Nursing Homes: More Can Be Done to Protect Residents from Abuse
Published: 2002-03-01T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Often suffering from multiple physical and mental impairments, the 1.5 million elderly and disabled Americans living in nursing homes are a highly vulnerable population. These individuals typically require extensive help with daily living, such as such as dressing, feeding, and bathing. Many require skilled nursing or rehabilitative care. In recent years, reports of inadequate care, including malnutrition, dehydration, and other forms of neglect, have led to mounting scrutiny from state and federal authorities, which share responsibility for overseeing the nation's 17,000 nursing homes. Concerns have also been growing that some residents are abused--pushed, slapped, or beaten--by the very individuals to whom their care has been entrusted.
section_title: What GAO Found
paragraphs: GAO found that allegations of physical and sexual abuse of nursing home residents are not reported promptly. Local law enforcement officials said that they are seldom summoned to nursing homes to immediately investigate allegations of abuse and that few allegations are ever prosecuted. Some agencies use different policies when deciding whether to refer allegations of abuse to law enforcement. As a result, law enforcement agencies were never told of some incidents or were notified only after lengthy delays. GAO found that federal and state safeguards intended to protect nursing home residents from abuse are inadequate. No federal statute requires criminal background checks for nursing home employees. Background checks are also not required by the Centers for Medicare and Medicaid Services, which sets the standards that nursing homes must meet to participate in the Medicare and Medicaid programs. State agencies rarely recommend that sanctions be imposed on nursing homes. Although state agencies compile lists of aids who have previously abused residents, which can prevent an aide from being hired at another nursing home, GAO found that delays in making these identifications can limit the usefulness of these registries. GAO summarized this report in testimony before Congress; see GAO-02-448T .

section_title: Letter
paragraphs: The 1.5 million elderly and disabled individuals residing in nursing homes  are a highly vulnerable population. They often have multiple physical and  cognitive impairments that require extensive assistance in the basic  activities of daily living, such as dressing, feeding, and bathing. Many  require skilled nursing or rehabilitative care. In recent years, increased  attention has been focused on the quality of care afforded nursing home  residents. Concerns with inadequate care involving malnutrition,  dehydration, and other forms of neglect have contributed to mounting  scrutiny from state and federal authorities. There is also growing concern  that some residents are abused—pushed, slapped, beaten, and otherwise  assaulted—by the individuals to whom their care has been entrusted.  Accordingly, the ability to both apprehend those who have abused nursing home residents and prevent further abuse has generated considerable  interest.
While nursing homes are expected to keep residents safe from harm, there  are a variety of federal, state, and local agencies—including law  enforcement entities—that typically play a part in investigating instances  of resident abuse. The federal government and the states share oversight responsibility for the almost 17,000 nursing homes in the nation. The  recently renamed Centers for Medicare and Medicaid Services (CMS),  formerly the Health Care Financing Administration (HCFA)—within the  Department of Health and Human Services (HHS)—is responsible for  establishing standards that nursing homes must meet to participate in the  Medicare and Medicaid programs. CMS contracts with state agencies, such  as departments of health, to conduct annual inspections—called surveys—  of nursing homes to certify that they are eligible for Medicare and  Medicaid payments. These state survey agencies are also responsible for  investigating complaints they receive about the care nursing homes  provide. In some instances, state survey agencies may notify state or local  law enforcement agencies to conduct criminal investigations involving  resident abuse. Depending on the policy of the survey agency, it may opt  to involve the state’s Medicaid Fraud Control Unit (MFCU), typically an  investigative component within the state’s Office of the Attorney General,  or the appropriate local police department in investigating abuse  allegations.
We have previously reported on deficiencies in the oversight of the quality  of care provided to nursing home residents, noting weaknesses in states’  complaint investigations, annual surveys, and enforcement actions. For  example, in March 1999, we reported that inadequate state procedures and  limited HCFA guidance and oversight resulted in, among other things,  extensive delays in investigating serious complaints alleging harmful  situations. Also in March 1999, we reported that state surveys identified  deficiencies that harmed residents or placed them at risk of death or  serious injury in more than one-fourth of nursing homes nationwide.Moreover, sanctions that HCFA initiated against a majority of these homes  for noncompliance with federal standards were often not implemented  and generally did not ensure that homes maintained compliance with  standards. More recently, in September 2000, we reported that, although  HCFA had begun requiring states to investigate complaints alleging harm  within 10 working days of their receipt, states were not consistently  meeting this time frame.
In response to your concerns with the adequacy of protections afforded  nursing home residents and the responsiveness of federal, state, and local  agencies to allegations of resident abuse, we (1) determined whether  allegations of abuse are reported promptly to local law enforcement and  state survey agencies, (2) assessed the extent to which abusers are  prosecuted and the impediments to successful prosecutions, and (3)  evaluated whether sufficient safeguards exist to protect residents from  abusive individuals.
To address these questions we limited our work to acts of alleged physical  and sexual abuse committed by nursing home employees against nursing  home residents. We did not address other forms of abuse such as neglect  or verbal abuse nor did we examine instances of nursing home residents  abusing other residents. We interviewed CMS officials and reviewed  agency policies and procedures for overseeing nursing home care quality.  We visited three states with relatively large nursing home populations—  Georgia, Illinois, and Pennsylvania. During these visits, we interviewed  state officials—including those in survey agencies and MFCUs—who are  responsible for responding to, and investigating, allegations of abuse. We  also reviewed relevant federal laws and regulations, as well as the state  laws and regulations pertaining to these three states.
To learn more about the manner in which abuse investigations are  conducted, we judgmentally selected and reviewed files documenting  Georgia, Illinois, and Pennsylvania state survey agency investigations of  158 physical and sexual abuse allegations, mostly from 1999 and 2000. Our  findings cannot be generalized or projected. Where the files indicated that  states had cited the nursing homes for deficiencies, we obtained  subsequent surveys conducted to determine what, if any, sanctions had  been imposed. We also determined the states’ policies and procedures  concerning employees with criminal backgrounds and examined records  of survey agencies’ actions related to nurse aides who had allegedly  abused residents. All three states we visited had established dedicated  telephone lines exclusively devoted to reporting complaints. We called  these lines to verify that they were working properly and to verify that  complaints of physical and sexual abuse would be accepted. We also made  similar calls to other organizations we identified in local Georgia, Illinois,  and Pennsylvania telephone books to determine whether these entities  would accept complaints regarding the abuse of nursing home residents or  make referrals to other organizations. Finally, to learn about law  enforcement’s role in responding to and investigating abuse allegations,  we interviewed officials in these states who represented 19 local police  departments and 4 local prosecutors’ offices. See appendix I for more  detailed information on our scope and methodology  We conducted our work from July 2000 through February 2002, in  accordance with generally accepted government auditing standards.
subsections: section_title: Background
paragraphs: Experts who have conducted studies on the issue of physical and sexual  abuse of nursing home residents have reported that it is a serious problem  with potentially devastating consequences. Nursing home residents have  suffered serious injuries or, in some cases, have died as a result of abuse.  Nursing homes are required to protect their residents from harm by  training staff to provide proper care and by prohibiting abusive behavior.
