Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents
Published: 1999-03-22T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Pursuant to a congressional request, GAO provided information on how states implement the federal requirement that establishes a process for nursing home complaint investigations, focusing on the: (1) effectiveness of state complaint investigation practices as a component of the system to ensure sustained compliance with federal nursing home quality-of-care standards; and (2) Health Care Financing Administration's (HCFA) role in establishing standards and conducting oversight of states' complaint investigation practices and in using information about the results of complaint investigations to ensure compliance with nursing home standards.
section_title: What GAO Found
paragraphs: GAO noted that: (1) federal and states' practices for investigating complaints about care provided in nursing homes are often not as effective as they should be; (2) among many of the 14 states GAO examined, GAO found numerous problems, including: (a) procedures or practices that may limit the filing of complaints; (b) understatement of the seriousness of complaints; and (c) failure to investigate serious complaints promptly; (3) serious complaints alleging that nursing home residents are being harmed can remain uninvestigated for weeks or months; (4) such delays can prolong situations in which residents may be subject to abuse, neglect resulting in serious care problems like malnutrition and dehydration, preventable accidents, and medication errors; (5) although federal funds finance over 70 percent of complaint investigations nationwide, HCFA plays a minimal role in providing states with direction and oversight regarding these investigations; (6) HCFA has left it largely to the states to decide which complaints potentially place residents in immediate jeopardy and must be investigated within the federally mandated 2 workdays; (7) if a serious complaint that could harm residents is not classified as potentially placing residents in immediate jeopardy, there is no formal requirement for prompt investigation; (8) more generally, HCFA's oversight of state agencies that certify federally qualified nursing homes has not focused on complaint investigations; and (9) GAO found that: (a) a HCFA initiative to strengthen federal requirements for complaint investigations was discontinued in 1995, and resulting guidance developed for states' optional use has not been widely adopted; (b) federal reviews of state nursing home inspections are primarily intended to focus on the annual surveys of nursing homes, and very few reviews are conducted of complaint investigations; (c) since 1998, HCFA has required state agencies to develop their own performance measures and quality improvement plans for their complaint investigations, but for several of the 14 states GAO reviewed, such assessments addressed complaint processes superficially or not at all; and (d) HCFA reporting systems for nursing homes' compliance history and complaint investigations do not collect timely, consistent, and complete information.

section_title: Letter
paragraphs: The 1.6 million elderly and disabled residents confined to nursing homes  are a highly vulnerable population.  They are frequently dependent on  extensive assistance in basic activities of daily living like dressing,  grooming, feeding, and using the bathroom, and many require skilled  nursing or rehabilitative care.  The vast majority of nursing homes  participate in Medicare and Medicaid and are expected to receive nearly  $39 billion in federal payments from these programs in 1999.  For these  nursing homes, providing adequate care is a federal mandate backed by  about $210 million in federal funding going to state agencies that inspect  and certify nursing homes’ compliance with quality standards through  annual surveys and complaint investigations.  About $42 million of this  goes to fund investigations of complaints that are lodged by various  sources, including residents, their families, and nursing home employees,  and incidents of potential abuse or neglect that nursing homes report to  states.
In our July 1998 report to you, we found that unacceptable care was a  problem in many California nursing homes, including one in three where  state surveyors identified serious or potentially life-threatening care  problems.  We also reported that federal and state oversight is not  sufficient to guarantee the safety and welfare of nursing home residents.   In a companion report issued last week, we further found that current  federal enforcement efforts cannot ensure sustained compliance with  federal standards for nursing home care.
Concerned that annual surveys alone are inadequate to meet the federal  goal of ensuring nursing home residents’ health and safety, you asked us to  examine how states implement the federal requirement that states  establish a process for nursing home complaint investigations.  Complaint  investigations offer a unique opportunity to identify and correct potential  care problems because they can provide a more timely alert than annual  inspections, and they target specific areas of potential problems identified  by residents, their families, the concerned public, and even the facility  itself.  Specifically, this report assesses the effectiveness of (1) state  complaint investigation practices as a component of the system to ensure  sustained compliance with federal nursing home quality-of-care standards  and (2) the Health Care Financing Administration’s (HCFA) role in  establishing standards and conducting oversight of states’ complaint  investigation practices and in using information about the results of  complaint investigations to ensure compliance with nursing home  standards. We assessed complaint investigation practices in Maryland,  Michigan, and Washington State; reviewed state auditors’ reports from 11 other states; and examined HCFA’s policies and procedures for  overseeing state complaint investigation activities.  Appendix I provides  more details about our scope and methodology.
subsections: section_title: Background
paragraphs: Nearly all nursing homes accept residents with either Medicare or Medicaid  and are projected to receive nearly $39 billion in federal payments from  these programs in 1999.  The federal government, through HCFA, has  responsibility for establishing requirements that nursing homes must meet  to participate in the Medicare and Medicaid programs and ensuring that  these standards are met.  HCFA carries out this responsibility by  contracting with states to monitor nursing homes.  As part of these  contracts, the states agree to comply with regulations and other general  instructions that HCFA prescribes.
The Omnibus Budget Reconciliation Act of 1987 revised the standards for  homes’ participation in these federal programs and defined federal and  state roles for ensuring that nursing homes meet these standards.  In this  regulatory framework, states (1) license nursing homes to do business in  the state, (2) certify to the federal government, by conducting reviews of  nursing homes, that homes are eligible for Medicare and Medicaid  payment, and (3) investigate complaints about care provided in the homes.   As part of their oversight, the states are required to conduct annual surveys  of homes.  While the annual surveys seek to provide a nationally uniform  process to evaluate whether nursing homes meet a comprehensive range of  federal standards, they are often predictable in their timing.  Complaint  investigations can be less predictable than annual surveys and generally  provide a unique opportunity for more frequent state inspections that  assess conditions at the nursing home while focusing on specific concerns  raised by residents, their families, or other observers.  HCFA oversees  states’ performance by monitoring at least 5 percent of states’ surveys and  by requiring states to develop a quality improvement program that  incorporates performance goals and measures in seven required core  performance areas--including complaint investigations--and other optional  state-identified areas.
In addition to the requirement that states establish a complaint  investigation process, HCFA requires that states investigate the most  serious complaints that allege situations immediately jeopardizing the  health or safety of residents within 2 workdays, but leaves the timing,  scope, duration, and conduct of other complaint investigations to the  discretion of the state survey agency.  Thus, states establish their own  priorities and time frames for investigating complaints that they determine  do not represent immediate jeopardy to resident health and safety.  In  addition, states require nursing homes to report and investigate incidents  such as injuries that might signal neglect or abuse.  The state then  determines whether it will further investigate the incident.
When states conduct a complaint investigation, they attempt to  substantiate whether the allegations are valid.  If a complaint is  substantiated, the state may cite the nursing home for violating either  federal or state standards.  In such cases, the state agency will require the  home to develop an approved plan of correction.  The state may choose to  take action under the state’s licensing authority, using applicable state  remedies and sanctions.  If the deficiency relates to federal standards,  information regarding the deficiency is also to be reported to HCFA.   Serious deficiencies require that the home attain compliance within a set  time frame or face enforcement sanctions, such as civil monetary penalties,  by HCFA or the state.
Both federal and state funds finance the costs state agencies incur in  inspecting nursing homes and investigating complaints.  In 1998, the federal  government paid states about $210 million for the nursing home survey and  certification process, including about $42 million (20 percent) for  investigating complaints.  States contributed an additional $17 million for  complaint investigations.  On average, federal funds account for 71 percent  of states’ complaint investigation expenditures.  Table 1 compares these  expenditures for the states visited.  Appendix II includes additional  expenditure information for all states and further discusses the allocation  of federal and state shares. Generally, the federal government finances  states’ complaint investigation costs for nursing homes in the same  proportion that it finances annual and other surveys.
section_title: Some States’ Complaint Practices Are Limited in Protecting Nursing Home Residents
paragraphs: Although investigations of complaints filed against nursing homes can  provide a valuable opportunity for determining whether the health and  safety of  residents are threatened, complaint investigation practices do not  consistently achieve this goal.  Some states use procedures that may  discourage the public from filing complaints.  Furthermore, some states fail  to recognize and promptly respond to complaints that may pose immediate  jeopardy to a resident’s health, safety, or life.  Likewise, some states do not  require that other serious complaints, including those that allege harm to  residents, be investigated for months after the complaint’s receipt.   Additionally, many complaints are not investigated within states’ required  time frames for conducting an investigation.  Consequently, we found  several instances in which, after an extended delay, the complaint  investigators substantiated that residents had been harmed and other cases  in which the state was unable to determine whether the allegations were  true partly because so much time had elapsed since the complaint was  received.
subsections: section_title: Procedures and Practices May Limit the Public’s Filing of Complaints
paragraphs: Because nursing home residents and the public need an effective and  expedient means to seek correction of problems that they perceive  endanger the health and safety of nursing home residents, the process of  filing a complaint should not place an unnecessary burden on the  complainant.  Nevertheless, some states we reviewed have procedures or  practices that may limit the number of complaints.  For example, when a  person calls with a complaint, Maryland and Michigan encourage him or  her to submit the complaint in writing.
Michigan requires that either complainants write a complaint or the  state will provide assistance in writing the complaint.  About 95 percent  of publicly reported complaints were submitted in writing between July  1997 and June 1998.
Maryland’s policy is to accept and act on a complaint by phone even  though callers are encouraged to submit a written complaint.  However,  state officials provided us conflicting information as to whether calls  would be consistently documented and investigated when callers agreed  to submit a written complaint but did not do so.  Over 70 percent of Maryland’s publicly reported complaints that the state investigated were identified as written complaints between July 1997 and June 1998.
In contrast, Washington readily accepts complaints by phone and nearly  all complaints are received by phone.  This contributes to Washington  receiving a considerably higher number of complaints than Michigan or  Maryland.
