By David Jackson and Gary Marx
Chicago Tribune
Reporters David Jackson and Gary Marx separately latched on to news brief about a 21-year-old psychiatric patient with a violent rap sheet who had been charged with raping a 69-year-old woman in a suburban nursing home.
Both reporters were startled by the young felon’s placement in a retirement home. They researched that case during breaks between assignments then discovered they were crossing paths, so partnered to begin the three-month investigation into the underlying policies and practices of Illinois nursing homes.
They found that Illinois is an outlier among states in its reliance on nursing homes to house younger adults with mental illness, including thousands of felons whose disabilities qualify them for Medicaid-funded nursing care. Jackson and Marx documented numerous recent cases in which violent psychiatric patients who were not receiving proper treatment assaulted, raped and even murdered their elderly and disabled housemates. The stories also showed how the chaotic and harmful behavior can spill outside the nursing home walls when patients are not properly supervised.
Government agencies responded immediately to the initial three-part investigation, “Compromised Care,” which ran Sept. 29-Oct. 1, 2009, and has included more than 20 follow-ups.
Jackson and Marx describe some of the techniques they used in the investigation:
Merge police and health department records
Police records – obtained through dozens of public records requests – were meshed with state health department inspection surveys and complaint investigation reports. It turned out that the police and health department officials were not sharing with each other their reports on homes or violent incidents. By collating the police and inspection records, the reporters were able to track broad trends, identify troubled homes and bore into specific cases of assault, rape and murder.
Lots of data available
We obtained state health department to get datasets on:
- the population census
- ages
- primary diagnoses captured in the CMS Minimum Data Set
- the number of felons and sex offenders reported to the state health department
We got a licensing file showing ownership and management information of nursing homes. We hand-built datasets from police agencies, including one showing more than 500 police reports on five categories of serious crime at Chicago facilities. We gathered safety fines and infractions data. We used staffing levels and quality ratings reported to CMS. We used scraping software to search for key phrases – such as “sexual assault” or “attack” – in the hundreds of thousands of health department inspection reports that are posted online but not readily searchable.
Once collated by facility, the data created a blueprint for the reporting, allowing us to hone in on a subset of dangerous homes, and to examine characteristics of facilities. We used SAS analytic software for statistical significance testing and explored relationships among data elements using JMP statistical software.
Human sources
Records on individual cases were extremely difficult to obtain because of medical privacy laws that surround nursing home patients. It is crucial to obtain internal files by developing sources, including nursing home inspectors, social workers, current and former facility employees and administrators, plaintiff’s attorneys in cases of alleged malpractice, hospital emergency room staff and nurses, police, and advocates for the elderly and mentally ill. Reporters wrote letters to nursing home residents to gain access to homes, conducted jailhouse interviews of perpetrators, and met with numerous families of victims.
Involved readers
The Tribune created a Web application that provides citizens with critical patient safety information not available from government agencies and nonprofit advocacy groups. The easily searchable site allows citizens to learn the number of convicted felons, sex offenders and mentally ill adults under the age of 65 at each Illinois home, as well as citations for misuse of psychotropic medication, crimes reported at Chicago nursing homes and fines levied because of deficiencies in patient safety. The entire dataset, which is constantly updated as websites are scraped, is also presented in downloadable format as a set of linked Excel spreadsheets. The site also includes a citizens’ guide to government and advocacy resources, and a guide to writing public records requests for police records on potential crimes at nursing homes (with a sample letter). Web applications and data management for the series were handled by reporters Brian Boyer, Joe Germuska and Ryan Mark.
Main findings
Government, law enforcement and the industry have failed to adequately manage the influx of younger residents who shuttle into the nursing facilities from jail cells, shelters and psychiatric wards – and the volatile mix of felons, mentally ill people and seniors serves none of those three populations.
A review of confidential case files showed the state’s background checks on new residents are riddled with errors and omissions that grossly understate their criminal records. The homes with the most felons have the lowest nursing staff-to-patient rations. State authorities didn’t track assaults and other crimes in nursing homes, and they were unaware of the patterns and problems. While mentally ill people are no more likely than others to be dangerous or to commit crimes if given proper treatment, case records raise questions about whether the nursing facilities provide meaningful psychiatric care.
Impact
Illinois Gov. Pat Quinn appointed a Nursing Home Safety Task Force which is pushing for a sweeping overhaul of the state’s unique reliance on nursing homes to house psychiatric patients who could be treated more cheaply and effectively in community settings. Two state Senate committees (human services and public health) held a joint hearing and are now working on legislative solutions. Illinois Attorney General Lisa Madigan has called on state public health officials to protect seniors and disabled adults who live in nursing homes alongside mentally ill felons. And hundreds of citizens have attended the task force hearings while dozens have written letters of gratitude and support to the reporters.
