Analysis finds clusters
of nursing home violations
by state, ownership

By LARRY WHEELER and ROBERT BENINCASA
Gannett News Service

WASHINGTON — Where a nursing home is and who owns it can be critical in determining the care given to America’s most frail and vulnerable, a Gannett News Service investigation has found.

Nearly three-fourths of the most severe and repeated nursing home patient care violations found in the past four years were concentrated in a dozen states. Additionally, patients at homes owned by for-profit companies fared worse in some ways than residents in government and nonprofit nursing homes.

“There are many flaws in the long-term care system,” said Thomas Scully, administrator of the Centers for Medicare and Medicaid Services, which directs federal nursing home programs. “We’re trying to look at them and fix them.”

The findings are the result of a four-month Gannett News Service investigation. GNS interviewed dozens of people and analyzed four years’ worth of federal data on inspections and patient well-being at the nation’s 16,000 nursing homes.

The analysis revealed significant weaknesses in the safety net designed to protect the nation’s 1.5 million nursing home residents, weaknesses not apparent on a nursing home quality Web site the federal government created. Star ratings for each Medicare- and Medicaid-certified nursing home, the vast majority of nursing homes nationwide, can be found by clicking the searchable database link at the top of this page. The analysis also ranks each home’s inspection results against peers in its home state.

Some findings:

— For-profit nursing homes accounted for 83 percent of the more than 500 nursing homes with repeated, serious violations, yet are only 65 percent of all Medicare- and Medicaid-certified nursing homes.

— Patients at for-profit homes had, on average, higher rates of infections and pressure sores than those the government and nonprofits own.

— Homes monitored by councils of residents’ family members tended to have a higher use of physical restraints and a lower rate of patients in pain.
Information about nursing homes and the care they provide is crucial to thousands of Americans who each year must confront the difficult decision of placing a loved one in a long-term care center.

As a nurse, Anne Smith of Salt Lake City is well aware of the troubled past and present of nursing homes. When she needed care for her 88-year-old mother who was recovering from a heart ailment, she asked the hospital discharge planner for help. The planner handed her a list of 31 nursing homes in the area.

“I said, ‘Can you help me find a good one?’ and she said she wasn’t allowed. And to tell you the truth, she probably didn’t know which ones were good or bad,” said Smith, 65.

Smith turned to a new consumer-oriented tool on the Internet, the federal government’s Nursing Home Compare Web site, which lists residents’ health status and inspection results for all Medicare- and Medicaid-certified nursing homes.

The site is part of the federal government’s major new nursing home initiative, which spent about $30 million to draw attention to the Web project. It features inspection and patient health results for every nursing home in the country.

Another $1 billion was pledged over three years to expand the role of quality improvement organizations, staffed by health care professionals, that work with nursing homes to lift the level of care delivered to nursing home patients nationwide. With a list from the Web site, Smith narrowed her choices, using proximity to her home and other factors.

“It helped me go into the nursing home with this information and ask them, ‘What is your strategy for caring for my mother because you don’t look very good on paper,’” Smith said.

Legislation ineffective

Consumer advocates who reviewed the GNS findings said they were not surprised that the investigation found a substantial number of repeat violations and links between poorer care and for-profit ownership.

They say nursing home residents continue to suffer from neglect and abuse despite new quality and information efforts and years of legislation and regulation intended to protect patients.

The National Citizens’ Coalition for Nursing Home Reform recently published a book depicting in graphic, heart-wrenching detail the neglect and pain 82 Texas nursing home residents suffered. The coalition is the nation’s largest consumer advocacy group focused solely on nursing homes.

Some examples:

— Lunnie C., 93, entered a Longview, Texas, nursing home suffering from a handful of ailments that included coronary artery disease. Twenty months later she was taken to the hospital suffering from deep pressure sores, more commonly known as bedsores; dehydration; malnutrition; and gangrene in her left foot. State inspectors found the nursing home staff had ignored and neglected her.

— Kenneth E., 65, entered a Tyler, Texas, nursing home suffering from Alzheimer’s disease. Less than two years later, he died from pressure sore infections he developed there. State inspectors found staff was negligent.
Incidents like these continue to occur despite government officials’ claims that care in nursing homes is improving, said Donna Lenhoff, the coalition’s executive director.