See table 2 for a comparison of the total number of nursing home  complaints received in a year by these states.
section_title: States Establish Widely Varying Categories for Prioritizing Complaints
paragraphs: When a complaint is received, the state agency ascertains its potential  seriousness.  HCFA requires that complaints that may involve immediate  jeopardy of a resident’s health, safety, or life be investigated by states  within 2 workdays of receipt.  For other complaints, states are permitted  to establish their own categories and time frames for investigation.  States  have established varying time requirements for complaint responses and  varying criteria for prioritizing these complaints, including criteria for  complaints that may involve a significant risk of actual harm to nursing  home residents.  Some states permit relatively long periods of time to pass  between the receipt of all such complaints and their investigation.  For  example, for complaints that may involve significant risk of actual harm to  residents,
Michigan’s statute allows 30 days, but in 1998 Michigan’s operating  practice was to allow 45 days;
Tennessee allows 60 days; and,
Kansas allows 180 days.
Some states have established other priority categories with similar time  frame classifications, but their criteria for determining which complaints to  include in these classifications differ substantially.  Maryland and  Washington both have classification schemes that include categories for  complaints to be investigated within 2, 10, or 45 workdays or at the next on- site investigation.  Similarly, Pennsylvania classifies complaints to be  investigated within 2, 5, 10, or 45 workdays or at the next on-site survey.   Criteria for complaints to be included in the 10-day category for  Washington and Pennsylvania are similar. Washington’s 10-day category  includes complaints alleging significant potential harm to a resident’s  physical and/or mental health or safety.  Similarly, Pennsylvania  characterizes 10-day complaints as those in which residents’ needs,  including medical, nursing, and dietary, are not being met.  Maryland’s 10- day time frame states that complaints in this category are those that appear  to be especially significant, sensitive, or could attract broad public  attention; those forwarded from a government or public official; and those  where the provider has a history of poor performance relative to the  allegations.
section_title: Complaints May Receive an Inappropriately Low Investigation Priority
paragraphs: States sometimes place complaints in an inappropriately low investigation  category, thus postponing a prompt review.  The infrequent use of high- priority levels in some states raises a question as to whether complaints are  being appropriately categorized.  Some states have explicit procedures or  operating practices that result in the downgrading of a complaint’s severity.   We found several instances of complaints that, in our opinion, were  inappropriately placed in a low-priority category.
As shown in table 3, two of the three states we visited seldom placed  complaints in the immediate jeopardy category for the 1-year period we  analyzed.  Maryland did not identify a single complaint as potentially  representing immediate jeopardy.  Michigan did prioritize some complaints  as immediate jeopardy, but they accounted for only 2 percent of total  complaints received.  The Pennsylvania state auditor also noted that the  number of complaints considered immediate jeopardy in that state had  dropped considerably during the first quarter of 1998 in comparison to  earlier years, raising the auditor’s skepticism and concern.
Some states also categorized relatively few complaints in other high- priority categories, such as those that should be investigated within 10  days.  For example, Maryland placed most complaints in its lowest-priority  category–to be investigated at the next on-site survey.  This contrasts with  Washington, which categorized nearly 90 percent of its complaints to be  investigated within either 2 or 10 workdays.  Table 4 compares the use of  similar priority time frames among the states visited.
Several states have explicit procedures or operating practices that place  serious complaints in lower-priority categories.  A Maryland official, for  example, acknowledged reducing the priority of some complaints because  the state recognized that it could not meet shorter time frames because of  insufficient staff.   Similarly, a Michigan official also told us that her office  gives a complaint low priority if the resident is no longer at the nursing  home when the complaint is received--even if the resident died or was  transferred to a hospital or another nursing home.  The state may  investigate these complaints during the home’s next survey or not at all.   Failure to investigate such a complaint in a timely manner may  compromise the health and safety of other residents who may also be  affected by problems cited in the complaint.  We identified several cases in  which a resident had died or been transferred from the nursing home that  were assigned to Michigan’s lower-priority (45-day) category, were  uninvestigated for several months, or had not yet been investigated at the  time of our visit.  For example, a complaint in Michigan alleged in July 1998  that a resident died because the home did not properly manage his insulin  injections or perform blood sugar tests.  Because the resident died, the  state had not investigated the complaint as of January 1999.  We question  why the state agency would not have concerns that this situation might  affect other diabetic residents in the home.
Michigan also delays investigating certain nonimmediate jeopardy  complaints against nursing homes that are undergoing federal enforcement  action.  Officials told us that they adopted this practice to avoid potential  confusion that may result from having two enforcement actions pending  simultaneously.  We believe this practice could unreasonably delay the  investigation of serious complaints at nursing homes already identified as  violating federal standards.
In reviewing complaints from the states visited, we identified several  complaints in two states that raise questions about why they were not  considered as potentially immediate jeopardy.  Examples of these  allegations include the following:
The complaint alleged that a resident was found dead with her head  trapped between the mattress and the side rail of the bed, with her body  lying on the floor.  The state categorized this complaint as one needing  to be investigated within 45 days. The state investigated this complaint  within 13 days and determined that 11 of 24 sampled beds had similar  side rail violations.  Our concern about whether this complaint was  appropriately classified is supported by another HCFA region’s  interpretation of HCFA’s guidance to states.  The Denver region would  have considered this situation to be an immediate jeopardy complaint to  be investigated within 2 workdays, noting that “an unexplained resident  death related to a medical device, side rails, or other restraints  exemplifies a possible immediate jeopardy situation requiring an on-site  investigation within two workdays.”
Another complaint alleged that an alert resident who was placed in a  nursing home for a 20-day rehabilitation stay to recover from hip  surgery was transferred in less than 3 weeks to a hospital because of  what the complainant termed an “unprecedented rapid decline [in the  resident’s condition].”  One of the members of the ambulance crew  transporting the resident to the hospital filed a written report stating  that the resident “had dried . . . blood in his fingernails and on his hands  . . . sores all over his body . . . smelled like feces and  unable to  walk or take care of himself.  Patient is in very poor condition as far as  his hygiene.  I personally feel he was not being properly cared for.”  The  state categorized this complaint as needing an investigation at the next  on-site inspection, took more than 4 months to begin its investigation,  and determined that the nursing home had harmed the resident.
Another complaint alleged that the home’s staff would not send a  resident with maggots in the sores on his feet to the hospital because the  home’s director of nursing did not want the state agency to be notified  by the hospital and investigate the home.  The state categorized this  complaint, received 105 days before our visit, as needing to be  investigated within 45 days, but it had not yet been investigated.
In another instance, the police reported suspected abuse and neglect to  the state survey agency after a resident was brought twice to the  hospital emergency room because of falls.  The resident’s first  hospitalization identified a broken elbow, and the second found a  contusion on the resident’s cheek.  The police did not believe the  nursing home staff’s account of how the resident had sustained these  injuries.  This complaint, filed 13 workdays before our visit, was being  held by the state until the next on-site investigation.
State auditors’ reports identified additional complaints that the auditors  found should have been placed in a higher category.  Examples follow:
Kansas’ auditors said that about 10 percent of 213 complaints reviewed  were classified too low, given their potential seriousness.  Among the  complaints categorized as not requiring an investigation until the earlier  of the home’s next annual survey or within 6 months of receipt was one  alleging that a resident had skin tears, purple lesions, feces and food on  his clothing, broken eyeglasses, and was not being fed regularly.  Another complaint charged that a  nurse’s aide abused several residents.
Pennsylvania’s auditors identified several complaints as categorized too  low, including one filed by a licensed practical nurse recently employed  by the home.  The nurse alleged that there had been at least 12 deaths at  the home over a 2-week period, including  a resident who choked to  death because she had mistakenly been given solid food; a resident who  was sent to the emergency room because her feeding tube had become  dislodged and was entirely within her stomach; and a resident who had  received 10 times the prescribed dosage of a medication.  This nurse’s  complaint was placed in the lowest category, delaying its investigation  until the home’s next annual survey.
section_title: States Frequently Do Not Investigate Complaints Within Required Time Frames
paragraphs: States often do not conduct investigations of complaints within the time  frames they assign, even though some states frequently place complaints in  lower investigation categories to increase the time available to investigate  them.  Some of these complaints, despite alleging serious risk to resident  health and safety, remained uninvestigated for several months after the  deadline for investigation.  These delays may contribute to investigators  being unable to determine whether the allegations are true because, by the  time the investigation starts, evidence needed to establish validity may no  longer be available.
To determine whether states investigate complaints within state-required  time frames, we reviewed state data covering 1 year from July 1997 through  June 1998.  Table 5 shows the percentage of complaints that met the  assigned time frame for investigation.
