Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

MARCH 1999 

OEI-02-98-00350 

Long Term Care Ombudsman Program: 

Complaint Trends 
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 
EXECUTIVE SUMMARY 

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 1 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 State’s 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 2 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 AoA’s technical comments. 

The full comments are presented in Appendix B. 

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LTC Ombudsman Program: Complaints Trends 3 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 4 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 5 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 6 OEI-02-98-00350 
published. This report utilizes NORS case and complaint data for 29 programs and preNORS 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 7 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 8 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 President’s Council on Integrity and Efficiency. 

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LTC Ombudsman Program: Complaints Trends 9 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 10 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 

60926 

65123 

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 11 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, 

1996 

Number, 

1997 

% Increase, 

1996 - 1997 

1. Info. re advance directive* 

2. Denial of eligibility 

3. Staff turn-over, overuse of 

nursing pools 

4. Psychoactive drugs-assessment, 

use, evaluation 

5. Other: activities & social svcs** 

6. Vision and hearing 

7. Administrator(s) unresponsive, 

unavailable 

8. Symptoms unattended, no notice 

to others of change in condition 

9. Staff training, lack of screening 

10 Fluid availability /hydration 

. 

11 Furnishing/storage 

. 

12 Weight loss due to inadequate 

. nutrition 

178 

188 

107 

122 

194 

174 

242 

1,193 

374 

459 

338 

216 

458 

292 

159 

176 

262 

226 

308 

1,507 

471 

576 

421 

267 

157% 

55% 

49% 

44% 

35% 

30% 

27% 

26% 

26% 

26% 

25% 

24% 

* 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 12 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 13 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 14 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. 

majority of these complaints (63 percent) fell into 2 of the 5 categories - 

percent) and residents’ rights (31 percent), as shown in Chart A below. 

complaints include personal care, restraints, and rehabilitation. 

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. 

comprise 31 percent of the total in the 10 States overall, in three States (NJ, CA and OH)

they represent 40 percent or more. 

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. 

All of these complaints were classified into one of five categories. The

resident care (32

Resident care

Residents’ rights

While residents rights’ complaints

Furthermore, in two States (MA and TX) quality of

Table 2 below shows what these 10 complaints are. Three of
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 

assistance 

2. Personal hygiene 

3. Dignity, respect-staff attitudes 

4. Accidents, improper handling 

5. Discharge/eviction-planning, 

notice, procedure 

6. Menu-quantity, quality, 

variation, choice 

7. Personal property lost, stolen, 

used by others, destroyed 

8. Physical abuse 

9. Shortage of staff 

10. Medications-administration, 

organization 

3,235 

2,515 

2,039 

2,011 

1,906 

1,865 

1,789 

1,757 

1,715 

1,595 

5% 

4% 

3% 

3% 

3% 

3% 

3% 

3% 

3% 

2% 

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 State’s 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 15 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 16 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 public’s 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 17 OEI-02-98-00350 
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. 

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 AoA’s technical comments. 

The full comments are presented in Appendix B. 

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LTC Ombudsman Program: Complaints Trends A - 1 OEI-02-98-00350 
A P P E N D I X A 

Complaints Per 1,000 Beds, 1996 and 1997 

State Complaints per 

1,000 Beds: 1996 

Complaints per 

1,000 Beds: 1997* 

%Increase or 

Decrease 

MA 

CA 

TX 

FL 

NY 

PA 

NJ 

IL 

TN 

OH 

187 

126 

69 

47 

42 

38 

45 

38 

35 

30 

180 

132 

75 

63 

48 

48 

44 

43 

34 

31 

-3.7% 

4.8% 

8.0% 

34% 

14% 

26% 

-2.2% 

13% 

-2.9% 

3.3% 

* Nursing home bed figures on based on 1996 data Source: NORS data 

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LTC Ombudsman Program: Complaints Trends 18 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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LTC Ombudsman Program: Complaints Trends 19 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 20 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 21 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 22 OEI-02-98-00350 
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LTC Ombudsman Program: Complaints Trends 23 OEI-02-98-00350