Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
Long Term Care Ombudsman Program: 
Complaint Trends 
JUNE GIBBS BROWN 
Inspector General 
MARCH 1999 
OEI-02-98-00350  OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to 
protect the integrity of the Department of Health and Human Services programs as well as the 
health and welfare of beneficiaries served by them.  This statutory mission is carried out through a 
nationwide program of audits, investigations, inspections, sanctions, and fraud alerts.  The 
Inspector General informs the Secretary of program and management problems and recommends 
legislative, regulatory, and operational approaches to correct them. 
Office of Evaluation and Inspections 
The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 
Inspector General.  It conducts short-term management and program evaluations (called 
inspections) that focus on issues of concern to the Department, the Congress, and the public.  The 
inspection reports provide findings and recommendations on the efficiency, vulnerability, and 
effectiveness of departmental programs. 
OEI's New York regional office prepared this report under the direction of John I. Molnar, 
Regional Inspector General, and Renee Dunn, Deputy Regional Inspector General.  Principal OEI 
staff included: 
REGION  HEADQUARTERS 
Demetra Arapakos, Project Leader  Susan Burbach, Program Specialist

Vincent Greiber

Ellen Vinkey

To obtain copies of this report, please call the New York Regional Office at 212/ 264-2000. 
Reports are also available on the World Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  E X E C U T I V E  S U M M A R Y  
PURPOSE 
To examine trends in Ombudsman program complaints. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home patients, 
recent reports by the Health Care Financing Administration (HCFA) and the General 
Accounting Office have raised serious concerns about patients care and well-being The 
Senate Special Committee on Aging held hearings in the summer of 1998 on these results. 
Committee staff requested the Office of Inspector General (OIG) to examine the issue of 
nursing home quality of care.  At the same time, we undertook additional studies aimed at 
assessing the quality of care in nursing homes.  This report attempts to determine the 
extent and nature of quality of care problems by examining trends in ombudsman 
complaint data.  Future OIG reports will address the trend in reported abuse of nursing 
home residents, the nursing home survey and certification process, and the availability of 
survey results. 
In response to growing concerns about poor quality care in nursing homes and to protect 
the interests of residents, the State Long Term Care Ombudsman program was established 
in 1978 in the Older Americans Act.  Ombudsmen advocate on behalf of residents of long 
term care facilities to ensure that they have a strong voice in their own treatment and care. 
The program operates in all 50 States, the District of Columbia and Puerto Rico, and in 
hundreds of local communities, using both paid and volunteer staff.  Beginning in 1995, 
the National Ombudsman Reporting System (NORS) has been used to report ombudsman 
data.  Twenty-nine States provided complaint data in 1995, and all States did so for 1996. 
Prior to 1995, States used a different, pre-NORS, system that was less detailed and lacked 
common definitions. 
We examined complaint data in the 10 States with the largest nursing home population. 
We also conducted telephone interviews with State and local ombudsmen, and State Unit 
on Aging Directors. 
FINDINGS 
Nursing Home Complaints Have Been Steadily Increasing In The 10 Sample 
States 
From 1989 to 1994, total complaints in the 10 sample States increased 44 percent overall, 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  from 57,954 to 83,669.  From 1996 to 1997, total complaints in the 10 States increased 
seven percent overall, from 60,926 to 65,123.  (Due to the transition to a new reporting 
system in 1995, no comparable data are available for that year).  We also calculated a 
complaint per bed ratio for each of the 10 States in 1996 and 1997.  In 1996, the 10 State 
average was 65 complaints per 1,000 beds.  This ratio increased to 69 complaints per 
1,000 beds in 1997. 
Beginning in 1996, all States reported complaint data using one of five main categories -
resident care, resident rights, quality of life, administration, and not against facility.  Of 
these 5 categories, resident care showed the biggest growth between 1996 and 1997, 
increasing by 13 percent.  This category includes complaints about personal care (such as 
pressure sores and hygiene), lack of rehabilitation (such as mental health services) and the 
inappropriate use of restraints.  Each of the remaining 4 categories increased less than 10 
percent. 
