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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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) 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. 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. 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. The first copy of each GAO report and testimony is free. Additional copies are $2 each. 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Summary: 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. 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.