeding machines or other equipment,” acknowledged Ciení Rodríguez, Secretary of the DF. “Many were already living alone or isolated when they were taken there (to the hospital),” she added.

But, Rodríguez admitted that the biggest challenge is budgetary in order to attend to these increasing cases. As of the end of February, there were 6,725 people subsidized by the DF or under its physical custody, at a minimum cost of about $20,000 a year, per case.

“With the $70 million (that the DF has) to subsidize (the care of) the elderly in Puerto Rico, that’s salt and water,” said the Secretary, who commented that another allocation of $12 million for the Programa de Ama de Llaves (Caregivers Program) is also insufficient because of so much demand for this service.

In the last seven years, there has been an increase in referrals from hospitals to the DF for foster care services. In total, 3,962 older adults have been abandoned in hospitals from 2017-2018. In 2022-23, the sum of 769 cases were reported, while in 2023-24, as of May, 693 had been reported, so it is presumed they might surpass 800 by the end of this year.

“We have gone to the federal Administration for Children and Families, region 2, seeking to expand those (federal) funds,” the government official mentioned, reiterating that the purpose is to attend to all cases.

Jonathan Morales Adorno, owner of Hogar Semilla de Amor and president of the Federation of Extended Care Institutions of Puerto Rico.
Jonathan Morales Adorno, owner of Hogar Semilla de Amor and president of the Federation of Extended Care Institutions of Puerto Rico. (Vanessa Serra Díaz)

According to Morales Adorno -of Semilla de Amor- less than 20% of the homes licensed by the Administración de Servicios de Salud Mental y Contra la Adicción (Mental Health and Addiction Services Administration) - 115 of 614 - and less than half of the nearly 1,150 licensed under the DF accept cases subsidized by the latter agency.

One of the main reasons, he said, is due to the low rates that the DF pays for these cases: about $1,300 in the metro area and between $700 and $900 in other regions of Puerto Rico. Late payments add to this picture, he added, noting that when he assumed the presidency of the Federation in May of last year, the DF had a debt of some $500,000 with some of the long term care facilities that service these cases.

However, Morales Adorno warned that, recently, the agency announced a rate increase starting in July, from $1,900 to $2,350 per case. The increase will be staggered, starting with the Guayama region, which has 45 foster care facilities. He also noted that, as of last December, a large part of the debt had already been paid off.

“I hope that now there will be more beds available to attend to this emergency, because this is not going to stop. Hopefully more people can open nursing homes because, with longevity and many people not having children, a lot of caregivers are going to be needed,” he said.

Following a uniform protocol

Glenda Gerena, head of the Administración de Familias y Niños (Family and Children’s Administration), an agency attached to the DF, noted that “many” of these cases are people who never married, while others have children that live outside the country. Also, there are relatives who do not want to take care of their elders if, in previous years, there was a pattern of abuse.

The regions of Ponce, San Juan, Arecibo and Caguas lead these cases, followed by Mayagüez, Carolina, Bayamón, Humacao, Aguadilla and Guayama.

“We have to create a uniform system from the moment the elderly person arrives at the emergency room,” Gerena said.

Currently, she acknowledged, each hospital has its own protocol, while the DF has its own. To standardize it, the DF has already met with more than 25 hospitals, establishing collaborative agreements and training personnel. Also, last year, the agency began an internal registry in the hospitals of the referrals where elderly neglect is alleged.

Currently, hospitals and Puerto Rico Department of the Family have different protocols for dealing with cases of elder neglect.
Currently, hospitals and Puerto Rico Department of the Family have different protocols for dealing with cases of elder neglect. (Vanessa Serra Díaz)

The goal is to have a uniform draft protocol in place by the beginning of the next fiscal year in July, she said.

Gerena said that currently, 707 DF-licensed homes receive seniors subsidized by the agency. With the upcoming rate increase, she said that they have already received more than six proposals from homes interested in offering this service.

In addition, they are identifying legal tools to take more cases to court and impose penalties for the abandonment of older adults.

Act 121 (a law approved in Puerto Rico in 2019 that created the Bill of Rights for Older Adults) protects persons 60 years of age or older, establishing a series of responsibilities and duties of family members for the care of their old relatives, with penalties for non-compliance of two years in jail or a maximum fine of $5,000. The statute also defines the role of the DF and other government agencies involved.

“They are sad cases”

In Hogar Semilla de Amor lives a 91 years old woman from the western side of the island that has Alzheimer’s. According to Morales Adorno, after the death of her parents, who took care of her, the woman went to the hospital every weekend to receive care and company. One day, she arrived at the hospital and did not want to leave. Five months passed while the case went to court, no family member was found to be responsible for her, the DF took custody of her and she was placed on this Home.

Another mental health patient, age 68, spent 14 months in a hospital, where she voluntarily entered until she was placed at home. She has never married or had children. Her brother lives in the United States and visits her occasionally, but is unable to care for her, so Puerto Rico’s government has physical custody of her.

Also, in this facility, there is a 78-year-old woman who lived alone in subhuman conditions until a neighbor reported it. She was hospitalized and, after four months, the DF took charge and placed her there. Although she has three children, two in the United States, in the two years and three months she has been in this Home, none of them have visited her.

The regions of Ponce, San Juan, Arecibo and Caguas lead in cases of abandonment of older adults in hospitals in Puerto Rico.
The regions of Ponce, San Juan, Arecibo and Caguas lead in cases of abandonment of older adults in hospitals in Puerto Rico. (Vanessa Serra Díaz)

Meanwhile, a 63-year-old woman lived in a nursing home until she faced living difficulties due to a mental illness. Initially, she was admitted to a mental health hospital for nine months. Since her children did not take over, the DF took temporary custody of her and, for the past four years, she has lived in Hogar Semilla de Amor.

“Christmas time is difficult because they see how others (residents) receive visits or go for a walk with their relatives, but they have no one,” Morales Adorno lamented.

Many of those referred from hospitals - after long stays - arrive disoriented and deteriorated, he added.

“Some even arrive with human scabies. As many hospitals do not have enough staff, and these cases are alone, they are not given the necessary care,” he said.

However, he established that, after an adaptation period of about two weeks, the residents become family and take care of each other. “Above all, they feel loved, but these are sad cases,” he stressed.



Law 121 of 2019 - Charter of Rights of Older Adults.


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