The vast majority of nursing homes participate in the Medicare and  Medicaid programs and were projected to have received about  $58.4 billion from the programs in 2001 for their care. State survey  agencies—such as Georgia’s Department of Human Resources, Illinois’s  Department of Public Health, and Pennsylvania’s Department of Health—  perform surveys at least every 15 months to assess nursing homes’  compliance with federal and state laws and regulations. These surveys are  designed to determine whether nursing homes are complying with  Medicare and Medicaid standards. Nursing homes found to be out of  compliance are cited with deficiencies, which can result in monetary  penalties or other enforcement actions, including termination from federal  programs, depending on their severity.
In addition to periodic surveys, state survey agencies investigate  complaints of inadequate care, including allegations of physical or sexual  abuse. CMS requires that states designate a specific telephone number for  reporting complaints and that all nursing homes publicize these numbers.
Complaints can be submitted by residents, family members, friends,  physicians, and nursing home staff. In addition, advocates of nursing  home residents, such as long-term care ombudsmen, may file complaints.When state survey agencies receive these complaints they are responsible  for investigating all allegations, determining if abuse occurred, and  identifying appropriate corrective actions.
CMS requires nursing home officials to notify the state survey agency of  allegations of abuse in their facilities immediately. Nursing homes are also  required to conduct their own investigations and submit their findings in  written reports to the state survey agency within 5 working days of the  incident. Depending on the severity of the circumstances, the state survey  agency may visit the nursing home to investigate the incident or wait until  the nursing home submits its report. Depending on the content of the  facility’s report, the survey agency may request the home to conduct  additional work or the agency may investigate further on its own. If the  agency opts not to investigate further, it may still review the manner in  which the home conducted its investigation during the agency’s next  scheduled survey of the home.
To protect residents from potentially abusive personnel, nursing homes  must adhere to federal and state requirements concerning hiring practices.  CMS’s regulations require that facilities establish policies prohibiting  employment of all individuals convicted of abusing nursing home  residents. Although there is no CMS requirement to do so, the three states  we visited require nursing homes to conduct criminal background checks  on some or all prospective employees. All nursing homes must also verify  with the relevant state board of licensing the professional credentials of  the licensed personnel, such as registered nurses (RN), they hire.
In nursing homes, the primary caregivers are nurse aides. According to  federal law, each state must maintain a registry of all individuals who have  satisfactorily completed an approved nurse aide training and competency  evaluation program in that state. Before employing an aide, nursing homes  are required to check the registry to verify that the aide has passed a  competency evaluation.Aides whose names are not included on a state’s  registry may work at a nursing home for up to 4 months to complete their  training and pass a state administered competency evaluation.
CMS requires that if a state survey agency determines that a nurse aide is  responsible for abuse, neglect, or theft of a resident’s property, this  “finding” must be added to the state’s nurse aide registry. The inclusion of  such a finding on a nurse aide’s record constitutes a ban on nursing home  employment. As a matter of due process, nurse aides have a right to  request a hearing to rebut the allegations against them, to be represented  by an attorney, and to appeal an unfavorable outcome. State survey  agencies are not responsible for disciplining other nursing home  professionals, such as RNs, who are suspected of abuse. Such personnel  are referred to their respective state licensing boards for review and  possible disciplinary action.
Local police departments may learn of suspected instances of resident  abuse and conduct criminal investigations. In addition, state survey  agencies may notify the state MFCU to pursue these allegations. States  were provided financial incentives to establish MFCUs as a result of the  enactment of the Medicare-Medicaid Anti-Fraud and Abuse Amendments  to the Social Security Act of 1977. Although one of their primary missions  is to investigate financial fraud and abuse in the Medicare and Medicaid  programs, MFCUs also have authority to investigate the physical and  sexual abuse of nursing home residents. MFCUs typically learn of such  allegations by receiving referrals from state survey agencies. If, after  investigating an allegation, the MFCU decides that there is sufficient  evidence to press criminal charges, it may prosecute the case itself or refer  the matter to the state’s attorney general or a local prosecutor.
section_title: Delays in Reporting Abuse Preclude Immediate Response by Law Enforcement or Survey Authorities
paragraphs: Most of the local police departments in the three states we visited told us  that they were seldom summoned to a nursing home following an alleged  instance of abuse. Several police officials indicated that, when they were  called, it was sometimes after others had begun investigating, potentially  hindering law enforcement’s ability to conduct a thorough investigation.  Instead, state survey agencies were typically notified of allegations of  abuse. However, these notifications were frequently delayed. Allegations  of abuse may not be reported immediately for a variety of factors,  including reluctance to report abuse on the part of residents, family  members, nursing home employees, and administrators. In addition,  individuals who are unaware that state survey agencies have designated  special telephone numbers as complaint intake lines may have difficulty  identifying these numbers in telephone directories, which could also result  in delays.
subsections: section_title: Police Not Immediately Notified of Abuse or Routinely Involved in Survey Agency Investigations
paragraphs: Victims of crimes ordinarily call the police to report instances of physical  and sexual abuse, but when the victim is a nursing home resident, the  police appear to be notified infrequently. Residents and family members  are not required to notify local police of abusive incidents. Several police  officials told us that, like any crime, police should be summoned as soon  as the incident is discovered. However, police told us that when they do  learn of an allegation of abuse involving a nursing home resident, it is  sometimes after another entity, such as the state survey agency, has begun  to investigate, thus hampering law enforcement’s evidence collection and  limiting their investigations. Most of the police departments also indicated  that they did not track reports of abuse allegations involving nursing home  residents and thus did not have data on the number of such reports.
When residents and family members do report allegations of abuse, they  may complain directly to the nursing home administrator rather than  contact police. According to one long-term care ombudsman, resident and  family members do not always view the abuse as a criminal matter.  Nursing homes are usually not compelled to notify local law enforcement  when they learn of such reports. There is no federal requirement that they  contact police, although some states—including Pennsylvania—have  instituted such a requirement. According to an Illinois state survey agency  official, a similar requirement will go into effect in that state in March  2002.
Our discussions with officials from 19 local law enforcement agencies  indicate that police are rarely called to investigate allegations of the abuse  of nursing home residents. Besides infrequent contact from residents,  family members, and nursing homes, officials from 15 of the 19 police  departments we visited told us that they had little or no contact with  survey agencies. Officials from several of these departments reported that  they were unaware of the role state survey agencies play in investigating  instances of resident abuse.
section_title: Abuse Allegations Not Immediately Reported to State Survey Agencies
paragraphs: Our review of 158 case files—mostly from 1999 and 2000—indicated state  survey agencies were often not promptly notified of abuse allegations.While individuals filing complaints are not compelled to report allegations  within a prescribed time frame, nursing homes in the states we visited are  required to notify the state survey agency of abuse allegations the day they  learn of the allegation or the following day. We found that both complaints  from individuals and notifications from nursing homes are frequently  submitted to survey agencies days, and sometimes weeks, after the abuse  has taken place.
As table 1 shows, 20 of the 31 complaint cases we could assess for  promptness of submission contained allegations that were reported to the  state survey agency 2 days or more after the abuse took place. Further,  eight were reported more than 2 weeks after the alleged abuse occurred.
There were comparable delays in facilities’ notifications of alleged abuse  to the state survey agencies. The three states we visited require that  nursing homes notify them of instances of alleged abuse immediately—  interpreted by survey agency officials in all three of the states to mean the  day the facility learns of the abuse or the next day. As table 2 shows,  however, only about half of the 111 nursing home notifications we could  assess for promptness were submitted within the prescribed time frame.
Delays in notifying survey agencies of abuse prevent the agencies from  promptly investigating and ensuring that nursing homes are taking  appropriate steps to protect residents. Residents may remain vulnerable to  abuse until corrective action is taken.
section_title: Untimely Reporting Attributable to Multiple Factors
paragraphs: Allegations of abuse of nursing home residents may not be reported  promptly for a variety of reasons. For example, a recent study found that  nursing home staff may be skeptical that abuse occurred. Residents may  also be afraid to report abuse because of fear of retribution, according to  another study and two long-term care ombudsmen we met with.According to one law enforcement official, family members are sometimes  fearful that the resident will be asked to leave the home and are troubled  by the prospect of finding a new place for the resident to live. In addition,  nursing home staff and management do not always report abuse promptly,  despite requirements to do so. According to law enforcement and state  survey agency officials, staff fear losing their jobs or facing recrimination  from co-workers and nursing home management. Similarly, they also said  that nursing home management is sometimes reluctant to risk adverse  publicity or sanctions from the state.
We saw evidence of delayed reporting by family members, staff, and  management in our file reviews, as illustrated by the following examples:
A resident reported to a licensed practical nurse that she had been raped  in the nursing home. Although the nurse recorded this information in the  resident’s chart, she did not notify nursing home management. She also  allegedly discouraged the resident from telling anyone else. Two months  later the resident was admitted to a hospital for unrelated reasons and told  hospital officials that she had been raped. It was not until hospital officials  notified police of the resident’s complaint that an investigation was  conducted. Investigators then discovered that the resident had also  informed her daughter of the incident, but the daughter, apparently not  believing her mother, had dismissed it. The resident later told police that  she did not report the incident to other staff at the nursing home because  she did not want to cause trouble. The case was closed because the  resident could not describe the alleged perpetrator. However, the nurse  was counseled about the need to immediately report such incidents.
An aide, angry with a resident for soiling his bed, threw a pitcher of cold  water on him and refused to clean him. Another aide witnessed the  incident. Instead of informing management, the witness confided in a third  employee, who reported the incident to the nursing home administrator 5  days after the abuse took place. The abusive aide was fired, and a finding  of abuse was recorded in her nurse aide registry file.
One nursing home employee witnessed an aide slap a resident; two other  employees heard the incident. The aide denied the allegation, yet the  resident developed redness, swelling, and bruising around her eye. The  witnesses reported the matter to nursing home management, which  investigated the situation and suspended the aide the next day. The aide  was subsequently fired. However, the state survey agency was not notified  of the incident by the home until 11 days after the abuse took place.
During our work we discovered that nursing home residents and family  members who are prepared to report abuse to the state survey agency  could encounter difficulty in identifying where to report a complaint of  abuse, which can further delay reporting. For example, telephone books  for Chicago and Peoria, Illinois, and Athens and Augusta, Georgia, did not  include complaint telephone numbers. Although telephone books in  Philadelphia and Pittsburgh, Pennsylvania, contained the correct numbers  for the state survey agency’s offices, they did not identify the designated  complaint number, making it difficult for an individual unfamiliar with the  agency to recognize its telephone number as an appropriate place to  report suspected abuse.
Individuals who are not already familiar with the state survey agency’s role  and its complaint telephone line may encounter a confusing array of  numbers both public and private in their local telephone directory. In the  three states we visited we reviewed the government and consumer pages  in nine telephone books and identified a wide variety of organizations,  which, by their names, appeared capable of addressing complaints.  However, many did not have the authority to do so. In this review, we  identified 42 entities that appeared to be organizations where abuse could  be reported and were not affiliated with the state survey agencies. Only six  of these entities represented organizations—such as long-term care  ombudsmen—that are capable of pursuing abuse allegations. The  remaining 36 entities either could not be reached or could not accept  complaints, despite having listings such as the “Senior Helpline.”  Sometimes these entities attempted to refer us to a more appropriate  organization, but with mixed success. For example, our calls in Georgia  resulted in four correct referrals to the state survey agency’s designated  complaint telephone line but also led to five incorrect referrals. Five other  Georgia entities offered us no referrals.
To facilitate reporting, nursing homes are required to post the telephone  numbers of complaint lines in a prominent location within the facility.  State survey agencies are expected to verify that these numbers are  properly displayed when they conduct their annual inspections and have  the option of citing homes with deficiencies if they fail to do so. However,  deficiency data compiled by CMS do not specifically identify the number  of homes cited for failure to display these numbers, and so it is not readily  apparent how often nursing homes do not comply with this specific  requirement.
Despite its requirement that nursing homes post the complaint telephone  numbers, CMS recognized that a greater awareness of how to report abuse  was warranted and so, in 1998, it initiated an educational campaign  regarding abuse prevention and detection in nursing homes. Because  publicizing the appropriate telephone numbers for reporting abuse is  critical, a key component of the campaign was the development of a  poster to be used by nursing homes nationwide. According to a CMS  official, the poster will identify several options for reporting abuse,  including notifying nursing home management, local law enforcement,  complaint telephone numbers, and CMS. In addition to displaying these  numbers, the posters will feature removable cards—which individuals may  retain—listing the organizations and telephone numbers contained on the  poster. A pilot test of the poster was conducted in 1999. Based on  feedback received from the pilot test, the poster was revised, but it has not  been approved for distribution.
section_title: Abusive Nursing Home Staff Difficult to Prosecute
paragraphs: Relatively few prosecutions result from allegations of physical and sexual  abuse of nursing home residents. We identified two impediments to the  successful prosecution of employees who abuse nursing home residents.  First, allegations of abuse were not always referred to local law  enforcement or MFCUs. When referrals were made it was often days or  weeks after the incident occurred, compromising the integrity of what  limited evidence might have still been available. Second, a lack of  witnesses to instances of abuse made prosecutions difficult and  convictions unlikely.
subsections: section_title: States’ Policies Regarding Referrals to Law Enforcement Varied and Limited Prosecutions
paragraphs: Each of the states we visited had a different policy for referring instances  of suspected abuse to law enforcement officials. While Illinois and Georgia  both relied on their MFCUs to pursue criminal investigations concerning  resident abuse, they followed different policies. Our review of case files  in Illinois showed that the state survey agency consistently referred all  reports of physical and sexual abuse—regardless of whether they were  complaints or incident reports—to the MFCU, which in turn determined  whether to open an investigation. As a result, the Illinois MFCU appeared  to play a substantial role in abuse investigations. On the other hand, the  Georgia survey agency evaluated each allegation and selectively referred  cases to its MFCU according to a mutually agreed upon procedure. In  accordance with this procedure, the survey agency screened complaints  and incident reports before making referrals to its MFCU based on an  assessment of the severity of the allegations or circumstances. Survey  agency officials also told us that, in making these assessments, they  considered the likelihood that reporting the abuse to the MFCU would  result in a criminal conviction.
