Safety of Nursing Home Residents Under Scrutiny
by Richard A. Sherer
| Geriatric Times |
 |
January/February 2002 |
|
Vol. III |
|
Issue 1 |
Nursing home residents may be facing a rising tide of abuse and
mistreatment, according to a report prepared for Democratic members of the U.S.
House Government Reform committee.
Rep. Henry A. Waxman (D-Calif.), the ranking minority member of the
committee, said in a briefing on nursing home abuse, “Common problems
include untreated bedsores, inadequate medical care, malnutrition, dehydration,
preventable accidents, and inadequate sanitation and hygiene.”
In addition, Waxman said, “Many of the nursing homes we examined were
being cited for physical, sexual or verbal abuse of the residents.”
Leaders of the nursing home industry did not dispute the allegations but
urged balance in interpreting the report. They called on the U.S. Congress to
increase funding for nursing homes under the federal/state Medicaid program to
enable nursing homes to hire more--and better--staff.
“Substantiated instances of less than high quality care are
unacceptable and must be corrected,” according to a statement issued by
the American Health Care Association (AHCA), which claims to represent
“nearly 12,000 non-profit and for-profit assisted living, nursing
facility, developmentally disabled, and subacute care providers that care for
more than one million elderly and disabled individuals nationally.”
Representatives of the AHCA declined a request to be interviewed for this
article.
“Incidents of abuses are, by far, the exception--and not the
rule,” the AHCA statement said, adding, “The nurse-staffing crisis
plaguing America’s health care providers, and endangering access to
quality care, must be met with federal assistance to recruit, train and retain
frontline caregivers.”
Waxman released his 15-page study at a hearing in July and used the occasion
to unveil a new piece of legislation designed to increase funds available for
nursing homes while instituting minimum staffing requirements. The proposed law
also would increase the penalties for nursing homes that violate patient safety
regulations and require criminal background checks for nursing home employees.
Finally, it would create a mechanism for posting the results of nursing home
inspections on the Internet.
The legislation is Waxman’s latest salvo in a long-running war against
nursing home abuses. For the last two years, his staff has been conducting
surveys of nursing home inspection reports for other members of Congress who
want to know about conditions in their districts.
In the latest report, staffers examined a two-year period from Jan. 1, 1999,
through Jan. 1, 2001, using two databases maintained by the federal government:
one that contains the results of annual inspection reports filed by state
inspectors and one that contains the results of complaint investigations
conducted by state investigators. They eliminated reports of abuse in 834
nursing homes that were categorized as presenting a risk of only minimal harm
to nursing facility residents.
They found that 5,283 nursing homes--almost one-third of the roughly 17,000
licensed nursing homes in the United States--had been cited for violating
standards designed to protect residents from abuse.
The 5,283 nursing homes were “cited for almost 9,000 abuse violations
during this two-year period,” the report said. “All these
violations had at least the potential to harm nursing home residents,”
the report stated, and more than 2,500 of those violations were “serious
enough to cause actual harm to residents or to place residents in immediate
jeopardy of death or serious injury.” A total of 1,345 nursing homes were
“cited for an abuse violation that actually harmed residents.”
More significantly, according to the report, many violations were missed or
overlooked by state inspectors. “Over 40% of the abuse violations--over
3,800 in the two-year period--were discovered only after the filing of a formal
complaint,” the report said.
Among violations cited in the report were:
- “Numerous instances of physical abuse, such as the case where a
nursing home attendant walked into a female resident’s room, shouted
‘I’m tired of your ass,’ hit the resident in the face and
broke her nose.”
- “The failure of many nursing homes to adequately protect residents
from other abusive residents. In one case, a resident with a history of over 50
instances of abusive behavior killed another resident when he picked her up and
slammed her into a wall.”
- “Cases where nursing homes ignored signs of serious abuse. In one
instance, state inspectors asked about a female resident who appeared to have
been sexually abused. The director of nursing replied, ‘Maybe she fell on
a broomstick.’”
Many nursing homes have been cited for more than one violation, the report
noted. “Overall, 1,327 homes were cited for more than one abuse
violation…A total of 305 homes were cited for three or more abuse
violations, and 192 nursing homes were cited for five or more abuse violations
in the two-year period…Moreover, 541 nursing homes were cited for at
least two abuse violations that caused actual harm to residents.”
Researchers also looked at the frequency of complaints, noting, “In
1996, 5.9% of all nursing homes were cited for an abuse violation during their
annual inspections.” The percentage increased every year, the report
stated, and by 2000 16% of all nursing homes were cited for an abuse violation
during their annual inspections.
Some of the increase, according to the report, “is likely due to
increased enforcement efforts…It is also possible, however, that some of
the increase in abuse violations represents an increase in the incidence of
abuse.” It cites the repeal in 1997 of the so-called “Boren
Amendment,” which guaranteed nursing homes would receive reasonable and
adequate payments from Medicaid. “Since the repeal…there is
evidence suggesting that Medicaid reimbursement rates have not kept pace with
the rising costs of providing nursing home care,” the report continued,
echoing an argument put forth by the AHCA.
In June, the AHCA told a Senate committee that the industry was in “a
crisis mode from a staffing standpoint.”
AHCA President Charles H. Roadman II, M.D., said, “When the
‘shortage of nurses’ is discussed, it’s critically important
to understand this isn’t just a problem concerning RNs--it’s also a
problem involving certified nurse assistants, LPNs and others on the front
lines.”
Waxman’s researchers underscored the point in an earlier study that
analyzed a report released by three other members of Congress on nursing homes
in Chicago. The report found, “84% of the nursing homes in Chicago--230
nursing homes--do not meet the preferred minimum staffing level” set by
the U.S. Department of Health and Human Services (HHS).
“Moreover…over 70% of the nursing homes in Chicago do not meet
even the lower minimum staffing level identified by HHS.”
“In July 2000...HHS released a comprehensive report on staffing levels
in nursing homes. It concluded that inadequate staffing is widespread and is
endangering the health of nursing home residents,” Waxman wrote in a
statement issued in conjunction with his legislation. “According to the
HHS report, residents in facilities with inadequate staffing were almost four
times as likely to develop pressure sores and almost twice as likely to suffer
significant weight loss than residents in facilities with adequate
staffing.”
But while Waxman has introduced legislation calling for higher reimbursement
rates and increased staffing at nursing homes, which the industry endorses, the
AHCA is also backing a bill by Sen. Spencer Abraham (R-Mich.) that would weaken
the government’s enforcement powers over nursing homes that violate
federal standards.
In a statement supporting his own bill, Waxman said, “The GAO [U.S.
General Accounting Office] reports have shown that the current enforcement
system does not succeed in holding nursing homes accountable because
‘sanctions initiated…against noncompliant homes were never
implemented in a majority of cases and generally did not ensure that homes
maintained compliance with standards.’”
According to an AHCA statement endorsing the Abraham bill, this bill would
“give Medicare providers the right to challenge directly the
constitutionality and statutory authority of the Health Care Financing
Administration’s regulations and policies.” (The Health Care
Financing Administration has since been renamed the Centers for Medicare &
Medicaid Services.) And the Abraham bill would “suspend the termination
and sanction process” against a nursing home while the appeal was being
heard, effectively delaying the imposition of sanctions until a court had ruled
on the constitutionality of the regulation.
The AHCA says the Abraham legislation is designed to overturn a “U.S.
Supreme Court ruling stipulating that a provider, or beneficiary, could not
challenge the legality of any Medicare regulation or policy without accepting
an adverse agency action and proceeding through a time-consuming and costly
administrative process.”
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2/02