Department of Health and Human Services 
OFFICE OF 
INSPECTOR GENERAL 
S O D : 
TATE  MBUDSMAN  ATA
N H C
URSING  OME  OMPLAINTS 
INSPECTOR GENERAL 
JULY 2003 
OEI-09-02-00160  O I G
FFICE OF  NSPECTOR  ENERAL

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, 
is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as 
the health and welfare of beneficiaries served by those programs.  This statutory mission is carried out 
through a nationwide network of audits, investigations, and inspections conducted by the following 
operating components: 
Office of Audit Services 
The OIG's Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting 
audits with its own audit resources or by overseeing audit work done by others.  Audits examine the 
performance of HHS programs and/or its grantees and contractors in carrying out their respective 
responsibilities and are intended to provide independent assessments of HHS programs and operations in 
order to reduce waste, abuse, and mismanagement and to promote economy and efficiency throughout the 
Department. 
Office of Evaluation and Inspections 
The OIG's Office of Evaluation and Inspections (OEI) conducts short-term management and program 
evaluations (called inspections) that focus on issues of concern to the Department, the Congress, and the 
public.  The findings and recommendations contained in the inspections reports generate rapid, accurate, 
and up-to-date information on the efficiency, vulnerability, and effectiveness of departmental programs. 
Office of Investigations 
The OIG's Office of Investigations (OI) conducts criminal, civil, and administrative investigations of 
allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by 
providers.  The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil 
monetary penalties.  The OI also oversees State Medicaid fraud control units which investigate and 
prosecute fraud and patient abuse in the Medicaid program. 
Office of Counsel to the Inspector General 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 
advice and opinions on HHS programs and operations and providing all legal support in OIGs internal 
operations.  The OCIG imposes program exclusions and civil monetary penalties on health care providers 
and litigates those actions within the Department.  The OCIG also represents OIG in the global settlement 
of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, 
develops model compliance plans, renders advisory opinions on OIG sanctions to the health care 
community, and issues fraud alerts and other industry guidance.  E X E C U T I V E   S U M M A R Y  
OBJECTIVE 
To describe nursing home complaints based on an analysis of the National Ombudsman 
Reporting System (NORS) data from 1996 through 2000. 
BACKGROUND 
To protect the interests of nursing home residents, Congress established the State Long Term 
Care Ombudsman Program in the Older Americans Act Amendments of 1978. The 
ombudsman program is administered by the Administration on Aging (AoA) within the 
Department of Health and Human Services. 
Long term care ombudsmen attempt to resolve problems of individual nursing home  residents 
and to bring about changes to improve nursing home care at the local, State, and national levels. 
They help nursing home residents and their families understand and exercise rights that are 
guaranteed by Federal and State laws. 
The Older Americans Act requires States to collect ombudsman complaint data and for the 
State ombudsman to report aggregate data to AoA. In fiscal year 1995, AoA implemented an 
ombudsman complaint reporting system called the National Ombudsman Reporting System 
(NORS).  NORS data consist of 128 complaint categories divided into 5 major groups. 
NORS does not identify individual nursing homes. 
We gathered data and information for calendar years 1996 through 2000 from NORS 
statistical reports, the annual ombudsman narrative comments submitted with NORS data, and 
interviews with State and local ombudsmen from nine selected States. 
FINDINGS 
We analyzed national NORS data from 1996 through 2000, as well as information regarding 
State-specific data obtained from 46 ombudsmen in 9 states. States are required to collect 
complaint data from ombudsmen and to report it to AoA. Nationally, the number of nursing 
home complaints increased, but the types of complaints have not changed significantly. 
However, the data are not comprehensive. NORS data should not be used to compare States 
with respect to the volume and types of complaints, because 
Nursing Home Complaints: State Ombudsman Data  1  OEI-09-02-00160  local ombudsmen do not report all nursing home complaints in NORS, and they do not always 
use the same categories to classify complaints. 
Nationally, from 1996 to 2000, the number of complaints increased, but the types 
of complaints did not change significantly 
The total number of nursing home complaints grew from approximately 145,000 in 1996 to 
approximately 186,000 in 2000; however, the types of complaints have not changed 
significantly. The highest frequency of nursing home complaints involves resident care, and 
these complaints grew 37 percent from 1996 to 2000. The number of abuse cases peaked in 
1998 and has declined about 3 percent since then. 
Among the sampled States, local ombudsmen do not report complaints uniformly 
Provisions in the Older Americans Act, as well as variations in State laws and policies, affect 
the number of abuse complaints that ombudsmen report. Local ombudsmen do not report all 
nursing home complaints into NORS. Furthermore, ombudsmen do not always use the same 
NORS categories to classify complaints, and they sometimes report a single complaint in 
several different categories. 
RECOMMENDATION 
We believe the consistency of NORS data could be improved if AoA shares the results of this 
report with State ombudsmen and continues to clarify and refine the NORS process. 
Agency Response 
AoA agreed that a lack of uniformity exists in the States reporting under NORS. AoA also 
agreed to distribute our final report to State ombudsmen and highlight the complaint trends. In 
addition, AoA plans to conduct regional and State training on the use of complaint codes. 
AoA indicated that the use of the word report, as applied to the Older Americans Act, 
caused confusion in our finding that local ombudsmen do not report complaints uniformly. 
Therefore, we have changed our finding to state that an ombudsman may not be able to file a 
formal complaint, rather than stating an ombudsman may not be able to report a complaint. 
The full text of AoAs comments appears in Appendix B. 
Nursing Home Complaints: State Ombudsman Data  2  OEI-09-02-00160  T A B L E   O F   C O N T E N T S  
PAGE