The differences in Illinois’s and Georgia’s referral policies yielded  dramatically different results. While the Illinois survey agency referred  approximately 300 allegations of abuse to its MFCU in 1999, Georgia only  referred 27 allegations in the same period. Although Illinois had more than  twice as many nursing home residents as Georgia—81,500 vs. 33,800—the  discrepancy in population size does not account for the significant  difference in the number of referrals. Our review of the 50 Illinois cases  revealed that the Illinois survey agency referred cases to its MFCU earlier  than the Georgia survey agency. The Illinois cases were referred to the  MFCU, on average, 3 days after receiving a report of abuse, while Georgia  referred cases, on average, 15 days after learning about an allegation.  Illinois’s policy of routinely referring all allegations to its MFCU enables  referrals to be made more quickly than Georgia’s system of evaluating and  screening all allegations prior to making selective referrals.
The state survey agencies in Illinois and Georgia referred 64 of the cases  we reviewed to the MFCUs for investigation. As indicated in table 3,  Georgia, which referred fewer cases to its MFCU, had fewer convictions.  By referring more cases to its MFCU, the Illinois survey agency presented  law enforcement with the opportunity to assess whether an abusive act  had been committed and whether it should be criminally pursued. In  addition, by referring its cases to its MFCU sooner, on average, than  Georgia, Illinois also enhanced law enforcement’s ability to conduct more  timely and effective investigations. The Georgia survey agency’s screening  process provided law enforcement fewer and less timely opportunities to  investigate allegedly abusive caregivers.
In discussing Georgia’s referral policy with survey agency and MFCU  officials, we learned that the agency substantially changed its MFCU  referral criteria in 2000, leading to an increased number of referrals—  111—that year. This change followed a new understanding between survey  agency and MFCU officials based on the MFCU’s expressed willingness to  investigate instances of abuse. Previously, the survey agency typically did  not refer instances that it considered less serious—such as incidents  involving nursing home employees slapping residents with no reported  visible injuries—to the MFCU. According to survey agency officials, they  did not refer such allegations because they believed that these cases did  not meet the referral criteria. In their view, it was unlikely that the MFCU  would consider such acts serious enough offenses to warrant an  investigation and prosecution.
section_title: Lack of Witnesses Reduce Likelihood of Successful Prosecutions
paragraphs: The lack of compelling evidence often precludes prosecution of those who  have abused nursing home residents. MFCU and local law enforcement  officials indicated that nursing home residents are often unwilling or  unable to provide testimony. The state survey agency and law enforcement  officials we spoke to agreed with this determination. Our file reviews  confirmed that residents were reluctant or unable to provide evidence  against an accused abuser in 32 of the 158 cases we reviewed, thus making  it difficult to pursue a criminal investigation. Our work also indicated that  resident testimony could be limited by mental impairments or an inability  to communicate. We noted several instances in which residents sustained  unexplained black eyes, lacerations, and fractures. However, despite the  existence of serious injuries, investigators could neither rule out  accidental injuries nor identify a perpetrator.
Prosecutions of individuals accused of abusing nursing home residents are  often weakened by the time lapse between the incident and the trial. Law  enforcement officials and prosecutors told us that the amount of time that  elapses between an incident and a trial could ruin an otherwise successful  case because witnesses do not always remember important details about  the incident. Although it is not uncommon for the memories of witnesses  in criminal cases to fade, impaired recall is even more prevalent among  nursing home residents. Our review showed that nursing home residents  may become incapable of testifying months after they were abused. For  example, in one case, a victim’s roommate witnessed the abuse and  positively identified the abuser during the investigation. However, by the  time of the trial—nearly 5 months later—she could no longer identify the  suspect in the courtroom, prompting the judge to dismiss the charges.  Moreover, given the age and medical condition of many nursing home  residents, many might not survive long enough to participate in a trial. One  recent study of 20 sexually abused nursing home residents revealed that 11  died within 1 year of the abuse. Law enforcement officials told us that,  without testimony from either a victim or a witness, conviction is unlikely.
section_title: Measures to Safeguard Residents from Abusive Employees Are Ineffective
paragraphs: The safeguards available to states do not sufficiently protect residents  from abusive employees. CMS’s requirements preclude facilities from  employing an individual convicted of abusing nursing home residents but  permit the hiring of those convicted of other abusive acts, such as child  abuse. Although some states have established more stringent  requirements, criminal background checks typically do not identify  individuals who have committed a crime in another state. Nursing homes  can be cited for deficiencies if they fail to adequately protect residents  from abuse, but these deficiencies rarely result in the imposition of  sanctions, such as civil monetary penalties, by state survey agencies. State  survey agencies, which also oversee the operation of state nurse aide  registries, do not adequately ensure that residents will be protected from  aides who previously abused residents. Finally, states are unable to take  professional disciplinary actions against other employees, such as security  guards or housekeeping staff, who may have abused residents but who are  neither licensed nor certified to care for residents.
subsections: section_title: CMS Employment Requirements and Background Checks Do Not Ensure Resident Protection
paragraphs: While CMS requires nursing homes to establish policies that prevent the  hiring of individuals who have been convicted of abusing nursing home  residents, this requirement does not include offenses committed against  individuals outside the nursing home setting, nor does it specify that states  conduct background checks on all prospective employees. CMS’s  requirement does not preclude individuals with similar convictions—such  as assault, battery, and child abuse—from obtaining nursing home  employment.
The three states we visited all apply a broader list of offenses that prohibit  employment in a nursing home. Each state’s prohibition of employees  includes those convicted of offenses such as kidnapping, murder, assault,  battery, or forgery and is not limited to offenses against nursing home  residents. However, the three states vary in their application of these  prohibitions. For example, Illinois’s prohibition does not apply to  employees who are not directly involved in providing care to residents and  allows nurse aides who have been convicted of such offenses to apply for  a waiver. Waivers may be granted if there are mitigating circumstances  and allow these aides to work in nursing homes. Pennsylvania’s  prohibition applies to all nursing home employees, not just those involved  in patient care. Georgia’s prohibition, enacted in 2001, also applies to all  nursing home employees, but only if they were convicted of abuse-related  crimes within the preceding 10 years.
Criminal background checks do not adequately protect residents, in part,  because, as in Illinois, they may not apply to all nursing home employees.More importantly, the background checks that are performed by state and  local law enforcement officials in the three states we visited are typically  only statewide. Consequently, individuals who have committed  disqualifying crimes in one state may be able to obtain employment at a  nursing home in another state.
Nationwide background checks on prospective nursing home employees  can be performed by the Federal Bureau of Investigation (FBI) if nursing  homes request them. These checks could identify offenses committed  elsewhere, but not all states take advantage of this option. According to an  FBI official, 21 states have requirements that subject some health care  employees to these checks, but state requirements vary and do not always  apply to prospective nursing home employees. This official told us that  most of the requests the FBI receives on health care personnel are from  these 21 states. He told us that, of the remaining states, only nursing  homes in North Carolina and Ohio request such background checks  regularly. Of the three states we visited, only Pennsylvania submits  background check requests to the FBI. However, these are limited to those  individuals who have lived outside the state during the 2 years prior to  applying for nursing home employment.