We asked each state visited to provide copies of all complaints in the  Baltimore, Detroit, and Seattle areas that had not yet been investigated and  that exceeded the assigned time frame.  Baltimore and Detroit each had over 100 such complaints, while Seattle had 40.  From the complaints  provided, we identified those for homes having at least three outstanding  complaints not investigated within the states’ prioritized time frames, and  we summarized the allegations of each complaint.  Many of these  complaints alleged potential resident abuse by staff; resident neglect,  including malnutrition and dehydration; preventable accidents; medication  errors; and understaffing.  See appendix III for this summary.
section_title: Delayed Investigations of Complaints Prolong Harm to Residents
paragraphs: Failure by states to investigate complaints promptly can delay the  identification of serious problems in nursing homes and postpone needed  corrective actions.  Furthermore, delayed investigations can prolong, for  extended periods, situations in which residents are harmed.  Table 6  identifies complaints received in early 1998 in which the state’s complaint  investigation concluded that the resident had been harmed.  In Maryland  and Michigan, a large percentage of such cases was not investigated for  extended periods.
section_title: HCFA’s Complaint Investigation Standards Are Minimal, and Its Oversight of States’ Complaint Practices Is Weak
paragraphs: Although HCFA funds, on average, 71 percent of state agencies’ complaint  investigation costs, HCFA has established minimal standards for  investigating complaints and has conducted little monitoring of states’  complaint practices.  HCFA provides limited guidance to states on  complaints beyond the 2-workday requirement for allegations classified as  posing immediate jeopardy to resident health and safety.  HCFA  established a taskforce in 1993 to develop more stringent federal policies  for complaint investigations, but it was disbanded in 1995, and formal  policies were not revised.  Finally, HCFA’s ability to oversee states’  performance in handling complaints is limited because major monitoring  efforts are focused instead on annual surveys; it primarily relies on states  to develop performance measures for complaint investigations; and it has  inadequate reporting systems for capturing the results of complaint  investigations.
subsections: section_title: Previous HCFA Efforts to Strengthen Federal Standards for Nursing Home Complaint Investigations Were Abandoned
paragraphs: Between 1993 and 1995, a HCFA task force worked to develop formal  complaint guidance for states and a complaint investigation manual to help  state investigators.  The task force activities included consideration of  additional minimum federal priority and time frame classifications,  including requirements that time frames be set for complaints alleging  serious care issues but at levels less than immediate jeopardy.  However,  the formal guidance and the manual were never finalized or released.   HCFA attributes the decision to discontinue this initiative to a shift in  HCFA’s focus toward revising enforcement regulations and its concern that  some states that exceeded the proposed federal standards might weaken  their standards.
Instead of formal guidance, HCFA sent a portion of the task force’s work to  its 10 regional offices as a set of optional protocols.  These were released as  “tools, not rules” for specific situations an investigator may encounter  while conducting an on-site complaint investigation.  These protocols did  not address the prioritization and timeliness aspects of complaint  investigations.  This optional guidance has not been widely used.  Officials  at several HCFA regional offices did not recall receiving these on-site  investigative protocols.  Another HCFA regional office reported that it did  not release the document to states in its area because the document  appeared to be in draft form.  HCFA does not provide additional guidance  to states on ways to manage complaint workloads efficiently, how to  categorize complaints, or when to expand a review beyond the residents  involved with the original complaint.
In contrast, the HCFA regional office in Boston established its own task  force to enhance the protocols.  The region adopted its own guidance for  how state agencies should classify complaints.  This guidance suggests that  “at a minimum, your  agency should have at least three action levels  based on the degree of safety or health hazard alleged: high-level action,  mid-level action, and low-level action.”
Although HCFA had not established a priority and timeliness scheme for  complaints other than those alleging immediate jeopardy to residents, the  form it uses for states to report the results of investigations includes four  priority and timeliness categories.  The form asks states to specify whether  an investigation was conducted within 2, 10, or 45 workdays or at an annual  survey.  It is intended for reporting state agencies’ investigation results for  all types of health care facilities--including home health agencies and  clinical laboratories–as well as nursing homes.  Thus, the form does not  formally establish additional time frames for nursing home investigations.   However, some states have interpreted the categories included on the  HCFA form as suggested priority and timeliness categories and have  modeled their standards after them.  For example, officials in Maryland and  Washington indicated that they adopted their priority categories in part to  conform with the categories on the HCFA form.  Other states, however,  maintain complaint priority levels and time frames that are distinct, and  often less stringent, than those identified on the HCFA form.
section_title: Federal Monitoring of States’ Complaint Practices Is Limited
paragraphs: HCFA’s major efforts to monitor states’ performance in surveying and  certifying nursing homes are largely focused on annual surveys–not on  complaint investigations.  HCFA requires its regional investigators to  replicate or observe a 5-percent sample of state investigators’ nursing home  inspections and requires states to develop performance measures and  quality improvement programs.  However, nearly all of the state nursing  home inspections that HCFA monitors are annual surveys rather than  complaint investigations.  Even though HCFA has begun requiring states to  include complaint investigations as part of their performance measurement  and improvement programs, some states have not yet begun to do so.  For  states that have developed quality improvement programs, some programs  have not identified or focused on concerns that state auditors and we have  found.
subsections: section_title: Few Federal Monitoring Surveys Are Performed for Complaint Investigations
paragraphs: HCFA’s principal method for monitoring state agencies’ performance in  certifying nursing homes is through the statutory requirement that HCFA  staff conduct monitoring surveys of at least 5 percent of the states’ nursing  home investigations.  This process allows HCFA either to repeat a state’s  survey of a nursing home and compare findings or to observe state  investigators while they perform a nursing home survey.  However, these  federal monitoring surveys are largely intended to focus on annual surveys  rather than on complaint investigations, and few federal monitoring  surveys are conducted of complaint investigations.
In 1998, of the 824 federal monitoring surveys that HCFA conducted  nationwide, only 39 were of complaint investigations.  Furthermore, 25 of  the 39 were conducted by HCFA’s Chicago regional office, which oversees 6  states, and 10 were conducted in Illinois.  Therefore, in the remaining 44  states and the District of Columbia, only 14 federal monitoring surveys  focused on complaint investigations. Thus, federal monitoring surveys  provide HCFA with little insight into state agencies’ performance in  conducting nursing home complaint investigations.
As of October 1, 1998, HCFA had revised its requirements for federal  monitoring surveys, allowing its regions to include only a small number of  complaint investigations in each state to meet the requirement that 5  percent of surveys be monitored.  Under this revision, HCFA may assess  only one complaint investigation as part of its quota for most states, while  even in the largest states, HCFA may include no more than four complaint  investigations as part of the 5-percent requirement.  As a result, it is clear  that HCFA intends that federal monitoring surveys principally should be a  method to oversee state agencies’ performance in conducting annual  surveys, resulting in minimal oversight of states’ complaint investigations.
section_title: Initial State Quality Improvement Reports Identify Few Problems With Complaint Practices
paragraphs: HCFA requires each state to evaluate its performance in complaint  investigations beginning in 1998 as part of the State Agency Quality  Improvement Program.  However, our review of the 1998 reports submitted  to HCFA by states that either we visited or had a recent state auditor’s  report indicated that several states had not yet developed performance  measures or improvement plans related to nursing home complaints, and  that the states that had evaluated complaint processes ignored concerns  that we and the state auditors raised.  Furthermore, under the new Quality  Improvement Program, HCFA regional offices appeared to be less directly  involved in evaluating state agencies’ performance in complaint handling  than with previous oversight approaches.
Among the states visited,
Maryland had not developed a Quality Improvement Program or  baseline performance measures for nursing home complaints.
Michigan’s final 1998 quality improvement report noted that staff  turnover had delayed its ability to begin evaluating whether all  complaints were investigated and processed within the time frames but  stressed that the state agency “feels confident that this [performance  standard] will be (and currently is) met.”  This statement conflicts with  our findings that most investigations in Michigan were conducted later  than the 45-day time frame adopted by the state agency.
Although Washington’s quality improvement program includes  performance measures related to training staff in conducting complaint  investigations and properly documenting the results, it did not evaluate  the timeliness of complaint investigations.  As noted above, we found  that Washington categorizes its complaints at a higher priority level than  do Maryland and Michigan and is more timely in investigating them.   Nevertheless, Washington met its time frames in only about 55 percent  of the complaints investigated.
For the states reviewed by state auditors, our review of the quality  improvement reports submitted to HCFA showed that several states had  not yet initiated quality improvement programs while few others identified  concerns regarding complaints.  Examples follow:
New York had not yet established performance standards for nursing  home complaints.
Tennessee reported that it planned to begin implementing new  complaint performance standards in October 1998.
Wisconsin cited the implementation of a new data system as the cause  of its delay in tracking complaints as part of quality improvement efforts  but stressed that “our belief is that we are fine, but we have no data to  support or refute this belief.”
North Carolina’s 1998 quality improvement report acknowledged that the  state agency “has fallen behind significantly on investigating complaints  within 60 days for nursing homes due to  shortage in nursing staff and  the large number of complaints.”  As remedial actions, North Carolina  reported that it intended to reevaluate its hiring practices, increase salaries  to attract and retain qualified staff, improve training, and request that the  state legislature either provide additional funds or repeal the 60-day  statutory requirement.
The relatively new process relies largely on self-measurement of  performance, resulting in less direct involvement by the HCFA regional  offices than previous approaches to evaluating state agencies’  performance.  For example, HCFA regional offices are no longer required  to review state procedures for complaint investigations and other types of  nursing home oversight.  Based on our interviews, some HCFA regional  offices have had very little involvement in developing or monitoring states’  quality improvement plans, even though this involvement is a HCFA  requirement.
section_title: Inadequate Reporting Systems Hamper Effective Federal and State Management of Complaint Investigations
paragraphs: An effective complaint reporting system is important to support both  federal and state efforts to maintain an accurate and complete record of a  nursing home’s federal compliance history as well as to track the state  agencies’ performance in complaint investigations.  Tracking of complaints  is integral to identifying the status of complaint investigations and to  managing complaint workloads to appropriately protect residents’ health.   In particular, a full compliance history is key to several parts of the survey  and certification process, such as HCFA’s enforcement and oversight of  standards, states’ prioritization of complaints, and HCFA’s ability to provide full information to consumers via its Internet page and other sources.  We  found that inadequacies in HCFA’s data system and the linkage between  state and federal systems hinder HCFA’s and states’ ability to adequately  track the status of complaint investigations and for HCFA to maintain a full  nursing home compliance history.  In short, one HCFA official stated that  the complaint system is “not used as a management tool.”
