Nursing Home Inspectors Often Miss Serious Care Problems Like Bed Sores, New GAO Report Concludes

According to a recent report prepared by the Government Accountability Office (GAO), state nursing home inspectors routinely overlook or minimize care deficiencies that pose a serious, immediate threat to patients.  The GAO report notes widespread “understatement of deficiencies,” including malnutrition, severe pressure ulcers (bed sores, pressure sores, decubitus ulcers), medication errors, and abuse.  “Poor quality of care — worsening pressure sores or untreated weight loss — in a small but unacceptably high number of nursing homes continues to harm residents or place them in immediate jeopardy, that is, at risk of death or serious injury,” the report states. 

Lewis Morris, chief counsel to the inspector general of the Department of Health and Human Services, commented on the deficiencies often found in nursing home inspections:  “We have found nursing home residents who were grossly dehydrated or malnourished  We’ve found patients with maggot infestations in wounds and dead flesh. We’ve found residents with broken bones that went unmended.”

State inspectors missed at least one serious deficiency in 15 percent of their nursing home inspections, claims the report.  In nine states (Alabama, Arizona, Missouri, New Mexico, Oklahoma, South Carolina, South Dakota, Tennessee, and Wyoming), state inspectors missed serious problems in more than 25 percent of surveys that were analyzed from 2002 to 2007.  Nationwide, about one-fifth of nursing homes were cited for serious deficiencies in 2007.  Read the GAO report.

The GAO study was done at the request of Senators Charles E. Grassley (Iowa - R) and Herb Kohl (Wisconsin - D), who is chairman of the Senate Special Committee on Aging.  Senators Grassley and Kohl have introduced a bill to upgrade nursing home care and increase the penalties for violations of federal nursing home standards.  The maximum fine, now generally $10,000, would be increased to $25,000 for a serious deficiency and $100,000 for one that resulted in a patient’s death.

Senator Grassley requested the GAO investigation following revelations about the care received by Maizie Bickley, an 89-year-old nursing home patient.  Bickley was found in poor condition at the facility by her daughter.  The nursing home had not obtained any medical attention for Bickley when her condition worsened.  Doctors later diagnosed Bickley with a bowel obstruction, infection, and dehydration that required life-saving surgery.  The nursing home fired an aide as a result of Bickley's poor care.   

Bickley's daughter complained to a state agency, which investigated and found no problems with the nursing home's care.  Bickley's daughter then complained to an ombudsman and Senator Grassley.  Shortly thereafter, the Centers for Medicaid and Medicare Services (CMS) investigated the quality of the state agency's investigation.  CMS determined state inspectors didn't conduct a thorough investigation of the Bickley case.  Grassley asked the GAO to investigate to determine if the inadequate investigation Bickley received is isolated or part of a larger problem.  Read more about Senator Grassley's investigation of the investigators.

My opinion?  State agencies that investigate nursing home care, at least the one in Virginia, probably do a better job than we give them credit for based on the funding and personnel with which they are forced to work.  Those agencies are in some states probably as understaffed and underfunded as the nursing homes and assisted living facilities they investigate.  We can't expect more oversight and better investigations of these facilities until we commit more resources (money and people) to police them.  I'm reminded of a quote by Abraham Heschel: "A test of a people is how it behaves toward the old. It is easy to love children. Even tyrants and dictators make a point of being fond of children. But the affection and care for the old, the incurable, the helpless are the true gold mines of a culture." 

We also need to ensure that offending nursing homes are hit with significant fines and monetary penalties to deter further neglect and abuse.  As Bickley's daughter correctly observed,  "problems with nursing homes are widespread . . . Too many homes are owned by corporations, and for them the bottom line is profit."  Until nursing home profits are threatened by meaningful and thorough inspections and complaint investigations, the owners of these facilities will never learn.

That's why I was glad to see a bill proposed by Senators Grassley and Kohl in February 2008 to require nursing homes with severe care deficiencies to pay civil fines of up to $100,000 -- a tenfold increase in the maximum fine that can be assessed.  In addition to stiffer fines, the bill, entitled the "Nursing Home Transparency and Improvement Act of 2008," authorizes the United States Department of Health and Human Services to develop a program to monitor nationally corporate-level problems in large nursing home chains.  More information would also be added to Medicare's Nursing Home Compare web site about nursing home ownership, Special Focus Facilities (SFFs), nursing home complaints, and the results of inspection reports.  

Deterrence is the goal of the new bill.  In theory, a nursing home should be deterred from abuse and neglect based on the risk of getting caught, the penalty that's imposed when it is caught, or both.  When nursing homes and assisted living facilities are caught more frequently and fined more significantly by state inspectors when they provide bad care, everybody wins!________________________________________________________________
Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia