As the ambulance crew rushed into the El Cajon nursing home in response to a 911 call about a medical emergency, they expected to find a person suffering a stroke, in cardiac arrest or bleeding and seriously injured. Instead, they found someone in need of a prescription refill. “You walk in, and they have empty prescription bottles that are sitting right there,” said William Redanz, American Medical Response paramedic supervisor stationed in Lemon Grove. Rather than performing CPR or other life-saving measures, they were asked to take someone to a hospital for a refill, he said. El Cajon officials say those and other types of 911 calls for non-emergency incidents have become more frequent and are stretching resources. In response, the city is exploring a program to charge for what it sees as excessive 911 calls, a fee that could be one of the first in the state, if not the nation. Other cities around the nation have complained that care facilities are misusing the 911 system, specifically to help lift people who have fallen. A Washington Post investigation from earlier this year found that calls for lift assists had jumped 30 percent nationwide in recent years, and cities in California, Nebraska, Florida, Alaska, Missouri and Wisconsin have introduced fees for the service. That is not the case in El Cajon. City Manager Graham Mitchell said a survey in fiscal year 2023-24 found that only two of the 372 calls citywide for lift assists were made from skilled nursing facilities. Many other calls, however, have left paramedics wondering why they were dispatched to a facility for an incident that could have been handled by on-site staff, Mitchell said. A study from last fiscal year found the 20 licensed care facilities in El Cajon made an average of 1.35 calls per bed; some made six times that many calls. “That’s clearly an abuse of the system,” Mitchell said. According to a city survey, 44% of calls from the city’s 20 licensed care facilities are for non-emergency incidents, and the 2,753 calls made from the facilities represented more than 15% of all fire department calls made last fiscal year. On average, the fire department responded to 7.5 calls a day to the facilities. Mitchell said he’s not sure why the calls have increased, but Redanz suggests it could be because of staffing shortages. “Every industry deals with understaffing,” he said. “Especially in medical industries. Sometimes you don’t have that veteran staff there that can kind of pick up on some of these situations and know when it’s appropriate to send us there.” Phil Lindsley, an attorney and principal with San Diego Elder Law Center, suspects bottom-line profits have become more of a motive at care facilities as many of them have been bought by investment firms and corporations, and now are more likely to take advantage of city-funded services. But Lindsley also said care facilities could be making the calls because of a legal requirement. “Nursing home facilities are all regulated by the Department of Healthcare Services, and they can be penalized and sanctioned for failure to call 911 in an emergency,” he said. “But they’ve also been sanctioned for failure to deal with it themselves, because they are a medical facility.” Since getting the go-ahead from council members Sept. 10, Mitchell has begun scheduling meetings with the facilities, and he expects a fee structure could be presented to the council early next year. The proposed fees, which could be as high as $487, would only be charged after a facility had made a certain number of calls beyond what’s considered a reasonable amount. Mitchell said the fees would be a financial incentive for facilities to use their own medical staff to attend to non-emergency issues rather than relying on city-funded services. In the case of a nursing home calling 911 for prescription refills, Redanz said the facility could have called a private ambulance service or found other transportation, but may have called the city-funded 911 service because they would respond faster. He’s not alone in noticing the issue. Capt. John Oslovar of Heartland Fire & Rescue said he lost count of how many times in his 17-year career he has heard a nursing staff member say they could have called a non-emergency ambulance service, but decided to call 911 instead simply because they would respond faster. Oslovar and Redanz said crews also have been called to assist someone who has fallen and needs help getting back in bed or who had an abnormal reading on a blood test and needs to see a doctor. Under fee options being considered, charges would kick in after a facility’s 911 calls exceeded the median number of per-bed calls by 25% or 50%. Mitchell said slightly more than 500 calls in the last fiscal year were above the median, costing the city about $250,000. “But the dollar amount is not as significant as the impact it has on the fire department,” he said. “I think we respond to more calls per capita than any other city in the county, so they’re already super busy. There’s a breaking point, and I think we’re very close to that.” The fee program is far from being finalized, and Mitchell said as talks begin with facilities, people in the industry may suggest other solutions that are easier to manage and have better outcomes.   