Compelling, heartbreaking stories of abuse and neglect from the daughters of two elderly women drove home a call for tighter regulations, better oversight and more careful screening of nursing home staff during a Senate Committee on Finance hearing on March 6. The hearing comes in the wake of another horrific story, when a woman in a 14-year coma at a long-term care facility in Arizona gave birth after being raped.
Legislators from both sides of the aisle expressed outrage over mistreatment, neglect and other serious violations at nursing homes, despite years of efforts to enact additional reforms and more government supervision.
“Hardly a week goes by without seeing something about nursing home abuse or neglect in the national news,” said committee chairman Chuck Grassley, (R-Iowa). “These are not isolated cases,” he said, referring to the witnesses. [Grassley’s full statement is here]
According to the Inspector General, one-third of nursing home residents experienced harm while under the care of their federally funded facilities. In more than half the cases, the harm was preventable, Grassley stated.
Patricia Blank described her mother’s death from neglect to committee members —a death which was totally avoidable, she told the panel. “During her 15 years at Timely Mission Nursing Home in Buffalo Center, Iowa, my family believed she was getting good care,” she told the panel.
It wasn’t until her mother, Virginia Orloff, was sent to the emergency room that Blank began to wonder how something could go so seriously wrong with the care at the facility — severe dehydration, high levels of pain and highly elevated sodium levels all pointed to likely neglect that had been going on for a while, the physician on duty told her.
A phone call from Des Moines Register reporter Clark Kauffman about a subsequent Department of Inspections and Appeals report confirmed that her mother had been severely neglected for weeks. The story picks up here.
Seniors in nursing homes are among the most vulnerable to life-threatening consequences of abuse and neglect, said ranking Democrat Ron Wyden of Oregon. “That vulnerability is being exploited in unimaginably cruel ways in nursing homes that are unsafe, under-staffed, and uninterested in providing even the most basic levels of humane care.” [Wyden’s full statement is here]
That point was highlighted by the testimony of Maya Fischer, daughter of 83-year old Sonja Fischer, who had suffered from dementia for more than a decade. Her mother was immobile and totally dependent on others for all of her needs, Fischer said. She described the phone call she received informing her that her mother had been sexually assaulted by a male caregiver. “And just like that, my mother became another statistic in the shocking reality of nursing home abuse.” [Fischer’s full testimony is here]
Staffing, reimbursement are ongoing challenges
Issues of staffing, quality and funding, particularly Medicaid reimbursement, were addressed by David Grabowski, Ph.D., a professor at the Harvard Medical School and David Gifford, M.D., who heads up quality and regulatory affairs for the American Health Care Association. Answering a question from Wyden, Grabowski predicted more closings of rural nursing homes due to low Medicaid reimbursement. Nursing homes can’t afford to pay people more, and there are few people in rural areas who want these minimum-wage jobs, he told the committee.
He cited a recent New York Times article on rural nursing home closures as a preview of what’s to come unless Congress acts to shore up reimbursements That could mean higher wages for staff and help reduce rampant turnover. “Research has found that nursing homes with higher staff turnover have worse quality,” he said.
Gifford noted that staffing isn’t the only serious problem in nursing homes. Monitoring compliance with rules and regulations is key, he told senators. He pointed out that when nursing homes are hit with inspection citations, consumers have difficulty understand the scope of the problem. And citations are often inconsistent from state to state.
He suggested nursing homes participate in and have access to the national practitioner data bank. It would help catch unqualified and dangerous staff who can obtain jobs in different states because background checks and databases are not linked. Without it, “it’s crippling to us knowing the truth,” he said.
Fischer told senators “the person that raped my mom had been investigated numerous times before; he was investigated and still kept his job, how can that be? Someone dropped the ball and my mom was a victim.”
Story after story have appeared in the media about staffing issues, abuse or neglect at nursing homes throughout the U.S. In Knoxville, Tenn, admissions were halted at one of the state’s largest nursing homes after a patient with dementia fractured both knees and despite being in extreme pain, did not see a doctor for nine days. In Florida, a USA-Today network investigation found the state’s regulatory agency at fault for lack of follow through after citations were issued — counting “7,200 violations in 54 of the worst homes in the state” over a five-year period, they reported. In Minnesota, reports of abuse are so widespread that legislators introduced a bill to allow hidden cameras in facilities to ferret it out.
Meanwhile, the Trump administration has rolled back some Obama-era rules, including fines against nursing homes charged with patient abuse or neglect, the New York Times reported in 2017.
Kate Goodrich, director, and chief medical officer, Center for Clinical Standards and Quality, at the Centers for Medicare & Medicaid Services, addressed staffing, abuse, and regulatory concerns. “When we learn a nursing home failed to report or investigate incidents of abuse, CMS takes immediate action against the nursing home.”
She told the committee that patient safety is a top priority, but monitoring and improving quality of care in nursing homes serving Medicare and Medicaid beneficiaries requires coordinated efforts across the federal government and states.
CMS implemented a revised resident-centered survey process in 2016; it provides surveyors with more information on quality of care. The agency also began using payroll-based journal data to help determine actual (not self-reported) staffing at facilities.
Goodrich defended the agency’s algorithm for Nursing Home Compare, saying CMS continues efforts to provide consumers with more information on quality measures and state rankings; however, Grabowski and several senators complained about the rating system, calling it an unreliable indicator of quality because so much information is self-reported.
“We need to make sure the ratings are accurate,” Grabowski said. He does not consider the information on quality of life or patient satisfaction to be helpful. “I can learn more about the hotel I stayed in last night than I can about the nursing home I want to put my mom in.”
In an e-mail statement, Katie Smith Sloan, CEO and president of LeadingAge, an association of nonprofit aging service providers, including nursing homes, said that issues of abuse and neglect along with poor quality of care should spur all stakeholders to work more closely together. [Smith’s full March 6 statement on the hearings is here.]
“This is a complex, multi-faceted problem and it’s going to take an equally complex set of responses. Ensuring high-quality care for older adults is truly an activity that requires input from policymakers, elected officials, providers, and consumers — older adults, their families and truly, voters,” she said.
Sloan said long-term care financing really goes to the heart of any discussion. Without a change, staffing and quality are going to continue to be challenges. The group’s members are supportive of pay increases as a means to retain good staff, but “if Medicaid pays for many services an average of about 60 percent of what Medicare or private insurance pays, where is the additional money going to come from?” She also suggested it’s time to revisit the 1985 Institute of Medicine study on nursing homes, and scientifically determine what works to improve quality, then create a quality assurance system for the 21st century.
The Center for Medicare Advocacy called the hearing “hollow,” saying the Committee did little to push back against misleading claims by CMS about the implementation and enforcement of the nursing home standards of care. “Ultimately, the hearing was a missed opportunity to have a serious conversation about ongoing resident concerns, such as inappropriate antipsychotic drugging, transfers and discharges, ownership concerns, and “no harm” deficiencies,” they said in a statement. The group, along with several other long-term care and elder advocacy organizations, issued a joint statement for the record detailing these persistent problems.
- ProPublica has built a database of some 60 thousand inspection reports that consumers can access to research quality and safety issues.
- Reach out to patient safety councils or consumer advisory boards at local nursing homes; ask about staffing, deficiencies, and action plans to correct issues. They may be able to put you in touch with families who can discuss specific situations, whether and how they were addressed by management or the state.
- Amid stories of abuse, neglect, deficiencies, and problems, what about nursing homes that are doing things right? What makes a “good” home? Why do some thrive and others sink?