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

INTRODUCTION ............................................................. 4

FINDINGS  .................................................................. 6

Number and types of complaints.............................................. 6

Ombudsmen reporting of NORS data.......................................... 7

RECOMMENDATION  ........................................................ 9

APPENDICES .............................................................. 10

A: Ombudsman Complaints: 1996-2000......................................10

B: Agency Comments ....................................................15

ACKNOWLEDGMENTS ..................................................... 18

Nursing Home Complaints: State Ombudsman Data  3  OEI-09-02-00160  I N T R O D U C T I O N  
OBJECTIVE 
To describe nursing home complaints based on an analysis of the National Ombudsman 
Reporting System (NORS) data from 1996 through 2000. 
BACKGROUND 
The Long Term Care Ombudsman Program 
To protect the interests of nursing home residents, Congress established the State Long Term 
Care Ombudsman Program in the Older Americans Act Amendments of 1978. The 
ombudsman program is administered by the Administration on Aging (AoA) within the 
Department of Health and Human Services. 
Long term care ombudsmen attempt to resolve problems of individual nursing home residents 
and to bring about changes to improve nursing home care at the local, State, and national levels. 
They help nursing home residents and their families understand and exercise rights that are 
guaranteed by Federal and State laws. 
The Older Americans Act requires States to collect ombudsman complaint data and for the 
State ombudsman to report the aggregate data to AoA.  In fiscal year 1995, AoA implemented 
an ombudsman complaint reporting system called the National Ombudsman Reporting System 
(NORS). The States developed training and certification programs for ombudsmen, which 
included training on reporting NORS data. NORS data consist of 128 complaint categories 
divided into 5 major groups.  NORS does not identify individual nursing homes. 
METHODOLOGY 
We gathered data and information for calendar years 1996 through 2000 from NORS

statistical reports, the annual ombudsman narrative comments submitted with NORS data, and

interviews with State and local ombudsmen from nine selected States. We analyzed national

and State-specific NORS data as well as information obtained from 

46 ombudsmen in 9 States.