HCFA requires states to develop tracking systems and to submit summary  information about all complaint investigations.  For monitoring purposes,  HCFA maintains a database of nursing home complaint investigation  information.  Although HCFA standards require states to report this  information, the process for collecting it results in inaccurate and  incomplete information.  For example, HCFA collects summary  information for on-site complaint investigations with a form that was  created for recording information about a single complaint.  Some states,  including Maryland and Michigan, use the form for multiple complaints.   Therefore, timeliness, prioritization, and other important tracking  information that relates to multiple complaints is reported as though it  applies to one complaint.  In this situation, states typically record the  highest priority level assigned to any of the individual complaints and are  limited to choosing timeliness dates reflective of only one of the  complaints.  As a result, HCFA is unable to effectively monitor states’  performance on prioritization and timeliness.
In our report on California nursing homes, we determined that the results  of complaint inspections are often cited as state, not federal, deficiencies.   Thus, the results of complaint investigations may not appear in federal  databases.  Furthermore, state officials reported that complaints might  appear to be unsubstantiated in federal databases when the state has  actually substantiated the complaint.  In contrast, Washington and  Michigan report that they record most violations they identify in both  federal and state information systems.  For example, Washington has  developed a crosswalk between its state licensing and federal regulations  to assist providing full information in both federal and state information  systems.
Overall, there is also a time lag on states reporting data to HCFA.   Washington, for example, estimated that its input into the federal data  system was 3 months behind.  HCFA estimated that some states might lag  by as much as 6 months in entering complaint investigation information  into federal management systems.
section_title: Conclusions
paragraphs: Our work in selected states reveals that serious complaints alleging harm  to residents often remain uninvestigated for extended periods.  Such delays  do not provide this vulnerable population the protections intended by the  federally mandated complaint investigation process.  Some practices, such  as Washington’s ready acceptance of phone complaints and its relatively  prompt investigation, as well as the HCFA Boston office’s guidance to  states recommending improved prioritization of complaints, merit  replication.  Despite these positive efforts, we identified frequent systemic  weaknesses in HCFA’s and many states’ practices that can leave nursing  home residents in poor care and unsafe conditions for extended periods.   The combination of inadequate state practices and limited HCFA guidance  and oversight have too often resulted in extensive delays in investigating  serious complaints alleging harmful situations, a lack of careful review of  states’ policies and practices, and incomplete reporting on nursing homes’  compliance history and states’ complaint investigation performance.
section_title: Recommendations
paragraphs: To make complaint investigations a more effective tool for protecting  nursing home residents’ health and safety, we recommend that the HCFA  Administrator revise federal guidance and ensure state agency compliance  through the following actions:
Develop additional standards for the prompt investigation of serious  complaints alleging situations that may harm residents but are  categorized as less than immediate jeopardy.  These standards should  include maximum allowable time frames for investigating serious  complaints and for complaints that may be deferred until the next  scheduled annual survey.  States may continue to set priority levels and  time frames that are more stringent than these federal standards.
Strengthen federal oversight of state complaint investigations, including  monitoring states’ practices regarding priority-setting, on-site  investigation, and timely reporting of serious health and safety  complaints.
Require that the substantiated results of complaint investigations be  included in federal data systems or be accessible by federal officials.
section_title: Agency, State, and Industry Comments and Our Response
paragraphs: We obtained comments on our draft report from HCFA and the three states  we visited.  (See apps. IV through VII for their written comments.)  In  general, HCFA and the states concurred with our recommendations and  highlighted efforts being taken to improve complaint investigations.  They  also suggested clarification on certain findings and technical changes,  which we included in the report where appropriate.
HCFA, in concurring with our recommendations, also immediately  announced several initiatives to address issues we raise.  These include a new interim requirement that states should investigate complaints  alleging actual harm to residents within 10 workdays, and a complaint  improvement project with the intention of developing additional  minimum standards for complaint investigations; increased federal oversight of complaints, including allowing HCFA  regional offices to conduct additional monitoring surveys based upon  complaints and new state agency performance measures relating to  complaints; and improved reporting on complaint information, including a review of the  form states use to report complaint information to HCFA, further  direction to states requiring that complaint findings be included in the  federal as well as state database in a timely manner, and a review of  potential long-term improvements in the federal data system.
Maryland, Michigan, and Washington each highlighted resource limitations  as contributing to the problems we identify.  Specifically, Maryland noted  that in recognition of many of the problems we identify, the state has  recently hired additional staff and plans additional improvements,  including merging its complaint and annual survey investigative staff and  improving the tracking of complaints.  Maryland also commented that the  scope of our work was narrowly focused on complaint investigations and,  as only one component of its broader nursing home oversight efforts,  should not be used to evaluate the state’s entire regulatory process.  While  we concentrated this aspect of our work on complaints, we continue to  believe that, in coordination with annual surveys, complaint investigations  are an essential component of state efforts to protect residents and ensure  that nursing homes provide adequate care.  They afford a unique  opportunity to increase state inspectors’ unexpected presence in homes  and to target specific areas of potential problems identified by residents  and other concerned individuals.
Michigan’s comments noted that prior to the period we examined the state  had experienced a loss of staff and that it has been hiring and training  additional investigators.  Michigan also reiterated its criteria for including  complaints in its highest priority level.  However, we found several cases  that appear to meet these criteria but were not classified as requiring a 24- hour visit.  Michigan also noted that several state practices we highlight  were developed with guidance from the HCFA regional office, including  investigating complaints concurrently with annual surveys and delaying the  investigation of certain complaints regarding nursing homes nearing the  deadline for enforcement actions.  Michigan disputes that its policy or  practice places egregious complaints in a lower priority level.  However, we  remain concerned that state investigators we interviewed reported that  some complaints where residents died or left the nursing home would not  be investigated until the next on-site inspection.  Furthermore, several  cases we reviewed where a resident had died or had been transferred from  the home were assigned to Michigan’s lower (45-day) category, were  uninvestigated for several months, or had not yet been investigated at the  time of our visit.  Michigan indicated that it plans a more thorough review  of its handling of complaints and intends to make recommendations to  address any concerns it identifies by April 1999.
Washington concurred with the importance of an effective complaint  system and stressed attributes of its system, including prioritizing most  complaints at a high level and a highly trained professional staff.   Washington acknowledged that, because of the large volume of complaints  categorized as requiring an investigation within 10 days and the need for  increased resources, the timeliness of complaints within this category  depends on investigators’ determinations of which complaints are the most  serious.
We also provided a copy of the report for review by the American Health  Care Association (AHCA) and the American Association of Homes and  Services for the Aging (AAHSA).  AHCA officials expressed agreement with  the report’s recommendations.  Both AHCA and AAHSA officials noted that  the report summarizes some uninvestigated complaints and that the  allegations had not yet been substantiated or unsubstantiated.  We  acknowledge that many of the complaints summarized reflect allegations  rather than substantiated problems and believe that the report adequately  reflects that many had not yet been investigated at the time of our visit to  determine their validity.  We included these allegations to reflect the  information that a state agency would have as it determines the priority  level to assign complaints and how promptly to investigate them.
We are making copies of this report available to the honorable Nancy-Ann  Min DeParle, the HCFA Administrator; appropriate congressional  committees; and interested parties upon request.
Please contact me or Kathryn G. Allen, Associate Director, at (202) 512- 7114 if you or your staffs have any further questions.  This report was  prepared by Jack Brennan, Mary Ann Curran, C. Robert DeRoy, Gloria  Eldridge, and Chick Walter under the direction of John Dicken.
section_title: Scope and Methodology
paragraphs: To develop this report, we examined state nursing home complaint  investigation practices in Maryland, Michigan, and Washington. We  selected these three states as case studies because they are geographically  diverse and have different approaches to investigating complaints.  For  each state, we reviewed laws, regulations, and policies and interviewed  leading state agency officials and complaint investigators.
In each of the three states visited, we interviewed state officials and complaint investigators and obtained  documentation of each state’s complaint investigation procedures and  practices, analyzed computerized data on all complaints the states had received  from July 1997 through June 1998, obtained and reviewed the files of complaints that each state received  and investigated in early 1998, and obtained and reviewed the files of complaints that the states had not yet  investigated at the time of our visits in late 1998 and early 1999.
For each of the 14 states included in our work, we reviewed the state  agency quality improvement program report that was submitted to HCFA at  the end of 1998.  In addition, we interviewed HCFA officials, including  representatives of each of HCFA’s 10 regions, regarding federal guidance to  and oversight of state agencies.  We also obtained from HCFA data on  federal and state expenditures on nursing home complaint investigations  for all states.
State Auditors’ Reports We also reviewed reports from 11 states whose state auditor (or similar  organization such as the Office of Inspector General) had performed  reviews of the state’s long-term-care activities and whose investigation  reports were issued between December 1995 and April 1998.  Each of these  reports addressed some aspect of the state’s nursing home complaint  process.  The 11 states were Iowa, Kansas, Kentucky, Louisiana, New York,  North Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Wisconsin.
subsections: section_title: Data Analysis
paragraphs: Each of the three states we visited provided us with electronic databases  on complaints received in 1997 and 1998.  These data include information  such as the number of complaints received and investigated, the priority  category assigned, and when the complaint was received and investigated.
Recognizing that there may be a lag in recording information regarding  complaints, we excluded data on complaints received after June 30, 1998,  and report data for the 1-year period from July 1, 1997, to June 30, 1998.  We  also only included complaints related to federally certified nursing homes.   For data on timeliness, we report data only for state-investigated  complaints, excluding any complaints that were either not investigated at  all or were investigated only by another entity, such as the ombudsman,  local law enforcement agencies, or the nursing home itself.  We excluded  any complaint that either did not have all dates in the database or would  have resulted in a negative number of days between receipt and  investigation of the complaint.
section_title: Complaints Received in Early 1998
paragraphs: We asked each state to give us access to its file of complaints received in  early 1998.
In Maryland, we reviewed 102 complaints that the state received  between January 1, 1998, and February 27, 1998.
In Michigan, we reviewed the 59 complaints the state received between  January 1, 1998, and January 15, 1998.