On a more specific level, the growth in certain complaints is particularly dramatic.  Out of 
128 specific types, when we looked at those types with at least 100 reported complaints, 
we found that 12 complaints increased by at least 24 percent from 1996 to 1997.  Two of 
the top 12 complaint types are related to nursing home staffing - staff turnover and lack of 
staff training.  These staffing complaints could indicate problems with the care residents 
receive.  Two examples of care problems which increased are hydration complaints, which 
grew 26 percent from 1996 to 1997, and complaints about weight loss due to inadequate 
nutrition, which increased 24 percent. 
Complaints About Resident Care And Residents Rights, Which Include Some Of 
The More Serious Complaints, Are Most Common In 1997 
In 1997, the majority of all complaints (63 percent) fell into 2 of the 5 categories -
resident care (32 percent) and residents rights (31 percent).  Resident care complaints 
include personal care, inappropriate use of restraints, and lack of rehabilitation.  Examples 
of residents rights complaints include abuse and neglect, problems with admission and 
eviction, and the exercise of personal rights. 
More specifically, the 10 most frequently reported complaints in 1997 comprise one-third 
of all nursing home complaints for that year.  Three of the top ten are related to 
insufficient nursing home staffing (unanswered call lights, dignity and respect/staff 
attitudes, and shortage of staff).  All of these can result in poor care for residents.  Specific 
examples of poor care, such as poor hygiene, physical abuse, and improper handling and 
accidents, are also among the top 10 complaints for 1997. 
Ombudsmen believe higher complaint rates do not always indicate more problems.  Some 
ombudsmen point out that higher complaint rates could be due to a greater presence of 
ombudsman staff in nursing homes.  However, when we compared each States staffing 
ratio and visitation rate to their complaint ratio, we found that States with more staff and 
more frequent visits do not necessarily have more complaints. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  Nevertheless, ombudsmen and State Aging Unit Directors confirm that problems continue 
to exist in some nursing homes.  The problem they report most frequently is insufficient 
nursing home staff, and all stress that such insufficient staffing directly impacts the care 
residents receive.  As an example of this impact, ombudsmen offer specific examples of 
how insufficient staffing can lead to other problems, such as failing to properly care for 
pressure sores and assist residents with eating so that they receive adequate nutrition. 
One-third or more of State and local ombudsmen also identify inadequate nutrition, bed 
sores, dehydration, and poor hygiene as big problems.  A number additionally mention that 
residents are often not treated with dignity and respect.  Finally, a few State Aging Unit 
Directors (three) and ombudsmen (two) say that physical abuse (intentional bodily harm) 
is also one of the biggest problems faced by residents in their State. 
A Few Nursing Homes Are Chronically Substandard, According to Ombudsmen 
While ombudsmen generally agree that most nursing homes in their State provides good 
care, three-fourths say there are some homes that routinely treat residents poorly. 
Virtually all of the 8 State ombudsmen that offer an opinion report that 10 percent or 
fewer of the nursing homes in their State routinely provide poor care.  Eight local 
ombudsman also estimate the number of chronically substandard homes in their locality. 
Two say 30 percent are chronic poor care providers, another 2 say between 10 and 20 
percent, and 3 report that less than 10 percent of the homes in their locality routinely 
provide poor care. 
CONCLUSION 
Both the volume and nature of complaints reported to ombudsmen suggest that more must 
be done to improve nursing home care. 
In OIG companion reports on nursing home care we offer specific recommendations about 
improvements that can be made in both the Ombudsman program and in the survey and 
certification process. 
AGENCY COMMENTS 
We received comments on the draft report from the Administration on Aging (AoA) and 
the Health Care Financing Administration (HCFA).  Some parts of the report were 
modified in response to AoAs technical comments. 