Two of the states we visited allow employees to report for duty before  background checks are completed. Pennsylvania and Illinois permit new  employees to report to work before criminal background checks are  completed, for up to 30 days and 3 months, respectively. However, Georgia  survey agency officials told us that nursing homes could be cited with a  deficiency if new employees assume their duties before the nursing home  receives the results of the background checks. Georgia requires that these  checks be completed within 3 days of the request.
CMS does not require that the results of criminal background checks be  included in nurse aide registries. Of the three states we visited, only  Illinois requires that the results be reported to the state survey agency by  the nursing home. If the check reveals a disqualifying criminal history, it  will be included in the Illinois registry. Therefore Illinois nursing homes  are able to identify some aides with disqualifying convictions before offers  of employment are made and criminal background checks are initiated.  Officials in Georgia and Pennsylvania explained that they verify the  completion of background checks for new employees, including nurse  aides, as they conduct their periodic nursing home surveys. As a result,  they told us that they do not believe that the results of these checks need  to be added to their registries.
section_title: Nursing Homes Rarely Sanctioned for Improperly Responding to Abuse
paragraphs: For the states that we reviewed, sanctions were rarely imposed against  nursing homes for deficiencies associated with their handling of instances  of abuse. Deficiencies considered the most severe—those resulting in  actual harm or immediate jeopardy to resident health or safety—could  result in an immediate sanction, such as a civil monetary penalty.  Deficiencies not resulting in actual harm or immediate jeopardy usually  resulted in nursing homes being required to submit a plan of corrective  action. Nursing homes that submit corrective action plans may also face  other sanctions.
The Georgia, Illinois, and Pennsylvania survey agencies eventually cited 26  nursing homes—from the 158 cases we reviewed—for abuse-related  deficiencies such as failing to report allegations of abuse in a timely  manner or failing to properly investigate them, as well as inadequately  screening employees for criminal backgrounds, as indicated in table 4.
The state survey agencies rarely recommended to CMS that civil monetary  penalties be imposed against nursing homes for abuse-related deficiencies,  primarily because most of the deficiencies cited for these 26 nursing  homes were not categorized as placing residents’ health or safety in  immediate jeopardy or resulting in actual harm to residents. Only 1 of  these 26 facilities—in Illinois—was assessed a civil monetary penalty.  However, the penalty was reduced on appeal. State survey agencies did  not recommend other sanctions on the 25 remaining nursing homes.
section_title: Nurse Aide Registries Do Not Ensure Resident Protection
paragraphs: We found that allegedly abusive nurse aides received different treatment  depending on the state in which they worked. In addition, when states  determined that aides were abusive, there were frequent and long delays  in the inclusion of this information in their registry files. Residents could  have been exposed to abusive individuals while their cases were pending.
Finally, we found that one state’s Web-based nurse aide registry lacked  complete information on aides who had been found to be abusive.
subsections: section_title: Inconsistent Treatment of Nurse Aides Poses Risks to Nursing Home Residents
paragraphs: CMS defines abuse as the willful infliction of injury, unreasonable  confinement, intimidation, or punishment with resulting physical harm,  pain, or mental anguish. CMS officials told us that states may use different  definitions so long as they are at least as broad as the CMS definition.While the three states we visited have definitions that appear at least as  broad as the CMS definition, variations in the way these states interpret or  apply their definitions affect whether aides’ actions are reflected in state  registries.
For example, the Georgia definition is very similar to CMS’s and defines  abuse to include, among other things, the “willful infliction of physical  pain, physical injury,  mental anguish.” Officials there told us, however,  that in order to add a finding of abuse to an aide’s registry file, they must  be convinced that the aides’ actions were intentional. They are less likely  to determine that an aide has been abusive if the aide’s behavior appeared  to be spontaneous or the result of a “reflex” response. Officials said they  would view an instance in which an aide struck a combative resident in  retaliation after being slapped by the resident as an unfortunate reflex  response rather than an act of abuse.
Similarly, Pennsylvania defines abuse to include, among other things,  “infliction of injury . . . or intimidation or punishment with resulting  physical harm, pain or mental anguish.” While this definition appears to be  at least as broad as the CMS definition, Pennsylvania officials told us that  they would be unlikely to annotate an aide’s registry file to reflect a finding  of abuse unless the aide caused serious injury or obvious pain. Our review  of Pennsylvania files indicated that most of the aides that were found to  have been abusive had, in fact, clearly injured residents or caused them  obvious pain. However, these files also indicated that in several instances  in which residents were bumped or slapped and indicated that they were  in pain as the result of aides’ actions, the survey agency decided not to  take action because the residents had no physical injuries. As in Georgia,  agency officials indicated that they needed to establish that the action was  intentional.
In contrast, Illinois defines abuse as “any physical . . . or mental injury  inflicted on a resident other than by accidental means.” Incidents like  those not reported to registries in Georgia or Pennsylvania—reflex actions  and those devoid of serious injury or obvious pain—are added to Illinois’s  registry. We saw 17 such cases in Illinois in which state survey officials did  find the aides to have been abusive. We also reviewed, in both Illinois and  Georgia, what appeared to be comparable complaints in which a nursing  home employee witnessed another staff member strike a combative  resident. Both survey agencies made preliminary determinations that the  employees had, in fact, abused residents. The Illinois survey agency not  only included its determination in the aides’ registry files, it also referred  the matter to its MFCU, resulting in a criminal conviction. The Georgia  survey agency reversed its initial determination that the aide was abusive  when the aide requested that the matter be reconsidered, even though the  aide did not provide new evidence to disprove the allegation. Notes in the  case file indicated that Georgia reversed its decision because the aide’s  action was reflexive. Consequently, Georgia did not annotate the aide’s  registry information to reflect a finding of abuse and did not refer this  incident to its MFCU. We identified four additional instances among the 52  Georgia cases we reviewed involving nurse aides who hit or otherwise  injured combative residents after these residents had tried, sometimes  successfully, to harm them first. None of these cases resulted in  determinations that aides were abusive. The files indicated that officials  had determined that the aides did not intend to hurt the resident and were  not abusive because the residents were combative. Consequently, no  further actions were taken.
CMS officials agreed with state survey agency officials that intent is a key  factor in assessing whether an aide abused a resident. However, they  would not necessarily find a reflex response to be unintentional. These  officials indicated that an aide who slaps a resident back could have  developed intent in an instant and thus should be considered abusive.
Of the 158 cases of alleged physical and sexual abuse that we reviewed,  105 involved nurse aides. States notified 41 of these aides of their intent to  annotate their registry files to reflect findings of abuse, which would  prevent them from obtaining future employment in a nursing home. As  table 5 shows, 27 of these 41 aides eventually had their registry files  annotated. Consistent with Illinois’s broad definition of abuse and the fact  that officials there have not narrowed its scope through its application,  most of these aides were from that state.
We found examples of delays between the time the state survey agencies  learned that a nurse aide had allegedly abused a resident to the date of the  agencies’ final determinations. Our review of the 71 case files from Illinois  and Georgia involving allegedly abusive aides, and our review of 1999  nurse aide registry records in Pennsylvania indicated that while some  determinations were made in less than 2 months, a substantial number—  12—took 10 months or more. Three of these 12 determinations took at  least 2 years. Such delays can put residents of other nursing homes at risk.  By the time state survey agencies have determined that some aides are  abusive, these aides may have already found employment in other homes.