In Washington, we reviewed the 133 complaints received between  January 1, 1998 and January 7, 1998.
We reviewed the nature of complaints received, the priority levels assigned,  whether the complaint resulted in an investigation and the timeliness of the  investigation, and whether an investigation substantiated the allegations  and resulted in any federal or state deficiencies.  Table 6 summarizes all  complaints received in the three states during these periods in early 1998  that resulted in the state identifying a violation of federal standards and  that were of a severity level that actual harm to residents was found.
section_title: Uninvestigated Complaints in Baltimore, Detroit, and Seattle
paragraphs: Each of the three states visited had a backlog of uninvestigated complaints  and we asked each state to give us the files for these complaints.  For the  Baltimore, Detroit, and Seattle metropolitan areas, the tables in appendix  III summarize the uninvestigated complaints that (1) had already exceeded  the state’s assigned time frame at the time of our visit and (2) were lodged against nursing homes with at least three such pending complaints.  In  Baltimore, these include only complaints that had not yet been assigned to  an investigator; they do not include additional uninvestigated complaints  assigned to an investigator.  For Detroit and Seattle, appendix III includes  any uninvestigated complaint (whether unassigned or uninvestigated)  meeting these criteria.
section_title: HCFA Oversight Efforts
paragraphs: We contacted each of HCFA’s 10 regional offices and requested the number of federal monitoring surveys the region conducted during  1996, 1997, and 1998, and how many of these represented reviews of  complaint investigations;
State Agency Quality Improvement Program reports for the 14 states we  or state auditors had reviewed and that the states had submitted to  HCFA at the end of 1998; and any additional guidance or oversight methods for complaint  investigations that the regional office had developed.
section_title: Complaint Investigation Expenditure Data
paragraphs: To estimate 1998 expenditures by state for nursing home complaints, we  collaborated with HCFA to develop a method to distinguish expenditures  associated with (1) nursing homes for the elderly and physically disabled  from other types of facilities, including those serving individuals with  mental health disabilities, and (2) complaint investigations from annual  surveys and other state certification and licensing activities.  These  estimates are based in large part on survey hours for complaint  investigations compared with all survey hours as reported to HCFA by the  states.  Expenditure data are from 1998, except in some states where the  information was not yet available for the fourth quarter of the federal fiscal  year.  In addition, 1997 survey hours were used because 1998 data were  not complete at the time of the analysis.  In addition to Medicare and  Medicaid expenditures, the expenditures include state licensing activities  of federally certified nursing homes in all states where federal certification  and state licensing activities are conducted as part of the same process.
Appendix II further discusses, by state, how these costs are allocated  between federal and state governments and reports expenditures for all  types of surveys; complaint investigations; federal and state shares;  complaint expenditures per visit, nursing home, and bed; and the number  of complaint visits per home and per thousand beds.
We conducted our work between October 1998 and March 1999 in  accordance with generally accepted government auditing standards.
section_title: Nursing Home Complaint Investigation Expenditures
paragraphs: In fiscal year 1998, about $300 million was spent by the federal and state  governments to certify and perform state licensing functions of federally  certified nursing homes, with the federal government contributing about 70  percent ($210 million) of these costs.  The federal government pays the  states for costs associated with certifying that nursing homes meet  Medicare’s standards and pays for 75 percent of the costs associated with  certifying that they meet Medicaid’s standards.  States contribute the  remaining share of the costs associated with Medicaid standards, and they  also pay additional costs related to ensuring that nursing homes meet state- established licensing standards.  States generally conduct these licensing  reviews concurrently with their federal certification activities.  HCFA and  each of the states agree on the share of total costs that corresponds to the  effort spent for state licensure during federal certification.  Most nursing  homes (77 percent) are dually certified for both the Medicare and Medicaid  programs.  The expenditures for these homes are split evenly between the  Medicare and Medicaid programs after deducting the portion to be paid by  the state for its licensing activities.
Nearly $60 million, about 20 percent of total nursing home certification and  licensing expenditures, was spent on complaint investigations.  The federal  government contributed about $42 million, or 71 percent, of the costs  associated with investigating complaints.  The proportion of federal and  state expenditures for annual surveys is similar to that for complaints.   Table II.1 shows the total expenditures by state for the federal certification  and state licensing activities for federally certified nursing homes, the  percentage dedicated to complaint investigations, and federal and state  shares of complaint investigations.
The total expenditures include those for Medicare, Medicaid, and state  licensing activities related to federally certified nursing homes.
The amount spent on complaint investigations was estimated by HCFA and  GAO on the basis of the staff time dedicated to complaints.  The  distribution of federal and state shares varied depending on the share of costs that are attributed to state licensing activities and not  shared by the federal government and the proportion of nursing homes that are Medicare certified, Medicaid  certified, and dually certified for Medicare and Medicaid.
Table II.2 presents complaint investigation expenditures, by state, per on- site investigation, nursing home, and federally certified bed, as well as the  number of complaint investigations per home and per 1,000 beds. (continued)
Nursing home complaint expenditures as a percentage of total expenditures (continued)
Nursing home complaint expenditures as a percentage of total expenditures (continued)
Number of complaint visits per 1,000 beds (continued)
section_title: Summary of Unassigned or Uninvestigated Complaints for the Baltimore, Detroit, and Seattle Metropolitan Areas
subsections: section_title: Baltimore
paragraphs: As of December 14, 1998, there were 101 complaints, received between  January and November 1998, filed against 56 nursing homes in the  Baltimore metropolitan area that had not yet been assigned to an  investigator and that also exceeded Maryland’s investigation timeframes.   The following table summarizes the complaints filed against 12 of these  homes that received three or more such complaints.
Table III.1:  Unassigned Complaints for Nursing Homes in Baltimore With Three or More Such Complaints Summary of allegation(s)
A nurse allowed a respite resident with Alzheimer’s disease to leave the nursing home; family  disputes nurse’s belief that resident was aware of where she was going.  Family requested that  a physician examine resident; however, a nurse examined her instead. Family was also  unaware that home ordered a psychiatric consultation resulting in medication being ordered,  and disputes home’s claim that family was notified.  Family alleges that the resident's medical  records were falsified.
Blind resident does not get needed assistance—such as identifying food provided her, or help  leaving room.
Understaffing, with 64 residents and only 3 to 4 aides.
Understaffing, with 64 residents and only 3 to 4 aides.
Nurse aide struck resident in the chest.
Nursing home and complainant agreed on a time to discharge a 91-year-old resident with  dementia.  Home discharged the resident earlier, and the new nursing home was unprepared  for resident's arrival.  The family was not notified that resident was transferred early and arrived  to help the resident move to find that resident had already been transferred.
Visitor overheard a nurse aide verbally abusing a resident.
Resident alleged that a nurse aide verbally abused her. Aide was suspended pending  investigation. (continued)
Summary of allegation(s)
No hot water for several weeks or months at a time, so resident was not bathed or cleaned  properly.  Inadequate supply of diapers, towels, washcloths, resulting in resident sitting in urine  for extended periods of time.  Lack of staff, resulting in resident not being adequately hydrated,  fed, turned, or kept clean.  Unskilled nursing assistants attended resident.  Charting of intake  and bowel movements was false.  It was charted that resident had a bowel movement, but  resident was severely impacted and needed immediate medical intervention.  Scales and  thermometers did not always function properly.  Fluids were not routinely offered and time was  not taken to make sure that the resident drank enough.  If feeding took too long, the staff would  not wait to ensure that the resident ate enough.  Resident was admitted to the hospital 4 times  in 10 years with dehydration and a urinary tract infection.
Complainant visited resident on a Saturday and Sunday and found resident dirty with dried  feces and no sheet on the bed.  On Sunday, resident was wet.  When complainant asked aide  for a towel, wash cloth, and soap, she was given paper towels and told the home did not have  any soap.  The complainant asked the home's staff for a water pitcher and was told that the  home does not use water pitchers, only cups in the utility closet.  Complainant could not find a  cup in the closet and the aide told her that none was available.  Call lights unanswered on both  days.
Staff does not stay to ensure that resident takes medications.  Resident in same clothes for 3  days.  Resident received no medications for 10 days; family not notified.
Resident sent to emergency room with diagnosis of possible infection.  Hospital staff found  resident’s intravenous line dirty and clogged because nursing home staff did not flush the line.
Physical, verbal, and emotional abuse of a resident by nursing home staff and resident’s  physician who is part of the home’s staff.
Resident feeds self with a special spoon but is dependent in all other activities of daily living.   On two shifts, aides refused to help the resident out of bed.  Resident’s supper tray was  delivered but the resident was not provided any assistance to eat.  Aide grabbed the resident’s  shoulder after the resident told the aide that her shoulder hurt.  Pressure sores have worsened  since admission to the home.
Resident developed contractures because the home did not provide range-of-motion exercises  as ordered.
Management’s treatment of employees is affecting care.  Promised pay raise never came.
Nursing home staff did not answer call lights. A resident with infection was not given an  antibiotic as ordered.
Nursing home offered no explanation to family for resident’s leg fracture, so the family moved  resident to another home.  Home told state survey agency that it would investigate; however,  no indication as of December 1998 that agency had received the home’s report.
Understaffing: unit has 1 nurse and 7 aides for 52 residents, including 2 with stage III and IV  pressure sores, 13 with stomach feeding tubes, and 13 requiring injections. The nurse is  unable to complete what she needs to do. (continued)
Summary of allegation(s)
Understaffing: only 1 nurse on the 7 a.m. to 3 p.m. shift with 8 aides for 52 residents, including  2 residents requiring treatment, others requiring injections, and 13 stomach tube feedings.
Resident alleged caregiver at the home bruised her right forearm and later threw the resident  onto the bed. The hospital emergency room report indicated that the arm had soft tissue injury.   Pictures of the resident show a “badly bruised arm.”