“These are severe breakdowns in the provision of health care services and in the provision of basic human decency,” she said. “There are a lot of nursing homes that are giving a lot of bad care.”

Federal officials, nursing home administrators and others representing the industry said recent reforms, especially the Nursing Home Compare Web site, have helped improve patient care.

“Getting people talking about quality, measuring poor quality, making people aware of quality is a big first step,” the Medicare agency’s Scully said.

“Long after we’re all gone, this is going to have a huge impact on the health care system — if we can manage to slowly turn around quality measures and public accountability,” he said.

Few states had most problems

Nearly three-fourths of severe and repeated violations of federal patient care standards from 1999 to 2003 were at nursing homes in 12 states. They are, in descending order: Texas, Illinois, Arkansas, Washington, New Jersey, Kansas, Missouri, Indiana, Oklahoma, North Carolina, Mississippi and Tennessee.

The violations included failing to protect patients from mistreatment, hiring staff without conducting criminal background checks, and allowing patients to be abused and physically punished.

In some cases, problems were isolated. But in others, dangerous conditions were widespread.

Government regulators, the nursing home industry and consumer advocates disagree on whether nursing home quality has improved or slipped in recent years. The theory behind the Bush administration's $1 billion quality improvement effort, barely 6 months old, is to encourage nursing homes to improve care for patients by offering them guidance from teams of experts and by holding their violations records up to public scrutiny. The program has not yet produced measurable results.

Some states such as Florida and Washington have gone beyond federal requirements by enacting their own reforms, but those, too, are so recent that results are not conclusive.

Terry Watters, a Maryland ophthalmologist who compiles nursing home information, said it is important to know which homes are cited repeatedly for severe violations.

“This means somebody is not doing their job,” said Watters, who founded the nursing home watchdog group Member of the Family.

Scully — whose agency sets nursing home care standards, payment and enforcement policies — said concentrations of repeat offenders in certain states do not necessarily mean those states have more problem nursing homes.

“Obviously in some states, due to different secretaries of health, different state legislatures, different funding, and different cultures, you may have more aggressive or less aggressive inspections,” he said.

Federal health quality measures can be similarly misleading.

The New Underwood Good Samaritan nursing home in New Underwood, S.D., recently reported 71 percent of its patients in pain. That’s seven times the average for all nursing homes nationwide.

Administrator Ron Kortemeyer said his nursing staff records and treats pain precisely as the Centers for Medicare and Medicaid Services recommend it be done, and the high number for his nursing home indicates strong oversight, not poor care.

“It is our understanding we’re doing it correctly,” Kortemeyer said. “Which suggests others are not.”
Officials with the trade association representing for-profit nursing homes argue that the inspection process is so inconsistent — from state to state and even within the same state — that any attempt to make comparisons or draw conclusions is misleading.

“The statistics are easily subject to misinterpretation,” said Alan DeFend, vice president for public affairs of the American Health Care Association. “Drawing sweeping conclusions could present readers with an incorrect picture of reality.”

DeFend said providing consumers with the information is helpful but focusing on violations and attempting to rate nursing homes give consumers false information.

DeFend’s group represents 12,000 for-profit and nonprofit nursing homes and other long-term care centers. It spent $305,000 lobbying Congress last year, and its political action committee made more than $800,000 in campaign contributions in the 2001-2002 election cycle, according to watchdog group PoliticalMoneyLine.

Quality data not all as they appear

Tom Patton of Richmond, Va., faced a difficult choice last year.

His 80-year-old mother, Elaine, was living in St. Petersburg, Fla., and had been diagnosed with lung cancer on top of the emphysema she had been struggling with for years. Patton decided to move his gravely ill mother to a nursing home closer to him in central Virginia but, like many people in his situation, was overwhelmed.

“I began frantically searching for a nursing home here not knowing the first thing about where to start,” said Patton, a home builder. “All I had was the Yellow Pages, newspaper ads and word of mouth.”

Patton, 55, found his way to the federal Web site, downloaded information about his local nursing homes and began visiting them before he settled on one.

“It was by process of elimination,” he said. “Quality of care was most important.”

Medicare director Scully said he is encouraged by the early experiences of people like Patton.

“It’s going to take a while” for people to understand what’s available, Scully said. “We’re just in the first steps.”