The full comments are presented in Appendix B. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  T A B L E  O F  C O N T E N T S 
PAGE

EXECUTIVE SUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  1

INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  5

FINDINGS

Total Complaints Steadily Increasing in 10 States . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  10

Complaints about Resident Care and Rights Most Common in 1997 . . . . . . . . . . . . . . .  13

A Few Homes Chronically Substandard, According to Ombudsmen . . . . . . . . . . . . . . .  16

CONCLUSION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  17

APPENDICES

A: Complaints per 1,000 Beds  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

B: Comments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  I N T R O D U C T I O N 
PURPOSE 
To examine trends in Ombudsman program complaints. 
BACKGROUND 
While many studies indicate that changes in law and regulations may have had a positive 
effect on improving the environment and overall health care of nursing home patients, 
recent reports by the Health Care Financing Administration (HCFA) and the General 
Accounting Office have raised serious concerns about patients care and well-being.  The 
Senate Special Committee on Aging held hearings in the summer of 1998 on these results. 
Committee staff requested the Office of Inspector General (OIG) to examine the issue of 
nursing home quality of care.  At the same time, we undertook additional studies aimed at 
assessing the quality of care in nursing homes.  This report attempts to determine the 
extent and nature of quality of care problems by examining trends in ombudsman 
complaint data.  Future OIG reports will address the trend in reported abuse of nursing 
home residents, the nursing home survey and certification process, and the availability of 
survey results. 
In 1987, Congress passed major nursing home reform legislation with the Omnibus 
Reconciliation Act of 1987 (OBRA 1987).  This legislation required nursing homes with 
Medicare and Medicaid residents to comply with specific quality of care standards by 
providing services and activities to attain or maintain the highest practicable physical, 
mental, and psychosocial well-being of each resident.  Now more than a decade later, 
concerns still exist about the quality of care provided in nursing homes. 
Ombudsman Program 
A nursing home is a long term care residential facility for individuals with physical or 
mental impairments that prevent them from living independently.  A nursing home 
provides its residents with a room, meals, assistance with daily living, and, in most cases, 
some medical care.  According to data provided in State ombudsman reports, in 1996 
there were 18,066 nursing homes and 1,845,791 nursing home beds.  Medicaid payments 
to nursing homes totaled $29.6 billion, while Medicare payments totaled $10.6 billion. 
In response to growing concerns about poor quality care in nursing homes and to protect 
the interests of residents,  the State Long Term Care Ombudsman program was 
established in 1978 in the Older Americans Act.  The ombudsmen advocate on behalf of 
residents of long term care facilities to ensure they have a strong voice in their own 
treatment and care. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  The Ombudsman Program operates in all fifty States, the District of Columbia and Puerto 
Rico, and in hundreds of local communities and uses both paid and volunteer staff.  The 
program receives funding from Federal, State and local levels, and is overseen by the 
Administration on Aging (AoA).  Most State ombudsmen operate within the State Units 
on Aging (SUA), some of which are independent and others of which are part of a larger 
State umbrella agency.  The remaining State Ombudsman programs are located 
organizationally outside of the SUA.  These programs are operated by non-profit 
organizations or legal services agencies, or they are freestanding Ombudsman programs. 
State Ombudsman programs have multiple functions which are mandated by law, many of 
which are closely tied to ensuring quality care for long term care residents.  They include: 
C	 identifying, investigating, and resolving complaints made on behalf of long term 
care residents; 
C  protecting the legal rights of patients; 
C  advocating for systemic change; 
C  providing information and consultation to residents and their families, and; 
C  publicizing issues of importance to residents. 
Several national associations have been established to support State Ombudsman 
programs.  One of these, the National Long Term Care Ombudsman Resource Center, 
was established by law in 1993.  This center is funded by AoA and run by the National 
Citizens Coalition for Nursing Home Reform (NCCNHR) in cooperation with the 
National Association of State Units on Aging (NASUA) and serves as a clearinghouse for 
information on the national Ombudsman program.  One of its functions is to identify issues 
of significance to the Ombudsman program, including identifying ways the ombudsman 
can improve quality of care in nursing homes; it also trains ombudsmen and provides 
technical assistance.  Additionally, the National Association for Long Term Care 
Ombudsman Programs (NASOP) was established by State ombudsmen to provide a 
common voice for all State programs and promote the sharing of ideas and experience 
among ombudsman staff. 
