Nursing Homes Escape Oversight, Patients Suffer

A flurry of news stories the last few weeks about the dismal safety record of U.S. nursing homes has renewed interested in beefing up inspections where 1 in 3 patients in skilled nursing facilities suffers a medication error, infection or some harm related to treatment, according to a government report by the Department of Health and Human Services (HHS).

When the report was issued, patient safety experts expressed alarm to because the shocking figures of harm exceeded even those of hospitals, where more invasive medical procedures are performed and which receive the most attention when something goes wrong.

“(The report) tells us what many of us have suspected — there are vast areas of health care where the field of patient safety has not matured,” Dr. Marty Makary, a physician at Johns Hopkins Medicine in Baltimore told ProPublica.

A “skilled” nursing facility, ProPublica explained, provides specialized care and rehabilitation to patients following a hospital stay of three days or more. There are more than 15,000 such facilities nationwide; about 9 in 10 also are certified as nursing homes, which provide longer-term care.

As hospital stays have become shorter, skilled nursing care has grown. Medicare, whose patients were the subjects of the new report, spent more than double on skilled nursing care between 2000 and 2010.

Dr. Jonathan Evans, president of the American Medical Directors Association, pointed out that because patients are released from hospitals sooner than they used to, many might have more intensive needs than nursing facilities are equipped to handle.

“You have a system of long-term care that’s trying to retrofit to be a system for post-acute care,” he told ProPublica, which has established a data bank of nursing home inspection results you can access.

The study by the HHS looked at treatment in skilled nursing facilities for as long as 35 days after a patient was discharged from an acute care hospital. Medical records of 653 randomly selected Medicare patients from more than 600 facilities were reviewed.

More than 1 in 5 patients suffered events that caused lasting harm and more than 1 in 10 were harmed temporarily. More than 1 in 100 patients died because of poor care, even though they had been expected to survive. Nearly 6 in 10 of the errors and injuries were preventable, according to the physicians who reviewed the records.

The study concluded that the injuries and deaths were caused by substandard treatment, inadequate monitoring, delays or failure to provide needed care. Mortality was the result of problems including preventable blood clots, fluid imbalances, excessive bleeding from blood-thinning medications and kidney failure.

The report called on the federal Agency for Healthcare Research and Quality and the Centers for Medicare & Medicaid Services (CMS) to promote patient safety efforts in nursing homes as they have done in hospitals. It also said the CMS should instruct state inspection agencies to review what nursing homes are doing to identify and reduce adverse events.

A few days after the report’s release, (KHN) and the Washington Post detailed oversight measures that the CMS is planning to implement. As required by the Affordable Care Act (“Obamacare”), it must improve nursing home care by establishing “quality assurance and performance improvement programs.” That’s supposed to happen sometime this year.

That includes the establishment of a website with resources and training materials that have been used, for example, to reduce the incidence of pressure ulcers (bed sores) and medication errors. The plan also includes a list of warning signs and instances of actual harm to enable nursing home operators and government inspectors to identify problems resulting from poor treatment quickly instead of assuming they’re the natural progression of disease in an elderly patient.

These tools are supposed to help nursing home inspectors detect problems that aren’t apparent during a typical in-the-moment inspection. Routine inspections, as opposed to those prompted by complaints, typically take three days and occur every nine to 15 months.

Inspectors review medical records of some residents, and check a range of other services from housekeeping to social activities and protection of residents’ rights.

But these inspections often aren’t a surprise, so the information they yield might be the result of atypical preparation, and not the normal course of events. That’s why Ruth Ann Dorrill, the HHS manager of the investigation, said the chances of nursing home inspectors discovering the astonishingly prevalent adverse events are “slim to none.”

Nothing brings that reality into focus more clearly than a story that broke in Los Angeles at the same time the HHS report was released. So overwhelmed were public health officials by a backlog of health and safety complaints about nursing homes, according to, that they told inspectors to close cases without fully investigating them.

The “Complaint Workload Clean Up Project” has been underway for at least a year and a half.

The documents detailing the dumping of public health responsibility don’t specify the nature of the incomplete investigations, but they could range from insufficient staffing to staff misconduct to unsafe conditions. They could involve patients with pressure wounds, or being given unnecessary medications.

One nursing home reform advocate called the county’s actions “unconscionable.” “They are supposed to take action to protect people from harm,” he told KHN. “They are supposed to set out right away, investigate and take action to stop it from occurring. … They don’t have the option of picking and choosing.”

State and federal officials, who contract with Los Angeles County to inspect nursing homes on their behalf, said they are now investigating the matter.

There’s no shortage of nursing home horror stories. Last month, PopTort, the civil justice blog sponsored by the the Center for Justice & Democracy, summarized a series from the nonprofit Wisconsin Center for Investigative Journalism about the impact of Wisconsin’s new nursing home “tort reform” law.

Families’ ability to hold potentially negligent nursing facilities accountable, it explained, have been diminished by a recent change in state law that bars records of abuse and neglect from use in the courts. Some long-term care facilities are failing to report deaths and injuries, as required by law.

The current Wisconsin political environment enabled legislation making it difficult or impossible for families to sue on behalf of their abused, neglected or deceased relative, making it virtually impossible for grossly negligent facilities ever to be liable for punitive damages.

The laws also prohibit families in such tragic situations from using any state investigation records as evidence in their lawsuit. PopTort quotes personal injury attorney Ann Jacobs, “When you’ve got these records that are part of the regulatory process, the idea that you wouldn’t be able to introduce them to the jury is just insane. Why would we hold that information back?”

Probably for the same reason you would tell investigators to close cases they never opened. Probably for the same reason people are being harmed unnecessarily in nursing facilities that aren’t subject to proper, consistent, authoritative oversight.

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