The process of determining whether an aide actually abused a resident can  be time-consuming. While CMS requires survey agencies to begin their  investigation of an allegedly abusive aide within two days of learning of an  allegation, it does not impose a deadline for completing these  investigations. State survey agency investigations can be prolonged,  particularly if law enforcement is involved.
Nurse aides are entitled to due process, but nursing home residents may  remain vulnerable to abuse until final determinations are made. Once  officials make an initial determination that an aide abused a resident, the  aide must be informed in writing. The notification must also inform the  aide that the agency intends to update the registry to reflect this  determination, which would prevent the aide from obtaining future  employment in a nursing home in that state. Because of the severity of  these consequences, aides are entitled to hearings. Hearings must be  requested in writing within 30 days of the notification from the state  survey agency regarding its determination and its intent to include a  finding of abuse in the registry. Hearings may not be held for several  months, and hearing officers may not render their decisions immediately.  No entry may be made in an aide’s registry record until a final  determination is made that the aide was abusive. Our analysis of nurse  aide registry records from 1999 indicated that, for all aides with abuse  findings recorded in their registry files in all three states, hearings added,  on average, 5 to 7 months to the determination process.
section_title: Inaccuracies in Nurse Aide Registry Web Sites May Compromise Resident Safety
paragraphs: We identified problems with the accuracy of information contained in one  state’s nurse aide registry Web site that could have resulted in the  provision of inaccurate information to nursing homes screening potential  employees. Our test of the accuracy of the sites for the three states we  visited showed that, in some instances, findings of abuse had been  annotated to an aide’s registry record but had not been included in registry  information posted on the Web site. For example, four Georgia aides with  final determinations of abuse did not have such findings reflected in their  files at the state’s registry Web site. Agency officials confirmed our results  and consequently closed the agency site for more than a week. However,  they told us that the problem was limited to the site and did not affect  their ability to provide correct information by telephone or fax. They also  reported that the agency’s ability to provide a complete list of abusive  aides in its quarterly bulletins to nursing homes was not compromised.
Just as background checks would typically reveal only offenses committed  in the state in which an applicant seeks employment, nurse aide registries  reflect an aide’s history in a particular state. In 1998, the HHS Office of  Inspector General recommended that HCFA assist in developing a national  abuse registry and expand state registries to include all nursing home  employees who have abused residents or misappropriated their property  in facilities that receive federal reimbursement. A CMS contractor is  currently conducting a feasibility study regarding the development of such  a registry. The study includes a cost-benefit analysis to assess the  implications of a centralized nurse aide registry and, to a lesser extent, the  implications of tracking all nursing home employees. The implications of  requiring other health care providers—such as home health agencies—to  query nurse aide registries is also under study. The contractor is scheduled  to report its findings as soon as March 2002.
section_title: Other Nursing Home Employees May Not Be Disciplined
paragraphs: Although nurse aides compose the largest proportion of nursing home  employees, other employees, such as laundry aides, security guards, and  maintenance workers have also been alleged to have abused residents.  While survey agencies can prevent abusive aides from working in nursing  homes and can refer licensed personnel, such as nurses and therapists, to  state licensing boards for disciplinary action, they have no similar  recourse against other abusive employees, who may continue to work in  nursing homes. Survey agencies can, however, cite facilities for  deficiencies if appropriate actions—such as reporting and investigating  the allegations—are not taken.
Of the 158 cases of alleged physical and sexual abuse that we reviewed, 10  suspected perpetrators were employees who were not subject to licensing  or certification requirements. None of the facilities in these cases were  cited for deficiencies. Although there is no administrative process to  enable the state to take actions against such employees, these employees  could be criminally prosecuted. Of these 10 cases, 4 involved allegations  that proved unfounded or for which evidence was inconsistent. One of the  10 employees ultimately pled guilty in court. Three others were  investigated by law enforcement but were not prosecuted. The remaining  2 employees were terminated by their nursing homes but were not the  subject of criminal investigations.
section_title: Conclusions
paragraphs: Nursing homes are entrusted with the well-being and safety of their  residents yet considerable attention has recently been focused on the  inadequacies of care provided to many nursing home residents. Along with  receiving quality care, residents are entitled to be protected from those  who would harm them. Residents who are abused need to be assured that  their allegations will be immediately referred to the proper authorities and  investigated expeditiously. In addition, law enforcement authorities need  to ensure that abusive individuals are prosecuted when appropriate, and  survey agencies should recommend to CMS that available administrative  sanctions be imposed against known abusers.
Our work shows that nursing home residents need both stronger and more  immediate protections. Law enforcement agencies, such as state MFCUs  or local police departments, are not involved as often or as soon as they  should be, especially when there are indications of potential criminal  activity. Additionally, determining where to report complaints of alleged  abuse can be confusing. Prompt reporting is especially crucial given the  often-limited evidence available.
CMS is taking important steps that may better protect residents. For  example, its feasibility study on the development of a national abuse  registry could lead to enhanced resident safety. However, other efforts  have fallen short. For example, an important tool could be the agency’s  educational campaign using a new poster in nursing homes nationwide to  better inform residents and family members about how to report abuse.  However, the poster has been under development for more than 3 years.
More should be done to protect nursing home residents. CMS’s  requirement that nursing homes not employ individuals convicted of  abusing residents does not sufficiently prevent the hiring of potentially  abusive individuals. Those who have committed similar offenses, such as  child abuse, are eligible to work in nursing homes unless states impose a  more stringent requirement. While CMS does not require criminal  background checks, some states have instituted them. However, they may  not be required for all prospective employees and may not identify  offenses committed in other states. In addition, CMS’s definition of abuse  is not sufficiently detailed to ensure that all states report every incident  that CMS would consider abusive. Affording due process to nurse aides  who have allegedly abused residents is important and necessary. However,  determinations that nurse aides have been abusive can be time-consuming,  leaving residents at risk if these aides continue to work in nursing homes.  Finally, nurse aide registries may have incorrect information, allowing  nursing homes to hire aides previously found abusive.
Recommendations for 	 To better protect nursing home residents, we recommend that the CMS  Executive Action
Ensure that state survey agencies immediately notify local law  enforcement agencies or MFCUs when nursing homes report allegations of  resident physical or sexual abuse or when the survey agency has  confirmed complaints of alleged abuse.
Accelerate the agency’s education campaign on reporting nursing home  abuse by (1) distributing its new poster with clearly displayed complaint  telephone numbers and (2) requiring state survey agencies to ensure that  these numbers are prominently listed in local telephone directories.
Systematically assess state policies and practices for complying with the  federal requirement to prohibit employment of individuals convicted of  abusing nursing home residents and, if necessary, develop more specific  guidance to ensure compliance.
Clarify the definition of abuse and otherwise ensure that states apply that  definition consistently and appropriately.
Shorten the state survey agencies’ time frames for determining whether to  include findings of abuse in nurse aide registry files.
section_title: Agency Comments and Our Evaluation
paragraphs: We received comments on a draft of this report from CMS, the Department  of Justice (DOJ), the three state survey agencies we visited (the Illinois  Department of Public Health, the Georgia Department of Human  Resources, and the Pennsylvania Department of Health), and the MFCUs  in Illinois and Georgia. We also received comments from two  organizations representing the nursing home industry—the American  Health Care Association (AHCA) and the American Association of Homes  and Services for the Aging (AAHSA).