Ombudsman Complaint Data 
States have recently started to collect and report standardized data.  In FY 1995, States 
began to systematically collect and report data under the National Ombudsman Reporting 
System (NORS).  Prior to NORS, States reported data to AoA which was of limited use 
due to the lack of common definitions for key data elements.  The NORS was created in 
response to earlier recommendations made by the General Accounting Office and the 
Office of Inspector General and was developed by the ombudsmen themselves.  It includes 
more specific data elements than were previously reported.  For example, it separates 
complaints by type and distinguishes between complaints and complainants.  In 1995, 29 
States reported under NORS, and all States did so annually in 1996. 
Also for 1995, the first Long Term Care Ombudsman Program Annual Report was 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  published.  This report utilizes NORS case and complaint data for 29 programs and pre-
NORS data for the other 23 programs, and describes both the experiences of long term 
care residents and the operation of ombudsman programs nationwide.  The report also 
describes the broad range of ombudsman activities, including training and technical 
assistance programs, visitations, and community outreach. 
Prior Studies 
Many studies have reported on the progress and impact of the Ombudsman program.  One 
of the most recent, Real People, Real Problems, published in 1995 by the National 
Academy of Sciences Institute of Medicine, reported on State compliance, conflicts of 
interest, effectiveness, resources, and the need for future expansion of the program.  It 
found that, overall, the Ombudsman program is effective.  It also reported lack of access 
to ombudsman services by residents and their families, disparities in ombudsman visitation 
patterns and service provisions, and uneven availability of ombudsman legal  services. 
Additionally, the Inspector General issued several reports on the Ombudsman program in 
1991 and 1992.  First, Successful Ombudsman Programs, (OEI-02-90-02120), the main 
report in a series, found that successful programs are highly visible and obtain adequate 
funding and support.  Furthermore, State Implementation of the Ombudsman 
Requirements of the Older Americans Act, (OEI-02-91-01516), found, among other 
things, that State program staffing and long term care facility visitation rates vary 
significantly.  It also found that ombudsmen use many methods to increase their visibility. 
In July 1998, the Secretary of the Department of Health and Human Services released a 
report to Congress on nursing home care.  While the report found that some progress had 
been made in nursing home care, particularly in the more appropriate use of physical 
restraints and drugs, it also indicated that further improvements were needed.  In 
conjunction with this report, the President announced a new nursing home initiative to 
provide enhanced protection to residents and target needed improvements in care. 
Also in July, 1998, the General Accounting Office (GAO) released a report on California 
nursing homes.  This report found that care problems still exist, despite Federal and State 
oversight.  Among the problems it describes are poor nutrition, dehydration, and pressure 
sores. 
METHODOLOGY 
We used two methods for this inspection.  First, we analyzed data from Ombudsman 
program reporting systems to determine complaint trends.  Second, we conducted 
telephone interviews with State and local ombudsmen, as well as State Units on Aging 
Directors to obtain their perspective on nursing home quality of care problems. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  Sample Selection 
We selected a purposive sample of 10 States for this data inspection.  These States are 
New York, California, Texas, Ohio, Illinois, Pennsylvania, Massachusetts, Florida, New 
Jersey, and Tennessee. They represent 55.8 percent of the total skilled nursing beds and 53 
percent of all Ombudsman program complaints nationally for 1996.  They also account for 
nearly half  (43 percent) of all State and local ombudsman programs nationwide and half 
of all program funding. 
Ombudsman Data Analysis 
We analyzed two sets of data for this inspection.  For 1996 and 1997, we analyzed data 
from the National Ombudsman Reporting System (NORS).  For 1989 to 1994, we 
examined data from the pre-NORS reporting system.  Most of our analysis is of NORS 
data, since it is both more recent and more comprehensive. 
In reporting our findings, we discuss several different data elements.  For pre-NORS data, 
we present figures for both total complaints and seven broad complaint categories.  For 
NORS data, we examine three levels of complaints.  First, we look at total complaints. 
Second, we look at the following five complaint categories: 
C  Residents Rights (abuse, neglect, admission, personal rights, and property); 
C  Resident Care (care, rehabilitation or maintenance of function, and restraints); 
C  Quality of Life (activities, social services, dietary, and environment); 
C  Administration, (policies and procedures, attitudes, and staffing); and 
C	 Complaints Not Against Facility (certification and licensing, State Medicaid 
Agency, and long term care system). 
Third, we looked at 125 specific complaint types.  We also report ratios for the number of 
complaints per 1,000 skilled nursing home beds in each State. 
Limitations of Data Analysis 
During our analysis, it became evident that NORS and pre-NORS data are not comparable 
for several reasons.  First, pre-NORS and NORS data do not count complaints in the same 
way.  Second, despite having some similar complaint categories, the individual data 
elements comprising those categories differ between pre-NORS and NORS.  Because of 
these differences between the two data sets, we were not able to combine them in our 
analysis.  We therefore present data from each of the two data sets separately.  We will 
refer to the former as pre- NORS data and the latter as NORS data. 
A final factor limiting our analysis is the lack of comparable data in 1995.  Due to the 
transition to the new NORS system in this year, only 29 States reported NORS data. 
Since only 5 of our 10 sample States reported NORS data for 1995, resulting in 
incomparable data, we do not report findings for that year. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  Telephone Interviews 
We conducted a total of 30 structured interviews for this inspection.  In each of the 10 
States, we spoke with the State ombudsman, one local program ombudsman, and the 
Director of the State Unit on Aging (except for one State, where we interviewed the 
Deputy Director).  We selected these three groups of respondents to obtain their different 
perspectives of the program. 
In selecting ombudsmen from local programs to interview, we selected individuals from a 
variety of local programs.  Five of the local programs represented are operated by Area 
Agencies on Aging (AAAs), while the other five are operated by non-profit or legal 
service agencies.  Furthermore, five of the local programs are rural and five are urban. 
During our interviews, we asked respondents about the problems faced by nursing home 
residents in their State.  We also discussed chronically substandard nursing homes. 
This inspection was conducted in accordance with the Quality Standards for 
Inspections issued by the Presidents Council on Integrity and Efficiency. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  F I N D I N G S 
Nursing home complaints have been steadily increasing in 
the 10 sample States 
From 1989 to 1994, total complaints increased 44 percent 
Based on pre-NORS data from 1989 to 1994, complaints in the 10 sample States have 
been increasing gradually.  As shown in Graph A below, total complaints in these States 
grew from 57,954 to 83,669, an increase of 44 percent.  (Due to the transition to a new 
data system in 1995, we do not have comparable complaint rates for that year). 
Graph A 
Total Nursing Home Complaints, 1989 to 1994 
Some differences among the 10 States in this time period are particularly noteworthy. 
Overall, complaints in Florida and Ohio decreased, 19 percent and 15 percent, 
respectively.  Complaints in Texas, Tennessee and Massachusetts, on the other hand, 
increased more than 100 percent during that time period (189, 123, and 108 percent 
respectively). 
Complaints about residents rights, nutrition and food, and resident care 
increased at a rate higher than the overall rate during this time period 
From 1989 to 1994, complaints were categorized into one of nine different categories. 
Some of these categories increased at an even higher rate than the overall increase.  The 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  largest growth was in administrative complaints, which increased 188 percent.  Resident 
rights complaints in the 10 States increased 125 percent during these years, followed by 
complaints about food and nutrition (89 percent) and resident care (72 percent). 
From 1996 to 1997, total complaints increased seven percent 
Data from NORS for 1996 and 1997 also show an increase in total complaints in the 10 
sample States.  Graph B below shows that complaints increased seven percent during this 
time period, going from 60,926 up to 65,123.  This is similar to the yearly rate from 1989 
to 1994. 