A dispatcher at American Medical Response in Kearny Mesa sits at screens showing East County and calls coming in to Heartland Fire & Rescue. The two groups work together to respond to 911 calls. El Cajon attempted to lower the number of calls with an educational outreach program in 2022, but a follow-up survey found the number of per-bed calls had decreased at only six facilities and had increased at the other 14. The largest jump came in the 77 calls from the 39-bed VOA Carlton G. Luhman Center for Supportive Living, which represented a 670% increase from 2022. In other examples, the 44 calls from the 23-bed Orlando Guest Homes was a 205.6% jump, and the 323 calls from the 305-bed Country Hills Post Acute was a 50.2% jump. Why East County? City managers throughout the county were asked if they had seen similar issues as those in El Cajon. Of those who responded, most said they had not. The exceptions were La Mesa and Lemon Grove, which like El Cajon also are served by Heartland Fire & Rescue. “We have the same issue, however not to the extent El Cajon does,” said Lemon Grove City Manager Lydia Romero. “If approved by their council, I’ll monitor the success to see if this is something Lemon Grove may want to consider in the future.” “I know that we have had similar issues with care facilities in La Mesa,” said La Mesa City Manager Greg Humora. In San Marcos, Community & Economic Development Director Tess Sangster said the city’s six largest care facilities make about 250 calls to their system each year. “These existing facilities continue to be among the top call generators in the city of San Marcos, and any new facility would need to implement mitigation measures to reduce the call volume,” she said. “We continue to work with these facilities to build collaboration, education and a service that is customer oriented.” Redanz suspected the issue could be more visible in East County because of its many care facilities. Oslovar said the growing number of calls also is a pressing issue in El Cajon because city resources have not kept pace with demands on the system. Calls for service have almost doubled since he started in 2007, while the department has had the same four fire engines and a ladder truck in that time. A paramedic team with a pickup truck was added in 2018, but the city has not opened a fire station since 1975. Oslovar said Heartland has been a trailblazer in sending the appropriate resources in response to calls through a triage system. Dispatchers who receive calls ask a series of questions to determine the severity of the incident, and in El Cajon, some may be sent to nursing navigators who can talk directly with people about their medical issue. For more serious calls, a Heartland firetruck with paramedics is dispatched and an AMR ambulance joins them if a patient needs to be transported to a hospital. Even with the triage system and nursing navigators, however, crews still find themselves responding to non-emergency medical issues. “There are times when we arrive, the patient’s condition is not an emergency, despite what the initial triage notes said,” Oslovar said. Despite his frustration with the situation, Oslovar said it is better to err on the side of caution when responding to calls at care facilities because clients usually are vulnerable and medically fragile. Possible legal challenges Many operators of facilities that would be subjected to the charges declined to comment or did not return phone calls or emails when contacted about the proposal. Quinton Berzins, executive director of Solstice Senior Living in El Cajon, was willing to talk and said he had heard that other facilities that would be subjected to the charges already have contacted their attorneys about challenging the plan. Berzins said the city had some valid concerns, but he also questioned whether basing charges on the number of calls would work. While he supports cracking down on facilities that abuse the 911 system, he said some calls may come from clients themselves. “I think they’re on the right track,” he said. “I just think the fining part is not going to hold up. You’re telling vulnerable citizens, ‘You can’t use 911.’” Corey Egel, director of public affairs for the California Association Of Health Facilities, said the proposed charges are a bad idea. “911 calls are made in critical situations where the health and safety of residents at skilled nursing facilities may be at risk,” he wrote in an email. “Placing an additional financial burden on SNFs that already deal with tight budgets for responding to such emergencies could unnecessarily lead to life-threatening situations. Patient care and safety should always remain a priority.” Anthony Chicotel, senior staff attorney for California Advocates for Nursing Home Reform, said it is “more than plausible” that an inappropriate level of 911 calls have been made at assisted living facilities, where residents live independently with a medical staff on hand, but not at nursing homes, which have a registered nurse on-site at all times. Still, he said charging fees for 911 calls is the wrong approach because it could lead to abuse and neglect going undetected. “The 911 calls are communicating important information about the quality of care in the facility,” he wrote. “Fees would likely stop some of these calls from being made, taking an expert outsider (and mandated reporter) out of the loop.”