Nursing Home Complaints: State Ombudsman Data  4  OEI-09-02-00160  We used a sample of nine States for more in-depth data analysis.  The sample States were 
California, Connecticut, Alabama, Maryland, Missouri, South Carolina, Texas, South Dakota, 
and New York.  These States provide a cross section of ombudsman programs from large 
urban areas to small rural communities, as well as diverse geographic locations. They also 
account for approximately 30 percent of the nursing home beds within the United States. 
In each of the sampled States, we analyzed NORS statistical data, tracked the trends within the 
State, and compared State and national data during the 5-year period. We did not validate 
NORS data.  We conducted telephone interviews with the State ombudsman and at least four 
local ombudsmen from urban and rural areas within each State. We asked the ombudsmen 
about complaint trends, major issues, and concerns they had identified in the complaint trends 
during the past 5 years. We compared these responses with the national data and the NORS 
annual report narratives for each sampled State. 
The inspection was conducted in accordance with the Quality Standards for Inspections 
issued by the Presidents Council on Integrity and Efficiency. 
Nursing Home Complaints: State Ombudsman Data  5  OEI-09-02-00160  F I N D I N G S  
We analyzed national NORS data from 1996 through 2000 as well as information regarding 
State-specific data obtained from 46 ombudsmen in 9 States.  States are required to collect 
complaint data from ombudsmen and to report it to AoA. Nationally, the number of nursing 
home complaints increased, but the types of complaints have not changed significantly. 
However, the data are not comprehensive.  NORS complaint data should not be used to 
compare States with respect to the volume and types of complaints, because local ombudsmen 
do not report all nursing home complaints in NORS, and they do not always use the same 
categories to classify complaints. 
Nationally, from 1996 to 2000, the number of complaints 
increased, but the types of complaints did not change 
significantly 
NORS data include the number and nature of nursing home complaints, both nationally and 
within States. (See Appendix A for related graphs and tables.) 
Nationally, the total number of nursing home complaints grew from approximately 145,000 in 
1996 to approximately 186,000 in 2000 (Figure 1).  During the same period, the number of 
complaints per 1,000 beds rose from 78.4 to 102.1 (Figure 2).  This represented a 28 percent 
increase in the number of complaints and a 30 percent increase in the number of complaints per 
thousand beds. 
The types of complaints reported into NORS since 1996 have not changed significantly. 
Nationally, each of the top 12 complaint categories remained in the top 12 between 1996 and 
2000 (Figure 3). In 2000, these top 12 categories accounted for more than one-third of the 
total number of complaints. The distribution of complaints per 1,000 beds shows a similar 
consistency. 
The highest frequency of nursing home complaints involves resident care.  By 1999, complaints 
concerning resident care (e.g., accidents, not responding to call lights, patient symptoms 
unattended) had surpassed those concerning resident rights (e.g., abuse, access to information, 
issues about transfer and discharge).  From 1996 through 2000, resident care complaints grew 
37 percent compared to a 21 percent growth for complaints 
Nursing Home Complaints: State Ombudsman Data  6  OEI-09-02-00160  involving resident rights (Figure 4). As of 2000, 6 of the top 10 specific complaint categories 
pertained to resident care: 
1.  failure to respond to call lights or requests for assistance 
2.  accidents and improper handling of residents 
3.  lack of adequate care plans and resident assessments 
4.  inadequate administration of medications 
5.  unattended resident symptoms 
6.  poor personal hygiene 
NORS data identify changes in the number of specific types of complaints.  Nationally, one of 
the most prominent changes (for categories with at least 1,000 complaints in the year 2000) is 
that complaints concerning staff turnover increased by approximately 208 percent between 
1996 and 2000 (see Figure 5). 
Abuse cases reported to NORS peaked in 1998 and have declined about 3 percent since then. 
The total for all reported abuse cases rose from 13,469 in 1996 to 15,501 in 1998, and 
declined to 15,010 in 2000 (see Figure 6).  During that period, among seven types of abuse 
categories, physical abuse was the most common type reported (see Figure 7). 
Among the sampled States, local ombudsmen do not report 
complaints uniformly 
Provisions in the Older Americans Act, as well as variations in State laws and policies affect 
the number of abuse complaints recorded into NORS.  For example, under the Older 
Americans Act, an ombudsman may not be able to file a formal complaint without the consent 
of the resident or legal representative of the resident.1 As a result, ombudsmen may not enter 
abuse complaints in NORS data unless they actually open a case file and investigate it.  Also, 
some States may have more abuse complaints reported into NORS because State law requires 
that all abuse complaints are reported to ombudsmen. Conversely, other States may have 
fewer abuse complaints reported into NORS, because their policy requires that all abuse 
complaints are reported to the licensing agency rather than to the ombudsmen.  As a result, 
almost half (21 of 46) of the ombudsmen surveyed believe that complaints may be significantly 
under reported in NORS. 
Ombudsman do not always use the same NORS categories to classify complaints. 
Thirty-nine of the 46 surveyed ombudsmen told us that they do not consistently follow the 
NORS categories in reporting complaints.  AoA provides definitions of complaint 
1 
42 U.S.C. 3058g(d) 
Nursing Home Complaints: State Ombudsman Data  7  OEI-09-02-00160  categories and instructions to ombudsmen for reporting NORS data. However, it is sometimes 
difficult for ombudsmen to categorize complaints when several definitions apply. Despite 
AoAs instructions, ombudsmen sometimes report a single complaint in several different 
categories.2 One State ombudsman and four local ombudsmen from another State told us that 
if a single complaint applied to multiple NORS categories, they would report the complaint in 
each category rather than choosing one. 
NORS data exhibited some inconsistencies. For example, one State had difficulty reporting 
data in 2000 because of Y2K problems.  In 1997, NORS data, which were posted on the 
AoA website, included two tables that contained conflicting numbers of reported complaints. 
According to one in three (15 of 46) ombudsmen interviewed, the number of ombudsmen, in 
relation to the number of nursing homes in a given state, may affect the number of complaints 
recorded in NORS. For example, a State with fewer ombudsmen has less resources to 
respond, investigate, and report nursing home complaints than a State which has more 
ombudsmen. 
2 
See www.aoa.dhhs.gov/notices/2002/complaint-codes.pdf to view the instructions for completing the State long term care 
ombudsman program reporting form. 
Nursing Home Complaints: State Ombudsman Data  8  OEI-09-02-00160  RECOMMENDATION 
We believe the consistency of NORS data could be improved if AoA shares the results of this 
report with State ombudsmen and continues to clarify and refine the NORS process. 
Agency Response 
AoA agreed that a lack of uniformity exists in the States reporting under the NORS. AoA also 
agreed to distribute our final report to State ombudsmen and highlight the complaint trends. In 
addition, AoA plans to conduct regional and State training on the use of complaint codes. 
AoA indicated that the use of the word report, as applied to the Older Americans Act, 
caused confusion in our finding that local ombudsmen do not report complaints uniformly. 
Therefore, we have changed our finding to state that an ombudsman may not be able to file a 
formal complaint, rather than stating an ombudsman may not be able to report a complaint. 
The full text of AoAs comments appears in Appendix B. 
Nursing Home Complaints: State Ombudsman Data  9  OEI-09-02-00160  APPENDIX A A 
Ombudsman Complaints:  1996-2000