In its comments, CMS generally agreed with our recommendations and  said that it is committed to protecting nursing home residents from harm  and explained that it is currently investigating new ways to combat  resident abuse and neglect. We have reprinted CMS’s letter in appendix II.
CMS also provided technical comments, which we have incorporated as  appropriate.
CMS agreed with our first recommendation and said it would instruct state  survey agencies to immediately notify local law enforcement agencies or  MFCUs of confirmed abuse allegations. CMS also said it would thoroughly  review this recommendation when it completes its analysis of its  Complaint Improvement Project. We believe that immediately notifying  law enforcement of suspected abuse will enhance the safety of nursing  home residents, and we urge CMS’s prompt action.
In responding to our second recommendation—that CMS accelerate its  education campaign—the agency said that it is working with HHS to  release its new poster as soon as possible, but did not indicate when it  might be distributed to nursing homes. In addition, CMS agreed to request  states to prominently list telephone numbers for reporting abuse in local  telephone directories.
CMS agreed with our third recommendation and said it will review state  policies and practices and reissue guidance regarding employment  prohibitions pertaining to individuals convicted of abusing nursing home  residents. We believe that an assessment of the current requirements, that  includes an evaluation of the states’ implementation of these requirements,  could have a lasting impact on resident safety.
In addressing our fourth recommendation—to clarify the definition of  abuse and ensure that states consistently and appropriately apply this  definition—CMS explained that states can use their own established  definitions of abuse. According to CMS, the state’s definitions may be used  when citing homes for deficiencies under their state licensure program  but, when performing a federal survey, CMS noted that the federal  definition must be used. CMS added that it would clarify this distinction  with the states. However, we believe that it is also of great importance to  clarify the definition of abuse that states should apply when considering  whether nurse aides have abused residents and consequently may have  this action reflected in their nurse aide registry files.
CMS agreed to consider our fifth recommendation—to shorten the time  frames for determining whether to include findings of abuse in the nurse  aide registry. CMS acknowledged that a considerable amount of time may  elapse before reports of abuse are finalized and reported to the nurse aide  registry. CMS added this is largely attributable to steps associated with  due process. CMS pointed out that, with the exception of the time taken by  the states to substantiate abuse allegations, all of these time frames are  specified by regulation. However, the regulations do not specify a time  frame for making a final decision once the hearing has been completed  and the hearing record has been closed. CMS said it would take our  recommendation into account when considering changes to these  regulations. We believe that reducing this time period will provide  residents with greater certainty that they will not be exposed to abusive  aides.
We received oral comments from the Coordinator of DOJ’s Nursing Home  and Elder Justice Initiative. She agreed with the findings in our report. She  also added that resident abuse may be underestimated, as studies suggest  a significant number of abuse cases are never reported. She said that, in  order to respond appropriately to victims of abuse, local law enforcement  and other “first responders” such as firefighters and paramedics, would  benefit from special training. In her view, this training should include  guidance regarding how to distinguish signs of physical abuse from other  types of injuries, advice on interviewing elderly and confused residents,  and investigative techniques and evidence preservation strategies unique  to the nursing home setting. Our work did not include an evaluation of the  training programs offered to law enforcement officials or “first  responders.” In addition, she pointed out that DOJ could become actively  involved in investigating abuse allegations in certain situations, such as  those involving facilities where a pattern of abuse has been detected and  instances where nursing home managers or employees have made false  statements to state surveyors regarding resident care. In addition to these  comments, we received technical comments from the FBI, which we  incorporated as appropriate.
We received comments from all three of the state survey agencies we  visited as well as the Illinois MFCU. These agencies described initiatives  they have undertaken to increase awareness of resident abuse and  improve reporting and offered technical comments, which we  incorporated as appropriate. Although we provided our draft to the  Georgia MFCU, it did not offer any comments.
Finally, we received comments from representatives of AHCA and AAHSA.  Both organizations generally agreed with our recommendations. AHCA  representatives told us that they suspect that abuse of nursing home  residents is underreported. They said that they support providing more  training to both caregivers and law enforcement officials. They noted that  such training could discourage abusive behavior by nursing home staff and  improve law enforcement’s responsiveness to instances of resident abuse.
Our work did not include an evaluation of such training programs.  Representatives of both AHCA and AAHSA indicated that they strongly  support the establishment of a national nurse aide registry and a national  criminal background check for nursing home employees. In addition, the  AAHSA representatives said that they strongly agreed with our  recommendation to clarify the definition of abuse. They noted that the  definition of abuse has long been the subject of debate and its clarification  by CMS is in the interest of residents, as well as nursing home  management and staff. In addition to these comments, both AHCA and  AAHSA offered technical comments, which we have incorporated as  appropriate.
As agreed with your offices, unless you announce its contents earlier, we plan no further distribution of this report until 30 days after its issuance date. At that time, we will send copies to the CMS administrator,  interested congressional committees, and other interested parties. We will  then make copies available to others upon request. If you or your staff have any questions about this report, please call me at (312) 220-7600. An  additional GAO contact and other staff who made major contributions to this report are listed in appendix III.
section_title: Appendix I: Scope and Methodology
paragraphs: To determine the federal requirements for responding to, and investigating  allegations of, abuse of nursing home residents, we reviewed federal laws  and regulations. We interviewed officials from the Centers for Medicare  and Medicaid Services (CMS ) regarding these requirements and also  discussed their oversight of the state survey agencies responsible for  surveying nursing homes and certifying their compliance with federal laws  and regulations. We conducted our work in three states with relatively  large nursing home populations—Illinois, Georgia, and Pennsylvania—and  discussed these requirements with survey and law enforcement officials in  these states. In addition, we met with officials from the three states’  departments on aging and local area agencies on aging because they may  also receive abuse referrals and conduct investigations. We reviewed and  discussed relevant state policies and procedures with these officials.  Finally, to become familiar with the general progression of abuse  investigations, we attended conferences and consulted with experts in the  field of elder abuse.
For each of the three states we visited, we reviewed cases involving  allegations of physical and sexual abuse. Most of these cases were opened  by Medicaid Fraud Control Units (MFCUs) or reported to state survey  officials in 1999 or 2000. We focused on the survey agencies’ and MFCUs’  files. We did not review any of the allegations investigated by the state  departments on aging or local area agencies on aging because of agency  officials’ concerns with confidentiality. In total, we reviewed 158 cases to  determine the circumstances and nature of the cases, the extent to which  the allegations were investigated and prosecuted, and the timeliness of  referrals and investigations. However, our findings cannot be generalized  or projected. To assess the timeliness of reporting abuse allegations, we  used the information from our case review and compared these results to  federal and state guidelines. For cases that the state survey agency  referred to the MFCU, we calculated the number of days between agency  receipt and referral to the MFCU. We also determined the number of  convictions resulting from these referrals.