Complainant not satisfied with the home’s investigation of an incident report that a resident had  fallen about 13 times in 4 months.  The last fall resulted in laceration of the resident’s forehead.
Understaffing—call lights not answered in a timely manner; residents not bathed as scheduled;  and residents not turned and changed as needed.  One aide for 15 residents requiring total  care on 7 a.m. to 3 p.m., and 3 p.m. to 11 p.m. shift.
Discharge planning at home is not done appropriately, for example, a hospital-style bed was  not ordered until resident’s Friday discharge, so was not delivered until Monday.  Residents not  given choices of home health agencies or equipment companies.  Residents' medical records  do not indicate discharge planning. Discharge planning form usually is not completed and  given to families to inform them of arrangements.
Family requested restraints for resident because of falls, but home refused.
Understaffing.  Resident lost 22 lbs. in 5 months.  Resident's feet have sores and are  bandaged, but not always changed as ordered.  Sores are beginning to smell.  Complainant  found resident's face swollen, but staff was unable to explain what happened.
Resident told therapist that an aide verbally abused her.  Home was to investigate and report to  the state survey agency.  However, as of December 1998, the state did not have the home’s  investigative report.
Aide smokes in the home and around residents.  Same aide mishandled residents—threw  them into bed and used nasty language. Home was to investigate and report to the state;  however, as of December 1998, there was no indication home had done an investigation.
After contacting home about its investigation of physical abuse of a resident, ombudsman was  uncomfortable with the home’s inconsistent responses.
Resident had discoloration of chest that family believed was bruise caused by physical abuse.   Home to investigate and report to the state; but, as of December 1998, there was no indication  home had investigated.
Understaffing, resulting in the dining room being closed for 2 days.  During this time, there were  only 3 aides for 70 to 80 residents.
Complainant saw a nursing home employee shaking resident.  Employee terminated by home.
Hygiene inadequate--resident was not bathed, teeth not cleaned, and hair not combed.   Weight loss from April to June, was 134 lbs. to 120 lbs.  Home said resident spit food out and  that home had recommended a stomach tube. (continued)
Summary of allegation(s)
Resident was not provided food from Monday night until Wednesday at 3:00 p.m. Resident was  sent to hospital after complainant insisted. At hospital, the resident was found to have infected  sacral decubitus ulcer, was dehydrated, and had urinary tract infection. Nursing home staff  said they had not sent resident to the hospital because resident was dying.
New aide tried to transfer resident without another aide to assist, although the care plan called  for two people for transfers. Aide said she could not get timely help, so attempted to do it by  herself. Five days later, resident was found to have two fractured legs.  Home wrote incident  report, but did not interview new aide as required until ombudsman opened a case as a result  of family's concern about home misrepresenting circumstances of resident's fall.  Family called  doctor, who ordered X-rays.  It is unclear whether home also called doctor simultaneously, or  earlier—as home reported.
Resident was blind, intelligent, and sociable.  Complainant has found resident alone, begging  for help, screaming “ . . .help, where am I?”, or “please, someone get me a drink of water,” or  “please take me to the bathroom."  No one responded or reassured resident that she was not  alone.  On one occasion, resident was found still in bed at 3:00 p.m.—urine-soaked, hungry,  and thirsty.  She had no breakfast or lunch.  Nurse said home was short of staff that day.
Aide spoke to resident in a very poor manner--told resident to “shut up” and if she kept ringing  her call bell, she would be the last one to be answered.  Administrator spoke with other staff  who noted that the aide’s attitude was poor toward residents and some staff had seen him in  altercations with residents.  They indicated that the aide appeared to be “fired/wired up.”
Aide was verbally abusive to resident in presence of the family.
When admitted to home from hospital in July, resident could bathe, walk, and feed self.  After 1  month in home, these activities stopped. Family met with home's staff about three times on  quality-of-care issues, but problems persisted.  Resident readmitted to hospital three times in  her 2-month stay--a result of poor care at the home.  Resident had series of falls.  Home said  no injuries resulted, but the resident suffers pain to the touch of bruised areas.  As organ  transplant recipient, needs sufficient fluids, but had not been getting, as evidenced by hospital  diagnosis of dehydration.  Hospital staff questioned whether resident had been receiving  medications as prescribed.   Staffing ratio at home was sometimes 1 aide to 20 residents on  evening shift, so family had to bathe resident and put to bed.  Resident placed on a toileting  program by the home, but family has found her with a saturated diaper on, indicating resident  was not being toileted on a regular basis.
Caregiver handled resident roughly causing her to “suffer all night.”  The resident was in a  rehabilitation unit receiving treatment for a fractured hip.  Resident’s roommate witnessed the  incident.
Aide was verbally abusive: called resident a “witch” and threatened to throw water on the floor  and make her walk in it, hoping she would slip; said he would put her out of the unit because he  was the boss on the floor; put a pillowcase over his head to try to disguise himself as resident’s  doctor; threatened to unplug another resident’s call bell.  Police were notified.
Resident had two bruises on her arms.  Ombudsman found no documentation of the bruises in  records. (continued)
Summary of allegation(s)
A resident diagnosed with schizophrenia alleged someone in the home was sexually abusing  her.  Complaint investigated by nursing home, but no formal report generated.
Resident alleged an aide placed a pillow over the resident’s face; resident removed pillow, and  aide did it again.
Resident said a nurse aide yanked the bed covers off and grabbed resident’s hand real hard.   Ombudsman noted resident’s hand had a discolored area.
This column represents the number of days from the date the complaint was received to the day GAO  visited the state agency.
section_title: Detroit
paragraphs: As of January 11, 1999, there were 129 complaints, received between  February and November 1998, filed against 62 nursing homes in the Detroit  metropolitan area that had not been investigated and that exceeded the  state’s 45-day investigation time frame.  The following table summarizes the  complaints filed against 17 of these homes that received three or more such  complaints.
Table III.2:  Uninvestigated Complaints for Nursing Homes in Detroit With Three or More Such Complaints Summary of allegation(s)
The nursing home changed its billing formula resulting in a large increase in fees.
The air conditioning does not work properly in one of the wings of the home.
Questionable infection control practices.  Two roommates died within days of each other of  complications of infections.  One roommate was admitted to the home with gangrene between two  toes and an ulcer on her foot, but with no oozing or infection.  Despite being diabetic, which  required close monitoring of her feet, the home did not change the dressings as her physician  ordered.  The resident’s foot began to ooze and became swollen.  A culture was taken and the  resident was moved to another room without explanation.  Twenty-five days after being admitted to  the nursing home, she was returned to the hospital where she died 6 days later.   The resident’s  roommate, who entered the home 11 days after the resident, was a diabetic with open wounds on  her feet and legs when she was admitted.  Twelve days after being admitted, the roommate had  an elevated temperature.  Despite her family’s request to have her hospitalized, her doctor  prescribed liquid Tylenol.  That same day, she experienced breathing problems, was given  antibiotics for an infection, and died.
Resident was not repositioned timely, developed pressure sores, and was neglected, resulting in  dehydration requiring hospitalization.
Resident’s condition declined visibly in a short period of time resulting in her becoming lethargic,  weak, and listless.  The complainant suspected dehydration even though she was taken to the  hospital and not treated for dehydration.  Later that week, the home advised the complainant that  the resident had “perked up” and that she would have dressings applied to her feet because of  skin breakdowns.   During a 4-hour visit 2 days later, the complainant contends that staff did not  reposition the resident during this 4-hour period and that the dressings promised earlier had not  been applied.           (continued)
Summary of allegation(s)
Complaint discussed treatment of several different residents over the past several years.  One  resident was dropped on the floor during the middle of the night, suffered knee damage, and was  placed back in bed.  She moaned with severe pain until the day shift nurse found her at 7:00 a.m.  She was sent to the hospital where her knee, although severely damaged, could only be  bandaged.  She died days later.  A second resident received the wrong medication that burned  her mouth, throat, and lower regions causing discomfort for many weeks.  She was later dropped  while being weighed.  A third resident entered the home with no visible skin problems but  developed bedsores that led to the amputation of a limb.
Resident’s feeding tube was running and vomit was evident in her mouth and on her hands and  face.  She was found lying in a urine-soaked sheet, and a pressure sore was also urine soaked.   She also had skin tears, but no wound care was performed.  On the day she was admitted, she  received no insulin as scheduled.  The staff reportedly said that there was no insulin in the nursing  home at that time.
The home failed to assess a resident’s injury in a timely manner.  The resident fell at 12:30 p.m.  suffering a broken left hip, but was not transferred to the hospital until the next day.
A resident sustained a fracture of unknown origin to the right hip.  Neglect is alleged.
A resident sustained a fracture of her wrist while taking a shower without supervision.
Family member found a portable X-ray company taking X-rays of resident without an explanation.   The floor nurse said the resident’s knee was swelling.  X-rays revealed a fracture in the knee.   Family questions if resident was properly restrained.  The hospital physician felt the resident was  either dropped or fell down.  The home staff stated they thought the resident might have bumped  the side rail. The family also felt the resident was not receiving required assistance with eating.
During lunchtime an employee of the nursing home slapped a resident who needs assistance with  eating.
A resident was not adequately groomed (soiled clothing), did not receive services ordered by a  physician, was harmfully neglected, and suffered a preventable injury.
Resident fell sometime during the evening or the early morning of the next day.  The facility put her  back in bed without ordering X-rays, even though she complained of pain in her leg.  X-rays were  not taken for 3 days and then were taken only upon the family’s insistence.  The resident was  transferred to the hospital where it was determined that she had a shattered hip.
A resident fell from her bed and suffered injuries including a skin tear on her hand and an abrasion  on her left temple.  X-rays also revealed a fracture to her left hip.
