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Get patient care quality ratings for
16,000 nursing homes nationwide
Nursing home enforcement efforts questioned

Gannett News Service

WASHINGTON — The Bush administration’s $1 billion push to improve nursing home care does not include clamping down on nursing homes that violate the law, a Gannett News Service investigation has found.

More than 500 nursing homes across the nation have been cited in the past four years for repeated and severe deficiencies, violations that brought harm to residents and exposed some to life-threatening conditions.

Yet the federal agency in charge of enforcing nursing home standards, the Centers for Medicare and Medicaid Services, has no program to target these repeat offenders.

Once a nursing home is found to be in violation of federal standards, called a deficiency and ranked on a 12-point scale, it is subject to penalties ranging from fines to license revocation.

However, nursing homes are rarely forced to shut down, said Charlene Harrington, a noted University of California nursing home researcher.

In 2002, the federal government kicked 12 nursing homes out of its Medicare and Medicaid programs, down from 41 just two years earlier, according to the Centers for Medicare and Medicaid. This is the equivalent of a deathblow to a nursing home, which relies heavily on Medicare and Medicaid payments.

“Some states do a good job in giving deficiencies,” Harrington said. “But even those states don’t follow up and get rid of facilities that are repeat violators and bad actors.”

The problem: tight budgets, inadequate staffing and weak political will.

“We can give billions in tax breaks and spend all this money on the war, but we won’t spend more money to get decent staffing into these nursing homes and state survey agencies,” she said.

Steve Pelovitz, director of the Centers for Medicare and Medicaid Services survey and certification branch, disagreed.

“The purpose of our oversight is to provide remedies and sanctions to try and help make sure nursing homes have a set of incentives to get into compliance and remain in compliance,” he said. “This is not a system which at its heart and core is one in which we look to decertify nursing homes or throw them out.”

In the last three years, 5,637 fines have been levied against nursing homes, according to the most recent data from the Centers for Medicare and Medicaid Services.

Fines can range from $50 to $10,000 a day. Fines in 2002 totaled more than $12.4 million for almost 2,200 cases, down from $23.7 million two years earlier on roughly the same number of cases.

Additionally, regulators issued 3,570 notices to nursing homes temporarily denying federal payment for new residents.

Consumer advocates say the fines amount to little more than a wrist slap considering the numerous severe violations — those that caused actual harm or put residents in jeopardy of death or serious injury — that regulators found in nursing home inspections between 2000 and 2002, according to the GNS analysis.

Pelovitz said his agency, which oversees nursing home payments, quality and enforcement, does not target repeat offenders. That is a function of state inspection teams.

“There is increased attention paid, but there isn’t a list of multiple offenders,” he said.

In the most extreme cases, when a resident dies and family members believe the death was from negligence, state and federal regulators can force a nursing home to shut down if their investigation warrants.

However, families often have little recourse but to file civil lawsuits. Many eventually are settled out of court.

Residents vulnerable

Ruth Tobey of Georgetown, Texas, found out the hard way just how wrong things can go in nursing homes.

Tobey, 65, placed her mother in a local nursing home because her mother’s Alzheimer’s disease made it too difficult to continue care at home. Tobey’s mother remained in the nursing home for five years with few difficulties.

In 1997, Tobey visited her mother in the nursing home for Christmas.

“A nurse told me she had a spot on her bottom they were keeping an eye on,” Tobey said. “I didn’t think anything of it. I had not seen my mother naked for some time. I trusted those folks to care for her.”

Less than two weeks later she received a disturbing phone call.

“I can remember it so clearly,” Tobey said. “I got an anonymous call at home from someone who said I had better check on my mom.”

Tobey rushed to the nursing home.

“When I saw my mom, it wasn’t the same lady I had seen 10 days earlier,” Tobey said. Her mother had developed an open wound near her coccyx, the bone at the lower end of the spinal column. Her wound was as large as a baseball and so deep her spine was exposed.

“The smell was so rancid, you couldn’t hardly enter the room,” Tobey recalled.

Tobey’s mother was transferred to a hospital that specializes in wound care. She remained there for five months before recovering enough to be placed in another nursing home, where she lived until her death March 13 at age 95.