Graph B 
Total Nursing Home Complaints, 1996 to 1997 
100000 
80000 
65123 
60926 
60000 
40000 
20000 
0 
1996  1997 
YEAR 
Total complaints increased the most dramatically during these 2 years in Florida (25 
percent)  and in Pennsylvania (19 percent.)  Another 5 States (California, Illinois, New 
York, Ohio and Texas) saw increases of 10 percent or less.  Complaints decreased slightly 
in New Jersey, Massachusetts, and Tennessee. 
To examine the volume of complaints ombudsmen receive in relation to the number of 
nursing homes they serve, we calculated a complaint ratio for each of the 10 States (see 
Appendix A).  In 1996, these ratios range from 187 complaints per 1,000 beds in 
Massachusetts, to 31 complaints per 1,000 beds in Ohio; the 10 State average was 65.  In 
1997, Massachusetts still topped the list with 180 and Ohio was still lowest with 31.  The 
average ratio for this year increased to 69 complaints per 1,000 beds. 
Resident care complaints had the largest overall growth from 1996 to 1997 
Beginning in 1996, all States reported complaint data using one of five main categories -
resident care, resident rights, quality of life, administration, and not against facility.  The 
category with the largest growth from 1996 to 1997 is resident care, which increased 13 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  percent.  This category includes specific complaints about personal care (such as pressure 
sores and hygiene), lack of rehabilitation (such as mental health services), and the 
inappropriate use of restraints.  Quality of life, administration and resident rights 
complaints each increased less than 10 percent from 1996 to 1997. 
Twelve specific complaints each increased at least 24 percent between these 2 
years, including complaints about hydration, inadequate nutrition, and nursing 
home staff 
On a more specific level, the growth in certain complaints is particularly dramatic.  Out of 
128 specific types, when we looked at those with at least 100 reported complaints, we 
found that 12 had increases of 24 percent or more from 1996 to 1997.  These 12 
complaints are shown in Table 1 below.  Two of the top 12 complaints are related to 
nursing home staffing - staff turnover and lack of staff training.  These staffing complaints 
could indicate problems with the care residents receive. 
Table 1 
Top 12 Increases in Complaints From 1996 to 1997 
Complaint Type  Number,  Number,  % Increase, 
1996  1997  1996 - 1997 
1. Info. re advance directive*  178  458  157% 
2. Denial of eligibility  188  292  55% 
3. Staff turn-over, overuse of 
nursing pools  107  159  49% 
4. Psychoactive drugs-assessment, 
use, evaluation  122  176  44% 
5. Other: activities & social svcs**  194  262  35% 
6. Vision and hearing  174  226  30% 
7. Administrator(s) unresponsive, 
unavailable  242  308  27% 
8. Symptoms unattended, no notice 
to others of change in condition  1,193  1,507  26% 
9. Staff training, lack of screening  374  471  26% 
10 Fluid availability /hydration  459  576  26% 
. 
11 Furnishing/storage  338  421  25% 
. 
12 Weight loss due to inadequate  216  267  24% 
. nutrition 
* Failure to notify resident in advance of changes in nursing home policy or procedure. 
**Miscellaneous complaints about resident activities and social services.  Source: NORS data 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  ))))))))))) 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  Complaints about resident care and residents rights, which
include some of the more serious complaints, are most
common in 1997
Resident care and residents rights complaints comprise more than half of all
complaints in 1997
In 1997, ombudsmen in the 10 sample States received just over 65,000 nursing home
complaints.  All of these complaints were classified into one of five categories.  The
majority of these complaints (63 percent) fell into 2 of the 5 categories -  resident care (32
percent) and residents rights (31 percent), as shown in Chart A below.  Resident care
complaints include personal care, restraints, and rehabilitation.  Residents rights
complaints include abuse and neglect, admission and eviction, and personal rights.
Chart A
Breakdown of Complaint Categories, 1997 
 
States vary in how their complaints are concentrated.  While residents rights complaints
comprise 31 percent of the total in the 10 States overall, in three States (NJ, CA and OH)
they represent 40 percent or more.  Furthermore, in two States (MA and TX) quality of
life complaints make up one-third of all their complaints, which is higher than the 10 State
average of 21 percent.    