Complainant alleged a series of problems with the care provided to her father: he had no access  to water despite being diabetic and was often very thirsty; he frequently slipped down in his  cardiac chair but was not offered a wheelchair because the home did not have one that would fit  him; the home failed to provide an assessment of the resident’s breast for breast cancer; his  oxygen machine was broken but complainant suspects that the home nevertheless bills Medicare  for oxygen; resident was advised that his family should come and help to feed him; the resident’s  belongings were missing and he was wearing the clothes of other residents; complainant was told  by staff that the laundry in the home is done infrequently.     (continued)
Summary of allegation(s)
During a 16-month period, the resident–who is unable to turn in bed, speak, or move her right  side–suffered pneumonia, numerous bruises, cracked ribs, a broken hip, a broken shoulder, and a  broken leg.
A resident was brought into the hospital and was not breathing, was severely dehydrated, and had  acute rib fractures and pneumonia.
A resident signed himself out of the home and did not return.
The resident had an untreated pressure sore. The complainant indicated that the staff intentionally  hid the resident’s condition from her for possibly up to one year.
Resident ran a temperature of 100+ degrees for three days without the home contacting the  family.  The resident died from bronchial pneumonia and a closed-head injury.
Nursing staff failed to provide the resident with a breakfast tray.  When the resident asked the  nursing assistant for the tray, the nursing assistant responded “because of your attitude, no one  wants to give it to you.  Do it yourself.”
The home schedules only one aide per floor on the midnight shift.  The home reuses the feeding  tube bags between the residents.  One resident was found to have maggots in the sores on his  feet, but the home would not send him to the hospital because it was afraid the hospital would call  the state.  The Director of Nursing specifically told the staff that the resident was not to go  anywhere “because the state would be called in to investigate and we do not need that right now.”
Resident sustained an injury (fracture of the femur) of unknown origin.
Resident sustained an injury (femoral neck fracture) of unknown origin.
Resident had a hematoma over her left eye, with bruising, as well as a black left eye.  The cause  of the injuries is unknown.
Resident sustained a fracture (left ankle and lower leg) of unknown origin.
Home was understaffed; a resident was found sitting in the dining room with wet pants; resident  found in a gown with no underwear; resident’s clothing missing; resident not helped to bathroom in  a timely manner; no therapeutic activities for residents; meals are inadequate; a dog is allowed to  roam through the nursing home; offensive odors in the home; resident has been injured as a result  of falls.
The resident was not allowed to take a leave of absence from the home; her privacy was not  protected; she had a difficult time getting her personal expense money from the administration.
The resident fell out of a chair and was sent to the hospital where she received six stitches in the  back of her head.  This was the fourth time she had fallen.  One of the falls resulted in permanent  loss of vision in her right eye.  The family also alleges that they have been denied access to her  clinical records. (continued)
Summary of allegation(s)
When resident returned to the home following amputation of part of his leg, the home did not take  necessary precautions to ensure that the leg did not become infected.  It became infected and  more of the leg had to be subsequently amputated.  He was also handled roughly, over- medicated, and his feeding tube was not kept clean.
Although the resident could not get out of bed without assistance, the home informed the family  that he had to be taken to the hospital emergency room because he had gotten out of bed and  fallen.  When the family saw him, his arm was completely black and blue.  He was also constantly  overmedicated.
The resident was in the home for three months recovering from a stroke.  Complainant alleges  that the resident was left in soiled clothing for hours and was prescribed a mixture of medication  that caused internal bleeding that led to a blood transfusion.  The nursing home advised the  resident on numerous occasions that insurance would cover all her costs and convinced her to  remain in the home for the entire period of Medicare coverage.  After leaving the home, she  received a bill for $7,000, which a credit agency is attempting to collect from her son.
The resident was not properly groomed; food was observed in the heaters; staff did not answer  call bells; staff harassed the resident and his family if they complained about care.
Resident developed pressure sores on both feet and had to have part of one leg amputated due to  improper care of the sores.
The home was short of staff and was falsifying the books.
Staff would not respond to the resident’s buzzer; resident was often found sitting in urine and  feces; a week before he died, he complained of an upset stomach and was vomiting, but staff told  the family there was a virus going around and there was nothing to worry about; family was not  informed of a change in his condition.
Resident was not washed or shaved; his teeth were not brushed and his fingernails were dirty; call  lights went unanswered.
The certified nursing assistants were not qualified to care for residents; staff failed to follow the  care plan that requires two people to move this resident; the resident was left alone in the  bathroom, fell down, struck her head, and suffered cracked ribs and various cuts and bruises.
Several residents fell out of bed one evening because the side rails were not put up; food was  served cold and there was no staff person to help residents eat; the home was very short staffed  and on several nights the complainant was the only nonresident adult in the wing; the resident’s  roommate was choking but no one responded when the complainant pulled the call light; during a  shift change, all the nursing staff was gathered around the nursing station calling in lotto tickets.     (continued)
Summary of allegation(s)
A resident made the following allegations: her telephone was taken away; she did not receive  adequate whirlpool baths ordered by her doctor; she did not receive two baths weekly; her food  was cold and unpalatable; she was not allowed to attend the church of her choice; her discharge  planning was inadequate.
The resident had injuries (bruises and swelling) of unknown origin.  The home provided conflicting  reports as to what may have happened.
The food was not palatable; the home was short staffed; physical therapy provided was very  limited; money was stolen from the night stand; beds did not raise up and down and the  mattresses were very thin.
The resident had bed sores on his heels; he was refused readmission to the home following a  hospital stay; he was not properly groomed (bathed and shaved); dirty bed linens were not  changed; he was not turned; physicians did not visit residents but instead took the word of the  nurses concerning residents’ condition; resident was not timely transferred to the hospital for  treatment, resulting in his death.
A nurse verbally abused the resident.
Staff failed to assess and monitor a resident who was later sent to the hospital for treatment of a  seizure; they did not take proper precautions for pressure sores; they did not treat the resident  with dignity and respect because they forced him to wear diapers.
The home did not check the blood sugar level of a diabetic resident for three days following his  admission.  On the third day he received two units of insulin when he should have received 100  units.  When brought to the attention of the nurse, she said they were not supposed to check his  blood sugar.  The resident’s wife insisted that the doctor be called, and it was determined that the  resident’s blood sugar was more than six times the normal amount.  On the physician’s order, the  home gave him potassium pills to normalize his sugar level, but his heart rate went so high that he  was taken to the hospital, where he died.
Nursing home staff would not permit the resident to leave the home to visit with his family.
Resident fell out of bed and suffered a cut on her head.  Staff bandaged the cut but because she  had no other marks on her body and could move her arms and legs, X-rays were not taken.  Three  days later she was taken to the emergency room with elevated heart rate, blood pressure, and  sugar level.  The doctor in the emergency room ordered an X-ray after noticing that she cried and  reached for her hip when he tried to turn her.  The X-ray confirmed a hip fracture, necessitating hip  surgery.  The complaint also alleges that the resident previously had experienced dehydration and  a urinary tract infection, had two hearing aids and her dentures lost in the home, and was  discovered wearing another resident’s dentures, which resulted in a sore mouth and an inability to  eat.
A resident walked out of the home and was found a block away by a passerby. He had fallen and  suffered a swollen eye, a bruised hand, and a knee abrasion.
An employee was verbally abusive to a resident.
A resident developed a cut on his foot that became infected.  It was left unchecked and spread into  the bone.  The heel had to be amputated.   (continued)
Summary of allegation(s)
The resident had a condition that, if vomiting takes place, dictates that the resident should be  taken immediately to the emergency room.  Although the resident was suffering spells of vomiting,  the nursing home failed to send her to the hospital until she was found unconscious.  Following  surgery, she improved, but died about a month later.  Although peritonitis was listed as the cause  of death, a doctor at the hospital told family members that “if she hadn’t been so dehydrated and  malnourished, she would have been better able to fight off the infection.”
An employee slapped a resident.
The resident had bruises on her chin, her stomach, and her arms and legs; the home did not notify  family when resident was hurt or sick; she suffered a head injury of unknown origin; the family had  to request that she be hospitalized after she was ill for several weeks; she was so over-medicated  that the doctor was unable to perform needed gall bladder surgery; she suffered a stroke but was  not sent to the hospital until the family observed the problem and insisted on hospitalization.
The home failed to provide proper dental care.  The dental progress notes were inconsistent and  of dubious accuracy.  Despite the home’s assurance to the complainant that its dentist was  capable of providing care, the resident had to visit an oral surgeon to resolve the problem that had  lasted for 15 months.
The resident was found on the floor bleeding from an injury to her head that required 17 stitches.  In addition to the head injury, the resident had bruises on her face by her mouth and under her ear  and her eyes were black and blue. The complainant feels she did not get a satisfactory answer  from the home about the reason for the injury.
This complaint included 28 separate allegations about the care provided to 17 residents. The  allegations include: the administrator would not order needed equipment (such as recliners and  geri-chairs) which forced the residents to stay in their beds; 90 percent of the home’s beds are old  and faulty (big gaps in the side rails); a resident got her head caught in the side rails, was sent to  the hospital, and later died; side rail pads are not put on the beds; the nurses are not passing the  medications; the administrator told staff to call EMS (the community emergency medical service)  instead of 911 when a resident was nonresponsive, possibly to save money; one resident was  gritting her teeth in the dining room and the director of nurses shoved her and her chair out of the  dining room because she couldn’t stand the sound; a resident was sent to the hospital due to  malnutrition and dehydration and died two weeks later; a resident who entered the home with both  legs is now a bilateral amputee because he developed pressure sores when staff failed to turn and  reposition him or provide heel protection or foot elevation; a resident frequently complained of leg  pains but his complaints were not addressed. It was later determined that he had deep vein  thrombosis; a resident was frequently sleeping but no assessment or lab tests were performed to  determine the problem; residents are restrained for convenience; as a result of understaffing,  residents are not cleaned, changed, or provided oral care; a resident was admitted with no  pressure sores, but developed sores on her heels and legs, became septic, and died; a resident  with very bad teeth and gums has received no dental care; residents complain that their food trays  are removed before they are finished eating.   (continued)
Summary of allegation(s)
The complainant alleges that this home does not care for its residents.  His father, a cancer  patient, has a radiation machine in his room.  Although this machine generates a great deal of  heat, the thermostat in his father’s room has not been adjusted accordingly and the room is very  hot.  The complainant also indicated that the home cannot accommodate its residents and make  them comfortable as it would have people believe.  The home is not clean and no one seems to  care.  Complaints are made to the home’s staff, but nothing improves.
