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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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