In 1997, the 10 most common types of complaints account for one-third of all
complaints; the 3 relating to insufficient nursing home staffing impact on resident
care 
The 10 most frequently reported types of complaint comprise one-third of total nursing
home complaints in 1997.   Table 2 below shows what these 10 complaints are.  Three of
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LTC Ombudsman Program: Complaints Trends OEI-02-98-00350 the 10 relate to insufficient nursing home staffing (unanswered call lights, dignity and 
respect/staff attitudes, and shortage of staff).  All of these can result in poor care for 
residents.  Specific examples of poor care, such as poor hygiene, physical abuse, and 
improper handling and accidents, are also among the top 10 complaints for 1997. 
Table 2 
Top 10 Complaints Types, 1997 
Complaint Types  Number  % of Total 
Complaints 
1.  Call lights, requests for  3,235  5% 
assistance 
2.  Personal hygiene  2,515  4% 
3.  Dignity, respect-staff attitudes  2,039  3% 
4.  Accidents, improper handling  2,011  3% 
5.  Discharge/eviction-planning,  1,906  3% 
notice, procedure 
6.  Menu-quantity, quality,  1,865  3% 
variation, choice 
7.  Personal property lost, stolen,  1,789  3% 
used by others, destroyed 
8.  Physical abuse  1,757  3% 
9.  Shortage of staff  1,715  3% 
10. Medications-administration,  1,595  2% 
organization 
TOTAL  20,427  31% 
Source: NORS data 
Ombudsmen and State Aging Unit Directors confirm that problems continue to 
exist in some nursing homes 
Ombudsmen believe higher complaint rates do not always indicate more problems. As 
discussed in our companion report on program capacity, some ombudsmen point out that 
higher complaint rates could be due to a greater presence of ombudsman staff in nursing 
homes; with more visits, they provide residents with more opportunities to register 
complaints.  However, when we compared each States staffing ratio and visitation rate to 
their complaint ratio, we found that States with more staff and more frequent visits do not 
necessarily have more complaints. 
Nevertheless, in all States, State and local ombudsmen, as well as State Aging Unit 
Directors, identify problems in nursing homes that compromise the quality of care 
residents are receiving.  In fact, a few of their written program procedures specify the 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  kinds of problems ombudsman staff should look for when visiting nursing homes.  Many 
of the problems ombudsmen identify are the same problems indicated by data in the 
National Ombudsman Reporting System.  In fact, ombudsmen generally rate this system 
high for accuracy, usefulness, and comprehensiveness. 
Insufficient nursing home staffing is the biggest problem ombudsmen see 
The problem ombudsmen say they see most frequently in nursing homes is insufficient 
nursing home staff; seven State ombudsmen and eight local ombudsmen believe that many 
nursing homes do not have enough staff to provide quality care.  Similarly, four State 
Aging Unit directors also suggest that inadequate nursing home staffing is a major 
problem.  For example, six State ombudsmen believe unanswered call lights is one of the 
biggest problems nursing home residents face.  As already shown, unanswered call lights/ 
requests for assistance is the most common nursing home complaint in 1997. 
Ombudsmen and State Aging Unit directors stress the importance of having sufficient 
nursing home staff because it directly impacts the quality of care provided to residents. 
As an example of this impact, ombudsmen offer specific examples of how insufficient 
staffing can lead to other problems, such as failing to properly care for pressure sores and 
assist residents with eating so that they receive adequate nutrition. 
Ombudsmen offer other examples of how inadequate staffing impacts nursing home care. 
One gives the example of a home where residents were left to sit in their urine and feces 
for extended periods of time before being cleaned because of insufficient staff.  Another 
says that in one home with a lack of staff, in the afternoon residents were often still in their 
nightgowns and in a disheveled state.  In addition to insufficient staffing, some 
ombudsmen say nursing homes often experience high staff turnover and others report that 
many staff are not qualified or sufficiently trained. 
