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Evaluating Nursing Homes: Why Is Information So Important So Hard to Get?

The complicated search for a quality nursing home.

Albert Salerno of Sacramento, Calif., embraced life with open arms. He served his country in World War II, was decorated for heroism and worked 45 years as a civil engineer. During 55 years of marriage, he and his wife, Vincentia, raised four children.

At 79, Salerno broke his hip and developed transverse myelitis, a disabling inflammation of the spinal cord. Suddenly, he could no longer dress or bathe himself, much less walk or move around the house. Over time, Salerno came to need more care than his wife and their grown children were able to provide, so in August 2002 they moved him into a nearby nursing home, Gramercy Court, where they could visit him almost every day.

Gramercy Court’s nurses, noticing that Salerno was leaving up to three-quarters of his food uneaten, created a plan to address his nutritional deficit. But the nursing staff failed to implement the plan, even as Salerno lost weight and became severely dehydrated.

One day in January 2003 Salerno aspirated food into his lungs, triggering a series of alarming symptoms. He received no medical attention, however, for five days. What’s more, Gramercy Court’s nursing staff failed to alert Salerno’s doctor to his changing condition, a clear violation of procedure. Even when Salerno’s symptoms worsened, the nursing staff took no action until his family insisted that he be sent to a hospital. Three days later Salerno died of renal failure.

The California Department of Public Health later found Gramercy Court to have been responsible for a series of violations that, it said, were the “direct proximate cause” of Salerno’s death.

All too common

The story is one of outrageous neglect and malfeasance. Shockingly, however, it isn’t all that rare. Throughout the United States, thousands of cases of abuse and neglect have been documented. Despite Americans' shift to remaining in their own homes as they age, the nation’s 16,000 nursing homes still have about 1.5 million residents at any one time.

The cases have included sexual assaults at the hands of staff members, fires in facilities that didn't have sprinkler systems, and bedsores left untreated for so long that limbs had to be amputated. In 2007 more than 90 percent of the nation's nursing homes were cited for violations of federal health and safety standards, according to the U.S. Department of Health and Human Services' inspector general. Seventeen percent of nursing homes committed violations that caused "actual harm or immediate jeopardy"—the most serious categories of abuse and neglect.

Some of these violations can lead to permanent disability, even death. In 2006 another resident of Gramercy Court died, state investigators later concluded, because she was not kept adequately hydrated, leading to renal failure. As a result, last June state health officials slapped Gramercy Court with an "AA" citation—the most severe under California law—and a $90,000 fine.

The following year, in Hemet Valley Healthcare Center in Hemet, Calif., Olga Baroncini, 81, suffered a head injury that was not even noted in her medical records. She died two days later as a result of bleeding in the brain. State authorities cited the facility for failing to follow proper procedures, including calling a doctor, and levied a $100,000 fine.

A 2007 New York Times investigative story about nursing homes owned by private investment firms reported on one such Florida facility where 15 residents died in three years because of negligent care, according to their families. Sen. Charles Grassley, R-Iowa, cited the history in a letter asking the Government Accountability Office to investigate how takeovers by private-investor groups affect the quality of care.

 Despite the pervasiveness of such violations, learning about them when choosing a nursing home is hard. Salerno family members say that with adequate information they  might not have chosen Gramercy Court in the first place. In the two years preceding Albert Salerno’s stay there, Gramercy Court had been cited seven times by state inspectors for its failure to identify care needs, implement care plans and notify a physician of changing symptoms—some of the very deficiencies that caused Salerno’s death.

The problem for the Salernos was that Gramercy Court’s record was largely out of sight, available only in legal files at the California Department of Public Health and in the courts. Even though California is one of several states that posts some relevant data on its website—including complaints, state enforcement actions and summaries of deficiencies—it does not offer the kind of details that could help steer families away from facilities with chronic problems.

“Gramercy Court looked good on its face, but there were things that weren’t posted,” says one of Salerno’s children, Barbara Salerno, a lawyer in Reno, Nev. “We didn’t know the home had been cited as the direct cause of a patient’s death. That would have been a huge red flag to us. We probably wouldn’t have put him there.”

In interviews with local reporters, administrators of Gramercy Court have denied the state's allegations of inadequate care. “Our primary concern is our residents,” Linda Gordon, the president of the nursing home’s parent company, told AARP Bulletin Today. “We regret having a citation. We will challenge it.”  Hemet Valley Healthcare Center closed in December 2008. According to a spokesman for the California Department of Public Health, both Gramercy Court and Valley Health System, Hemet Valley’s corporate parent, have challenged the 2008 citations and fines in court. For the New York Times story, staff members at the Florida nursing home declined to comment and its corporate owner said that it bore no responsibility for resident care because it leased the property to an independent company.