At the Illinois Department of Public Health (IDPH)—the state survey  agency—we identified and reviewed 50 cases involving physical or sexual  abuse that were reported by individuals as complaints or by nursing  homes in incident reports. All of these allegations were referred by IDPH  to its MFCU. These included all of the allegations of physical or sexual  abuse for which the MFCU had opened investigations in 1999 and closed  at the time of our review. We reviewed the relevant files at both agencies.  We also examined 1 month of referrals that the MFCU reviewed but  ultimately did not investigate. These referrals typically involved bruises of  unknown origin, old injuries, a lack of witnesses, or instances in which the  intent to hurt a resident was questionable or unfounded.
In Georgia, we reviewed 52 abuse allegations. Of these, 14 were either  complaints or incident reports that the state Department of Human  Resources (DHR)—in which Georgia’s state survey agency is housed—had  referred to the MFCU in 1999. These 14 cases represent all of the  allegations of physical or sexual abuse that DHR referred to the MFCU in  1999 and for which the MFCU opened and subsequently closed an  investigation. We reviewed these 14 cases at both agencies. Because DHR  does not refer all physical and sexual abuse cases to the MFCU, we  judgmentally selected and reviewed 38 additional abuse cases that DHR  had received but had not referred to the MFCU. We chose these additional  cases from the survey agency’s 1999 log of complaints, which included 60  physical and 14 sexual abuse cases, as well as from its 1999 log of incident  reports, which included 361 physical and 47 sexual abuse cases. We  selected cases based on the proportion of the allegations that involved  physical and sexual abuse, as well as complaints and incident reports.
Because local law enforcement in Pennsylvania is assigned primary  responsibility for investigating the physical or sexual abuse of nursing  home residents, our case file selection for this state differed from that of  Illinois and Georgia. As the MFCU is typically not involved in these cases,  the files we reviewed included 56 cases reported to Pennsylvania’s state  survey agency—the Department of Health (DOH)—in 1999 and 2000.  These cases included a mix of complaints and incident reports as well  instances of both physical and sexual abuse.
To identify agencies that might accept reports of abuse, we obtained  several telephone books from each state, including those for large and  small metropolitan areas. We reviewed government and consumer pages  to identify complaint telephone numbers for state survey agencies, other  social service and law enforcement agencies (excluding local police  departments), and other organizations, such as long-term care  ombudsmen, that appeared to be potential places for reporting abuse of  nursing home residents. We called these numbers to verify that the  organization would accept such a complaint. We also made follow-up calls  when we were referred elsewhere.
To determine the extent of law enforcement’s involvement in investigating  abuse allegations, we interviewed MFCU officials in Illinois, Georgia, and  Pennsylvania. We also spoke with representatives from 19 police  departments from these states—including both urban and rural areas—  and four prosecutors’ offices. Some of these departments and prosecutors  were chosen because of their involvement in some of the cases we  reviewed.
To determine the extent to which nursing homes were sanctioned for  violations related to abuse, we identified from the files we reviewed the  nursing homes that had been cited for deficiencies related to the abuse  allegations. We then searched state Web sites to obtain surveys pertaining  to these homes from the time of the abuse allegation to the present and  reviewed the surveys to determine what, if any, sanctions had been  recommended.
To evaluate whether sufficient safeguards exist to protect residents from  abusive individuals, we reviewed federal and state laws regarding criminal  background check requirements for nursing home employees and state  nurse aide registries. We also interviewed state survey agency officials and  obtained relevant documentation.
We tested the accuracy of online nurse aide registry Web sites in each  state we visited to verify that findings of abuse had actually been posted to  the site. Survey officials in the three states provided us with lists of nurse  aides who had been found to be abusive through their administrative  processes. Using those lists, we tested the registries to determine whether  all names and information provided to us were accurately reflected by  each state’s Web site. In addition, we obtained copies of state agencies’  1999 and 2000 quarterly bulletins that were sent to nursing homes and  compared the names of nurse aides with abuse findings listed in these  bulletins to the list originally obtained from the state agency.
In Georgia and Illinois, we reviewed lists of aides notified by the survey  agencies that their registry files would be annotated to reflect a finding of  abuse. From these lists, we determined the number of aides requesting an  administrative hearing and the number of findings actually entered in the  registries. In Pennsylvania, we reviewed a similar list, although it only  included those aides who actually had findings of abuse annotated in the  registry. For all three states, we calculated the average length of time  between when the state notified aides of its plan to annotate the registry to  the date the agency ordered that the findings be posted. Finally, we  interviewed state agency officials about their policies regarding  professionals and other staff who abuse nursing home residents.
section_title: Appendix III: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact
section_title: Staff Acknowledgments
paragraphs: Lynn Filla-Clark, Tiffani Green, Barbara Mulliken, and Christi Turner also  made key contributions to this report.
section_title: Related GAO Products
paragraphs: Nursing Workforce: Recruitment and Retention of Nurses and Nurse  Aides Is a Growing Concern. GAO-01-750T. Washington, D.C.: May 17,  2001.
Nursing Homes: Success of Quality Initiatives Requires Sustained  Federal and State Commitment. GAO/T-HEHS-00-209. Washington, D.C.:  September 28, 2000.
Nursing Homes: Sustained Efforts Are Essential to Realize Potential of  the Quality Initiatives. GAO/HEHS-00-197. Washington, D.C.:  September 28, 2000.
Nursing Home Care: Enhanced HCFA Oversight of State Programs  Would Better Ensure Quality. GAO/HEHS-00-6. Washington, D.C.:  November 4, 1999.
Nursing Homes: HCFA Should Strengthen Its Oversight of State Agencies  to Better Ensure Quality Care. GAO/T-HEHS-00-27. Washington, D.C.:  November 4, 1999.
Nursing Home Oversight: Industry Examples Do Not Demonstrate That  Regulatory Actions Were Unreasonable. GAO/HEHS-99-154R. Washington,  D.C.: August 13, 1999.
Nursing Homes: HCFA Initiatives to Improve Care Are Under Way but  Will Require Continued Commitment. GAO/T-HEHS-99-155. Washington,  D.C.: June 30, 1999.
Nursing Homes: Proposal to Enhance Oversight of Poorly Performing  Homes Has Merit. GAO/HEHS-99-157. Washington, D.C.: June 30, 1999.
Nursing Homes: Complaint Investigation Processes in Maryland.  GAO/T-HEHS-99-146. Washington, D.C.: June 15, 1999.
Nursing Homes: Complaint Investigation Processes Often Inadequate to  Protect Residents. GAO/HEHS-99-80. Washington, D.C.: March 22, 1999.
Nursing Homes: Stronger Complaint and Enforcement Practices Needed  to Better Ensure Adequate Care. GAO/T-HEHS-99-89. Washington, D.C.:  March 22, 1999.
Nursing Homes: Additional Steps Needed to Strengthen Enforcement of  Federal Quality Standards. GAO/HEHS-99-46. Washington, D.C.: March  18, 1999.
California Nursing Homes: Federal and State Oversight Inadequate to  Protect Residents in Homes With Serious Care Violations. GAO/T-HEHS- 98-219. Washington, D.C.: July 28, 1998.
California Nursing Homes: Care Problems Persist Despite Federal and  State Oversight. GAO/HEHS-98-202. Washington, D.C.: July 27, 1998.