“Who do I blame?” Tobey said. “It’s difficult to say. The people there were nice, but I feel like they didn’t have enough training. And I think they were overworked. There were too few staff members on each wing, and I think perhaps people got overlooked.”

Tobey sued the nursing home for negligent care and received an out-of-court settlement, the terms of which she isn’t allowed to discuss.

Misreading easy, some say

GNS’ analysis found that 83 percent of homes with severe and repeated violations over the past four years were for-profit nursing homes, which account for 65 percent of all nursing homes nationwide.

Officials representing for-profit nursing homes reviewed the findings and disagreed with the implication that for-profit nursing homes were more likely to be cited for severe violations than nursing homes under other ownership.

“The statistics are easily subject to misinterpretation,” said Alan DeFend, public affairs vice president for the American Health Care Association that represents 12,000 nonprofit and for-profit nursing homes and other long-term care centers. “Drawing sweeping conclusions could present readers with an incorrect picture of reality.”

Executives who represent nonprofit nursing homes offered a diplomatic response.

“We don’t want to be looked at as gloating, but we work hard on quality,” said Susan Weiss, a senior vice president with American Association of Homes and Services for the Aging. The group represents 5,600 nonprofit nursing homes.

“The particular advantage of not-for-profit (nursing homes) is that you get to take all the resources you have and plow them back into quality of care,” she said.

State and federal regulators can impose a variety of penalties on nursing homes not in compliance with government standards. The violations — also called deficiencies — range from failing to protect patients from mistreatment, hiring staff without conducting criminal background checks, and allowing patients to be abused and physically punished.

Among the penalties from the government:

— Levying fines from $50 to $10,000 a day.

— Denying payment for newly admitted residents until a deficiency is corrected.

— Prohibiting training for new nurse aides for up to two years.

The harshest sanction, revocation of a nursing home’s license that closes a home, is rarely used.

Numerous appeals and dispute resolutions can delay a sanction or eliminate it entirely, common occurrences that draw criticism from nursing home consumer advocates.

“This is nothing more than a charade,” said Terry Watters, a Maryland ophthalmologist who formed Member of the Family. The advocacy group runs a Web site that compiles nursing home information.

Appeals take time

Nursing home administrators defended the appeal and dispute resolution process.

“Just because a surveyor comes in and says something is deficient doesn’t make it so,” said Scot Sauder, a senior vice president and general counsel of Peak Medical Corp., which owns and operates 41 nursing homes in seven states.

Peak’s Sweetbriar Nursing Center in Midwest City, Okla., has been cited for severe violations 16 times since 2000.

Sauder said the nursing home appealed the citations and had many of them reduced or overturned.

Harrington just completed an analysis of federal and state nursing home enforcement actions that will be published in an upcoming academic journal. She found that the number of deficiencies state inspectors are citing at nursing homes is increasing but the severity is decreasing. “There is no question overall the penalties assessed through the enforcement process have been insufficient to deter repeat or continued abuse or neglect,” said Donna Lenhoff, executive director of the National Citizens’ Coalition for Nursing Home Reform. The coalition is the nation’s largest consumer advocacy group focused solely on nursing homes.

By telling her mother’s troubling story, Tobey said she hopes others responsible for a parent or loved one will be more cautious about nursing home care.

“You can’t go to school to learn how to choose a nursing home. It just happens,” Tobey said. “You’ve got to check with local and state agencies. See if there have been complaints. Interview the nursing staff. Pop in on them at different times of day. And keep a detailed diary on every visit and every telephone call.”



Analysis finds clusters
of nursing home violations by state, ownership
Nursing homes with unblemished records are rare
Tips on choosing a nursing home
Nursing home analysis used federal records, statistical tools
Nursing home terminology steeped in bureacracy
Resources on the Web to learn more about nursing home care

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About the project writers

About the project


Fines, terminations decline

In the past three years the number of nursing homes kicked out of the federal Medicare and Medicaid programs has decreased by 70 percent and the amount of fines collected for violating patient care standards has dropped by almost half.

2000: 41 homes terminated; $23.7 million in fines collected; 2,162 cases.

2001: 19 homes terminated; $17.8 million in fines collected; 2,362 cases.

2002: 12 homes terminated; $12.4 million in fines collected; 2,192 cases.

Source: Centers for Medicare and Medicaid Services


All contents © 2003, Gannett News Service