The need for due diligence

Congress has been trying for more than 20 years to bring nursing homes under tighter scrutiny and accountability. In 1987 it passed the Nursing Home Reform Act, which required regular inspections, and it since has put into place a rating system for multiple deficiencies that is based on a facility’s three most recent inspections. Each of the identified deficiencies is accompanied by a “level of harm” rating from one (“potential for minimal harm,” the least serious category) to four (“immediate jeopardy,” the most serious), along with a notation about how many residents were affected (few, some or many).

Nonetheless, the percentage of nursing homes with deficiencies uncovered in annual inspections has risen in the past decade—from 81 percent in 1998 to 91 percent in 2007. And the average number of deficiencies per nursing home increased 19 percent from 2001 to 2007, according to a recent report by researchers at the University of California, San Francisco. The most alarming trend, says Charlene Harrington, the report’s author, is that the hours registered nurses spent with nursing home residents dropped 25 percent from 1999 to 2007.

Of particular concern to reform advocates is the fact that for-profit nursing homes have higher deficiency rates than their nonprofit counterparts. A 2007 investigation by the New York Times found that the acquisition of nursing home chains by private investment firms has led to declines in service and to “Byzantine” multilayered ownership structures that make it exceedingly difficult for aggrieved families to sue for negligent care. The Times investigation, focusing on data from 2000 to 2006, concluded that “by many regulatory benchmarks, residents at those nursing homes are worse off, on average, than they were under previous owners.”

The buck stops where?

Reform advocates argue that some private investment firms see nursing homes as a no-lose investment, with new waves of boomers hitting retirement age, and that their focus is on reducing costs, raising shareholder value and, in some cases, flipping the properties for other uses.

“People living in homes owned by big corporate chains are at the mercy of people trading real estate,” says Janet Wells, the public policy director of the National Citizen’s Coalition for Nursing Home Reform, a nonprofit consumer advocacy organization. “These owners are more concerned with real estate values than with quality care values.”

In interviews with local reporters, administrators of Gramercy Court have denied the state's allegations of inadequate care. “Our primary concern is our residents,” Linda Gordon, the president of the nursing home’s parent company, told AARP Bulletin Today. “We regret having a citation. We will challenge it.”  Hemet Valley Healthcare Center closed in December 2008. According to a spokesman for the California Department of Public Health, both Gramercy Court and Valley Health System, Hemet Valley’s corporate parent, have challenged the 2008 citations and fines in court. For the New York Times story, staff members at the Florida nursing home declined to comment and its corporate owner said that it bore no responsibility for resident care because it leased the property to an independent company.

Not all nursing homes, of course, have bad records; many provide good care. But the fact that there are enough bad apples to taint the entire industry gives pause to anyone looking for an appropriate facility for a family member. It adds urgency to the need for clear, comprehensive and useful sources of information about nursing homes and their records of violations and citations. “Above all,” says Sen. Charles Grassley, R-Iowa, who has championed the cause of nursing home reform on Capitol Hill, “consumers need access to accurate, meaningful and current data.”

The logical first place to turn for that data is the federal Centers for Medicare & Medicaid Services (CMS). Because a large portion of nursing home patients live mainly on funds from those two programs, CMS is the primary source of revenue for nursing homes—about $75 billion a year in all, or roughly two of every three dollars they take in. For years, CMS has tried to make nursing home data available to the public through a website called Nursing Home Compare. The site lists every facility in the nation that receives money from CMS.

Yet for all its comprehensiveness, the site lacks detailed reports on identified deficiencies and doesn’t specifically cite injuries or deaths caused by negligence. Over the years AARP has pushed for improvements in Nursing Home Compare. In mid-December CMS added a long-awaited five-star rating system to the Nursing Home Compare site.

Meanwhile, Grassley and Sen. Herb Kohl, D-Wis., continue to push their Nursing Home Transparency and Improvement Act. They say the legislation is designed to update the 1987 law and bring greater transparency to the reporting and inspection system for nursing homes. The measure didn’t pass in 2008, but Kohl and Grassley are expected to reintroduce it early in 2009. With pressure building for nursing homes to clean up their acts, and a flood of older retirees seeking long-term care, it will be a timely piece of legislation for the 111th Congress to consider. Only then, reform advocates say, will the nation be able to get control of what many consider to be a growing crisis.

Peter Ross Range is a freelance writer based in Washington, D.C.

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