Growth in Complaints 
Nationally, the total number of complaints grew from approximately 145,000 in 1996 to 
approximately 186,000 in 2000. 
Figure 1: Total Reported Complaints, 1996-2000

190,000 
180,000 
s 
nt
ai 170,000 
pl
m
o 160,000 
c
of 
er  150,000 
b
m
u 140,000 
N
130,000 
120,000 
1996  1997  1998  1999  2000 
Year 
During the same period, the number of complaints per 1,000 beds rose from 78.4 to 
102.1. 
Figure 2:  Complaints per 1,000 Nursing Home Beds, 1996-2000

Nursing Home Complaints: State Ombudsman Data  10  OEI-09-02-00160  The Most Common Types of NORS Complaints 
Nationally, each of the top 12 complaint categories has remained in the top 12 between 1996

and 2000.

Figure 3: Top Ombudsman Complaint Categories, 1996-2000

Percent 
Cod  1996  1996  2000  2000 
Top Complaints  Growth 
e  Total  Rank  Total  Rank 
1996-2000 
F40  Accidents  6,661  1 7,675  2  15.2% 
F41  Request for Assistance  5,441  2 8,676  1  59.5% 
F45  Personal Hygiene  5,301  3 7,279  5  37.3% 
Dignity, Respect-Staff 
D26  4,882  4 7,351  4  50.1% 
Attitudes 
F42  Care Plan  4,453  5 7,550  3  69.5% 
M97  Staff Shortage  4,332  6 6,625  6  53.0% 
A1  Physical Abuse  4,321  7 4,350  11  0.7% 
J71  Menu Quality  4,295  8 5,540  8  29.0% 
C19  Discharge, Eviction  4,110  9 5,762  7  40.2% 
E38  Personal Property  3,598  10 4,227  12  17.5% 
F44  Meds Administration  3,123  11 4,914  9  57.3% 
F48  Symptoms Unattended  3,198  12 4,617  10  44.4% 
Nursing Home Complaints: State Ombudsman Data  11  OEI-09-02-00160  Resident Care Complaints 
The highest frequency of nursing home complaints involve resident care.  By 1999, complaints 
concerning resident care (e.g., accidents, not responding to call lights, patient symptoms 
unattended) surpassed those concerning resident rights (e.g., abuse, access to information, 
issues about transfer and discharge). 
Figure 4:  Ombudsman Complaints by Major Category, 1996-2000 
s 60,000 
t 1996 
n
i
la50,000  1997 
p
m 1998 
o40,000 
c 1999 
 
