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## LongTerm Care Ombudsman Annual Report: FY 1995

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## ExecutiveSummary

State and local long term care ombudsmen speak and act onbehalf of the approximately 2.4 million residents of nursing andboard and care homes and similar long term care facilities.

In FY 1995, ombudsmen investigated over 218,000 complaintsmade by over 162,000 individuals. Most nursing facility (NF)complaints were filed by residents and friends and relatives ofresidents; most complaints concerning board and care and similar(B&C) facilities were filed by ombudsmen and residents. About75% of these complaints were resolved or partially resolved. Over85% of the complaints related to nursing home residents; almostall of the remainder related to residents of B&C facilities.

The five most frequent nursing home complaints concerned:

> - Accidents, improper handling;
- Dignity, respect: staff attitudes;
- Menu: quantity, quality, variation and choice of            food;
- Personal hygiene; and
- Call lights (unanswered), requests for assistance.

The five most frequent complaints made by or on behalf ofresidents of board and care and similar adult care facilitiesconcerned:

> - Menu: quantity, quality, variation and choice of            food;
- Equipment/building: disrepair, hazard, poor lighting,            fire safety;
- Medications: administration, organization;
- Dignity, respect: staff attitudes; and
- Cleanliness, pests.

The following sample cases illustrate the range of complaintswhich ombudsmen are called upon to address:

> 
**California -**An anonymous caller to the    Ombudsman Program alleged that a frail, elderly female    resident of a board and care home was being over-medicated    with an unprescribed psycho-tropic drug with intent to cause    her death. The ombudsman went to the facility and found the    resident in a catatonic state. The ombudsman contacted local    law enforcement, Adult Protective Services and an ambulance    service; the resident was transferred to an acute emergency    center for respiratory failure. Further investigation    revealed an intricate conspiracy between the owner of the    facility, an ex-son-in-law, and a treating physician. The    Ombudsman Program played a significant role in pulling all of    the investigatory forces together and collecting information    that ultimately lead to a criminal conviction of the guilty    parties.

> 
**Florida -**A relative questioned charges    to Medicare of over $1000 for an "anti-contracture"    device for his parent, who lived in a nursing home. The    ombudsman went to the facility and found that a "Dr.    A" had visited the facility and ordered such brace    devices for almost all of the 90 residents. The contraptions    were stored in residents' closets; they didn't help any of    the frail, sick people they were given to; and in many cases    they caused pain and skin abrasions. The ombudsman reported    her suspicion of massive Medicare fraud to the appropriate    authorities, providing documentation of what she had observed    at the facility. "Dr. A" was ultimately convicted    of organized fraud in several facilities.

**Indiana -**A nursing home resident wished    to transfer to another facility where her sister resided. The    home in which the resident lived opposed the transfer,    apparently because its census was down. Although arrangements    had been made for the move, the home intimidated the    resident, and she was afraid to leave. She appealed to the    ombudsman for assistance. After investigating the situation,    the ombudsman remained with the resident throughout the    transfer process, assuring that the resident's right to    transfer was respected. Following up on the case later, the    ombudsman found the resident doing well and eating lunch    daily with her sister and another sister who lives in the    community.

In addition to working on individual complaints, ombudsmen atboth the state and local level:

- work in a variety of ways to resolve major issues which        impact on large numbers of residents;
- provide training and technical assistance to other        ombudsmen in the statewide program and managers and staff        of long term care facilities — the most frequently        mentioned topic of both ombudsman training and        consultation to facility managers and staff was        residents' rights ;
- provide information and consultation to individuals        — nationwide, ombudsmen in 29 states assisted over        93,000 people in FY 1995; selecting and paying for a        nursing home and alternatives to nursing homes were the        most frequently mentioned topics of individual        consultation;
- visit residents on a regular basis (not in response to        complaints) — the 27 states which reported this        information reflected visitation rates of 77% of nursing        facilities and 49% of board and care and similar        facilities; 
- participate in facility surveys;
- work with resident and family councils and provide        community education; and
- work with the media to publicize the concerns of        residents.

In FY 1995 there were a total of 565 local ombudsman entities(programs), 913 paid full-time equivalent staff at both state andlocal level, and 11,580 volunteers, 6421 of whom were trained andcertified to investigate complaints. Total program funding was$40.9 million, about $1 million less than in FY 1994. Of thistotal, Older Americans Act funding was almost 65%, state fundingwas 22%, and other non-federal funding was 13%.

States reported a total of 18,911 licensed NF's and 1,819,069licensed NF beds and 36,904 licensed B&C or similarfacilities covered in their ombudsman program's purview, with atotal of 662,199 beds in those facilities. The national ratio oflong term care facility beds to paid ombudsman program staff was2,718. (A 1995 Institute of Medicine report on the OmbudsmanProgram recommended program funding sufficient to provide onepaid ombudsman staff person per every 2,000 beds.)

Major issues identified in the state reports, barriers toresolving the issues, and ombudsman actions and recommendationsfor resolving the issues are summarized in Part V of the reportand presented extensively in Appendix D. Issues addressed bythree or more states involved:

- Board and care and similar adult day care facilities;
- Inadequate state nursing facility regulations and        enforcement, and inadequate state resources to enforce        regulations;
- Abuse of residents and issues related to state protective        systems, reporting requirements, and the need for abuse        prevention;
- Staff shortages in general and chronic shortages of well        trained and equitably compensated certified nurse        assistants;
- Transfer and discharge issues - related to issue # 6;
- Lack of placement, needed services, and staff training        for those caring for mentally ill and dementia residents;
- Ensuring that rules and regulations established in the        federal Nursing Home Reform Act (OBRA '87) are continued        and enforced;
- Subacute care and "distinct parts" (related to        difficulty in finding a bed, issue # 10);
- Inappropriate and excessive use of chemical and physical        restraints, and related issues;
- Difficulty in finding a nursing home bed for those in        need — especially for Medicaid-eligible individuals,        those with special care needs, and those with moderate        financial resources (financial discrimination in        admissions);
- Improving communication and coordination with licensure        and certification agency staff;
- Medicaid reductions/eligibility delays, denials;
- Bedhold — nursing facilities sending residents to a        hospital or local mental health center for evaluation or        care and refusing to readmit the resident;
- Lack of needed services for elderly and disabled;
- Advocacy through education about rights, benefits and        costs and the residents' perspective on life in a nursing        home; and
- Ombudsman program coverage (cited by 10 states but        distinguished from the other issues as a program        operation rather than resident/facility issue).

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For questions about the LTC Ombudsman Program, contact Sue WheatonHypertext conversion by Saadia Greenberg,June 18, 1997