Nutrition and other types of personal care problems are also noticed 
Malnutrition and other dietary concerns are also volunteered by four State and seven local 
ombudsmen as some of the biggest problems nursing home residents face in their State. 
One says some homes do not provide residents with adequate nutrition, while another 
speaks of homes that generally do not provide enough food.  Some ombudsmen speak of 
nursing homes that do not allow their residents enough time to eat and do not assist 
residents with eating who need such help. 
State and local ombudsmen, as well as State Aging Unit Directors, report other types of 
personal care problems nursing home residents face in their State.  These include bed 
sores, dehydration, poor hygiene, over-medication, and toileting.  Furthermore, a number 
of ombudsmen specifically mention that nursing home residents are not treated with 
dignity and respect, with one saying that nursing home residents are treated as objects. 
Complaints about personal hygiene and lack of dignity and respect are the second and 
third most frequently reported complaints for 1997. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  Physical abuse is cited by a few ombudsmen and State Aging Unit directors 
Three State Unit on Aging Directors and two ombudsmen volunteer that physical abuse is 
one of the most significant problems faced by nursing home residents in their States.  In 
fact, physical abuse is one of the top 10 most frequently reported complaints in 1997, 
comprising 3 percent of all complaints for that year.  In discussing physical abuse, some 
ombudsmen generally make a distinction between abuse caused by intentional bodily harm 
and gross neglect due to inadequate staffing.  Says one, while the number of cases which 
we hear about that curdle your blood is relatively small, such cases do happen enough [to 
warrant the publics attention.] 
A few nursing homes are chronically substandard, according 
to ombudsmen 
Ombudsmen report that some nursing homes routinely provide poor care 
While ombudsmen generally agree that most nursing homes in their State provide good 
care, three-fourths say there are some homes that routinely treat residents poorly.  Of the 
8 State ombudsmen that offer an opinion, 7 report that 10 percent or fewer of the nursing 
homes in their State routinely provide poor quality of care.  The remaining State 
ombudsman says it is many as 30 percent.  Local ombudsmen cite higher percentages of 
homes that provide poor quality of care.  Of the eight that offer an opinion, two say 30 
percent are chronic poor care providers, another 2 say between 10 and 20 percent, and 3 
report that less than 10 percent of the homes in their locality routinely provide poor care. 
The remaining local ombudsman says no nursing home in his locality provides poor care. 
Several State and local ombudsmen identify certain types of nursing homes that are more 
likely to provide poor care than others.  Several mention that nursing homes in urban 
communities more likely to have serious problems than those in rural communities, 
because the latter are smaller, and the nursing home staff and residents are more likely to 
have personal relationships.  Two other ombudsmen believe nursing homes that serve 
lower-income populations are more likely to provide poor care. 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  C O N C L U S I O N  
Both the volume and nature of complaints reported to ombudsmen suggest that more must 
be done to improve nursing home care. 
In OIG companion reports on nursing home care we offer specific recommendations about 
improvements that can be made in both the ombudsman program and in the survey and 
certification process. 
COMMENTS 
We received comments on the draft report from the Administration on Aging (AoA) and 
the Health Care Financing Administration (HCFA).  Some parts of the report were 
modified in response to AoAs technical comments. 
The full comments are presented in Appendix B. 
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A - 1 
LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  A P P E N D I X  A 
Complaints Per 1,000 Beds, 1996 and 1997 
State  Complaints per  Complaints per  %Increase or 
1,000 Beds: 1996  1,000 Beds: 1997*  Decrease 
MA  187  180  -3.7% 
CA  126  132  4.8% 
TX  69  75  8.0% 
FL  47  63  34% 
NY  42  48  14% 
PA  38  48  26% 
NJ  45  44  -2.2% 
IL  38  43  13% 
TN  35  34  -2.9% 
OH  30  31  3.3% 
* Nursing home bed figures on based on 1996 data  Source: NORS data 
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LTC Ombudsman Program: Complaints Trends  OEI-02-98-00350  A P P E N D I X  B 
In this appendix, we present in full the comments from the Administration on Aging and 
the Health Care Financing Administration. 
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