f
o 2000 
r 30,000 
e
b
m
20,000 
u
N
10,000 
Residents' Rights  Resident Care  Quality of Life  Administration  Not Against 
Facility 
Types of complaints 
Nursing Home Complaints: State Ombudsman Data  12  OEI-09-02-00160  Specific Types of NORS Complaints 
Between 1996 and 2000, of the categories with at least 1,000 complaints in 2000, 

complaints concerning staff turnover have the highest national growth, with an increase  of

approximately 208 percent. 
Figure 5: Complaint Categories with the Largest Growth, 1996-2000

Percent 
1996  2000 
Code  Complaint  Growth 
Total  Total 
1996-2000 
M99  Staff Turn-Over  330  1,015  207.6% 
J70  Dehydration  1,122  2,219  97.8% 
K81  Infection Control  562  1,074  91.1% 
M101  Supervision  1,825  3,326  82.2% 
Exercise Choice and/or 
D27  2,211  3,803  72.0% 
Civil Rights 
K78  Cleanliness, Pests  2,242  3,832  70.9% 
F42  Care Plan/Assessment  4,453  7,550  69.5% 
F41  Call Lights, Requests for  5,441  8,676  59.5% 
F44  Medications - Administration  3,123  4,914  57.3% 
Staff Unresponsive, 
M100  2,376  3,700  55.7% 
Unavailable 
Nursing Home Complaints: State Ombudsman Data  13  OEI-09-02-00160  Reported NORS Abuse Cases 
The total for all reported abuse cases rose from 13,469 in 1996 to 15,501 in 1998, then 
declined to 15,010 in 2000. 
Figure 6: Reported Abuse Complaints, 1996-2000 
16,000 
15,501 
15,500 
s 
t
n 15,010 
ai 15,000  14,871 
pl
m
o
f c 14,500 
o
r 
e 14,025 
b
m 14,000 
u
N
13,469 
13,500 
13,000 
1996  1997  1998  1999  2000 
Year 
During that period, among seven types of abuse categories, physical abuse was the most 
common type reported. 
Figure 7: Types of Abuse Complaints, 1996-2000 
6,000 
5,000 
s  1996 
nt
plai 4,000  11999978  
m
o 1999 
of c 3,000  2000 
r 
e
mb 2,000 
u
N
1,000 
0 
Physical abuse  Resident to  Verbal/ mental Gross neglect  Other Abuse  Financial  Sexual abuse 
resident abuse  abuse  or Exploitation  exploitation 
Abuse types 
Nursing Home Complaints: State Ombudsman Data  14  OEI-09-02-00160  APPENDIX B A 
Agency Comments

Nursing Home Complaints: State Ombudsman Data  15  OEI-09-02-00160  Nursing Home Complaints: State Ombudsman Data  16  OEI-09-02-00160  Nursing Home Complaints: State Ombudsman Data  17  OEI-09-02-00160  ACKNOWLEDGMENTS 
This report was prepared under the direction of Paul A. Gottlober, Regional Inspector General 
for Evaluation and Inspections, and Deborah W. Harvey, Assistant Regional Inspector General 
for Evaluation and Inspections, in San Francisco.  Other principal Office of Evaluation and 
Inspections staff who contributed include: 
Timothy Brady, Project Leader  Sandy Khoury, Program Specialist

Michael Henry, Program Analyst

Thomas A. Purvis, Program Analyst

For information or copies of this report, please contact

the Office of Inspector General's

Public Affairs office at (202) 619-1343.

Reports are also available on the World Wide Web at our home page address:

http://www.oig.hhs.gov/ 
Nursing Home Complaints: State Ombudsman Data  18  OEI-09-02-00160