Staff told complainant that her husband had fallen and that the fall was likely due to his  medication.  When complainant went to the resident’s room, she found that he was shaking, hot,  gasping for air, that his respirations were only 30-38, and that his hands were blue.  Complainant  indicates that the physician assistant had been in her husband’s room only two minutes earlier  and had only ordered a chest X-ray.  The resident was taken to the emergency room where it was  determined that he had a temperature of 103 degrees and was placed on life support.  The  emergency room doctor determined the resident had pneumonia.
The resident receives cold showers and once went for two weeks without a shower; she lays in  urine and feces; staff lost her address book and she cannot contact any of her friends; she has  been denied seeing a doctor to explain her pain; no one helps her with her meals; the facility is  short staffed.
A nurse aide, thought to be but later determined not to be certified as a nurse aide, was verbally  and physically abusive to a resident.
Nurse aide was seen striking a resident with a towel.
A resident’s personal belongings (clothes and shoes) were missing and the resident had to wear  another resident’s shoes to a doctor’s appointment; when she returned from the late-afternoon  appointment, she was given cold leftovers as her evening meal; she suffered facial cuts of  unknown origin; she was constantly falling but the home failed to notify the legal guardian; the  home failed to coordinate transportation for a medical appointment; during visiting hours,  residents were being changed in their rooms with the doors left wide open.
An employee slapped a resident across the face.
The resident was hospitalized for a blood infection and pressure sore; she experienced a  significant weight loss; another resident was observed eating the resident’s food and using her  comforter; her personal property was missing.
A former employee said the home fired her after 3 weeks of employment because she refused to  falsify documents; the home is understaffed; wound care is put off for two to three days; falls and  aspirations (introducing food or liquids into the lungs) are common but are often not documented  or reported; supplies are low; the home learned that state officials were coming for an inspection  and directed the employee to falsify residents’ charts.
The home failed to change the resident’s incontinence products, resulting in a rash and blisters;  he was hospitalized for fluid in the lungs because the home failed to provide adequate care; he  lost at least 40 pounds because his dentures were lost and the home failed to provide the  necessary dental care to ensure that his new dentures fit properly. (continued)
Summary of allegation(s)
At 10:00 a.m., family members arrived at the home to take the resident to a medical appointment  and found her lying in bed, totally soaked in urine, including her hair and pillow.  She was lying on  top of the made bed, dressed in a hospital gown with her bare feet and legs totally exposed.   Complainant believes she was left this way all night because no other beds on the ward were  made.  A week later, another family member found the resident in a similar condition.  This time,  she was wearing a sweatshirt, but no underwear or diaper.  There were no clothes in her closet for  her to be changed into.  A week later, the resident was rushed to the hospital with an extremely  low sugar level. She has never had diabetes and never had a problem with her blood sugar.   Complainant believes it is possible that the resident was accidentally or intentionally injected with  insulin (possibly that of her roommate, who is a diabetic).
This column represents the number of days from the date the complaint was received to the day GAO  visited the agency.  Because Michigan measures its time frame in calender days, not in workdays, as  do Maryland and Washington, we show only calendar days for Michigan.
section_title: Seattle
paragraphs: As of January 6, 1999, there were 40 complaints, received between  September 1998 and December 1998, filed against 11 nursing homes in the  Seattle metropolitan area that had not been investigated and that exceeded  the state’s investigation time frame.  The following table summarizes the  complaints filed against nine of these homes that received three or more  such complaints.
Table III.3:  Uninvestigated Complaints for Nursing Homes in Seattle With Three or More Such Complaints Summary of allegation(s)
Floor of resident’s room was dirty; urine on floor at noon was still there at 4:30 p.m.  Staff  never asked preference on meals.  Staff told resident he could not have bed rails because it  was against the law.
Resident fell from wheelchair and was cut above eye.  Complainant asked staff to call  medical aid, but staff said not needed because laceration was not deep.  Complainant  insisted, and resident was taken to hospital where he received 6 sutures and was observed  for pain in right arm.  Complainant was removing the resident from this home, but was  concerned about the residents who remain. (Same resident and incident as previous complaint; new allegations.) Fell from wheelchair,  apparently because staff did not strap in properly.  Staff of new nursing home visited home  where incident occurred and was allowed to read resident’s chart without a release from the  resident.  Complainant concerned about confidentiality.
Staff did not feed resident and told the complainant to feed resident. Staff ignored resident  after they learned family complained to state.  Did not maintain cleanliness of urinary  catheter.  Resident now hospitalized, and home will not take resident back.
Insufficient staffing resulted in inadequate hygiene, resident falls.  Resident was charged for  wheelchair management training, but home never provided training.
Resident (same as in above complaint) billed for wheelchair management training, but never  received training.
Resident sustained two fractures of her leg, which home believed occurred while moving  resident.  Sent resident to hospital for X-ray, and suspended person who made the transfer.
Nurse allowed relative and others to give resident his medication.  Nurse did not always  administer recommended dosage of morphine, but gave more.  Room and facility not always  clean and staff did not bathe resident until complaint was made. Nurses changed diet from  regular to liquid to keep him from throwing up, and would not restore regular diet because  didn’t want to clean up the mess if he threw up again.  Doctor never came to see resident.
Resident did not receive pain medications ordered by the doctor.  Resident’s family was not  given proper admission paperwork to sign.
Summary of allegation(s)
Resident who was generally confined to bed got up, walked down hall, fell, and fractured hip.   Was in hospital for surgery.
Stolen items.  Facility reeks of urine.  A resident lies on floor in front of elevator and attacks  visitors.
Resident was found urine-soaked every visit.  Left in nightclothes.  Not wearing eyeglasses  or hearing aid.
Resident fell out of bed in spite of side rails, and suffered head laceration requiring stitches.
Staff member slapped resident on leg, which already had nerve damage.
Verbal abuse and public humiliation of talkative resident by therapist.
Fracture of leg below kneecap of unknown origin.  Patient has osteoporosis.
Home is billing 12 percent interest on outstanding charges.  Home cannot locate lift chair that  was owned by deceased resident.
Verbal abuse by nursing assistants, including a threat to take away call light because of the  resident’s frequent use of it.
Alleged neglect--untreated leg wound was bed sore; leg may have to be amputated.  Patient  showing mental decline, without satisfactory diagnosis.
Home trying to force a resident out, into adult home not suitable to needs of wheelchair- bound resident.
Resident with history of hitting staff and other residents apparently hit fellow resident on  head, causing bruise and abrasion with slight bleeding.
Resident with history of aggression hit another resident in jaw.
Poor care and service; quality of care in home has declined.  Catheter leaked and soaked  resident, but aide left resident wet; so resident called 911--taken to hospital.
Resident wanted to leave nursing home, as could function on own.  Overmedicated to point  that could not think and speak clearly.  Nothing to do in nursing home.  Disagreements  among family, resident, and nursing home staff impeded eventual transfer to independent  living.  Nursing home social worker and state case manager tried to prevent independent  living by labeling suicidal.  A near-failure of system of rights and protections, requiring  ombudsman’s repeated intervention.
Resident has had numerous falls--12 within a few weeks--in spite of mats around bed,  special alarm, lap tray on wheel chair.  Latest fall required emergency room visit and stitches,  as did another fall.
Resident found covered in blood, feeding tube pulled out, yet resident unable to have pulled  out on own due to physical limitations.  Hospitalized. (continued)
Summary of allegation(s)
Resident had burn on leg, which was brought to complainant’s attention by home’s staff.
Resident was served cup of coffee so hot that it caused her to drop it and burn her right leg.
Resident, who is being treated for mental and other difficulties, receives visits from son who  verbally abuses resident.  Resident gets upset and stops eating.  Complainant fears son  contributing to recurrence of mental difficulties.
Ongoing problem with theft of resident’s personal items.  Difficult to contact nursing home  staff by phone to resolve issue.  Facility has not resolved issue.
Neglect, inadequate staffing, untrained staff: Resident looked like swallowed watermelon due  to impacted bowel—a recurrent problem.  No bowel movement charted in 10 days.   Medications not given, but appears records falsified to show given.  Home discontinued  ordered medication.
Home unresponsive in addressing care problems brought to its attention.  Due to reduced  staff, administration of medications is erratic.  Call lights not answered for 2 hours, so not  getting to bathroom timely—now have rash from being urine-soaked.  Missed 3 weekly  baths.  Turnover of temporary staff creates communication problems.
Concern over care needs not being met.
Staff shortages leading toward burnout.
Resident says young man fractured his hand.  Staff treated resident roughly and tried to  force him to eat.  Doctor unable to answer questions about medications or other care  questions.
Staffing inadequate to meet needs of residents.  Call lights not answered, or answered late.   Reportable incidents not reported and recorded properly.
Medication error—order was changed but missed by staff, so that resident received higher  dosage than ordered for a month.
Medication error—mix-up of residents, so that resident received own medications and  another resident’s on same morning.  Doctor and nurses intervened, and close monitoring of  vital signs followed.
This column represents the number of days from the date the complaint was received to the day GAO  visited the state agency.
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