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The Nursing Home Abuse Crisis

Increasingly, Americans are facing difficult decisions about nursing homes. The decision to move a loved one into a nursing home raises very real questions about how the resident will be treated at the nursing home. Will the resident receive proper food and medical treatment? Will the resident be assisted by staff with basic daily activities, such as bathing and dressing? Will the resident be able to live out his or her life with dignity and compassion? These are all legitimate concerns, and they are becoming more common as America ages. In 1966, there were 19 million Americans 65 years of age and older.That figure has now risen to 35 million Americans, or 12.4% of the population.

By 2030, the number of Americans aged 65 and older is expected to increase to 70.3 million, or 20% of the population. This aging population will increase demands for long-term care. In 2000, there were 1.5 million people living in more than 17,000 nursing homes in the United States. The Department of Health and Human Services (HHS) has estimated that 43% of all 65 year olds will use a nursing home at some point during their lives. Of those who do need the services of a nursing home, more than half will require stays of over one year, and over 20% will be in a nursing home for more than five years. By 2050, the total number of nursing home residents is expected to quadruple from the current 1.5 million to 6.6 million.

Through the Medicaid and Medicare programs, the federal government is the largest payer of nursing home care. Under the Medicaid program, a federal-state health care program for the needy, all nursing home and related expenses are covered for qualified individuals. Under the Medicare program, a federal program for the elderly and certain disabled persons, skilled nursing services are partially covered for up to 100 days. In 2002, it is projected that federal, state, and local governments will spend $65.9 billion on nursing home care, of which $51.5 billion will come from Medicaid payments ($32.8 billion from the federal government and $18.7 billion from state governments) and $12 billion from federal Medicare payments. Private expenditures for nursing home care are estimated to be $37.8 billion ($26 billion from residents and their families, $7.7 billion from private insurance policies, and $4.1 billion from other private funds).

The overwhelming majority of nursing homes in the United States receive funding through either the Medicaid program or the Medicare program, or both. Under federal law, nursing homes that receive Medicaid or Medicare funds must meet federal standards of care. Prior to 1987, these standards were relatively weak: they focused on a facility's ability to provide adequate care, rather than on the level of care actually provided. In 1986, a landmark report by the Institute of Medicine found widespread abuses in nursing homes.

This report, coupled with national concern over substandard conditions, led Congress to pass comprehensive legislation in 1987 establishing new standards for nursing homes.This law requires nursing homes to "provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident."

The 1987 law and the implementing regulations limit the use of physical and chemical restraints on nursing home residents. They require nursing homes to prevent pressure sores, which are painful wounds or bruises, caused by pressure or friction, that can become infected. They also establish other health standards for nursing homes, such as requiring that residents are properly cleaned and bathed, receive appropriate medical care, and are supervised to prevent falls and accidents. The regulatory requirements are codified at 42 C.F.R. Part 483.

Recently, investigators have begun to examine whether nursing homes are meeting the requirements of the 1987 law and its implementing regulations. The results have not been encouraging. Certain abusive practices documented by the Institute of Medicine in 1986, such as the improper use of physical restraints and antipsychotic drugs, have been reduced. But health violations appear to be widespread. In a series of 1999 reports, the U.S. General Accounting Office (GAO), an investigative arm of Congress, found that "more than one-fourth of the homes had deficiencies that caused actual harm to residents or placed them at risk of death or serious injury"; that these incidents of actual harm "represented serious care issues . . . such as pressure sores, broken bones, severe weight loss, and death"; and that "[s]erious complaints alleging that nursing home residents are being harmed can remain uninvestigated for weeks or months."

Abuse of Residents Is a Major Problem in U.S. Nursing Homes

5,283 nursing homes -- almost one out of every three U.S. nursing homes -- were cited for an abuse violation in the two-year period from January 1, 1999, through January 1, 2001. All of these violations had at least the potential to harm nursing home residents.

In over 1,600 of these nursing homes, the abuse violations were serious enough to cause actual harm to residents or to place the residents in immediate jeopardy of death or serious injury.

Federal health and safety standards protect the vulnerable residents of nursing homes from physical, sexual, and verbal abuse. To enforce these standards, the U.S. Department of Health and Human Services contracts with the states to conduct annual inspections of nursing homes. These inspections assess whether nursing homes are meeting federal standards of care, including the prohibitions on abuse of residents. In addition, when an individual files an abuse complaint, state inspectors are required to investigate these allegations and assess whether federal standards of care were violated by the nursing home.

Thousands of nursing homes have been cited for abuse violations.

Over thirty percent of the nursing homes in the United States -- 5,283 nursing homes -- were cited for an abuse violation that had the potential to cause harm between January 1999 and January 2001. These nursing homes were cited for almost 9,000 abuse violations during this two-year period.

Many of these abuse violations caused harm to residents.

Over 2,500 of the abuse violations in the last two years were serious enough to cause actual harm to residents or to place residents in immediate jeopardy of death or serious injury.

In total, nearly 10% of the nursing homes in the United States -- 1,601 nursing homes -- were cited for abuse violations that caused actual harm to residents or worse.

Many of these abuse violations are discovered only after the filing of a formal complaint. State inspectors can find evidence of abuse either during annual inspections or during an inspection after a formal complaint is filed. The data indicate that over 40% of the abuse violations -- over 3,800 in the two-year period -- were discovered only after the filing of a formal complaint. In over one-third of these cases, the violation was determined to have caused actual harm to the resident.

The percentage of nursing homes with abuse violations is increasing. The percentage of nursing homes cited for abuse violations has increased every year since 1996. In 2000, over twice as many nursing homes were cited for abuse violations during annual inspections than were cited in 1996. The reasons for this increase are unclear.

State inspection reports and citations describe many instances of appalling physical, sexual, and verbal abuse of residents. In some cases, the nursing homes were cited because a member of the nursing staff committed acts of physical or sexual abuse against the residents under his or her care. In other cases, nursing homes were cited because they failed to protect vulnerable residents from violent residents who beat or sexually assaulted them.

Examples of incidents:

Physical abuse:

A nursing home attendant walked into a female resident's room, shouted "I'm tired of your ass," hit the resident in the face, and broke her nose.

Nursing home attendants used cigarettes to bribe a brain-damaged resident to attack another resident, then watched as the two residents fought each other.

The failure of many nursing homes to adequately protect residents from other abusive residents:

A resident with a history of over 50 instances of abusive behavior killed another resident when he picked her up and slammed her into a wall.

Sexual abuse:

A male nurse aide molested two elderly residents, putting his finger in their vaginas while bathing them,

A male aide was found attacking a resident with senile dementia. The aide was found on top of the resident with his pants down and the resident's legs spread.

Cases where nursing homes ignored signs of serious abuse:

A female resident appeared to have been sexually abused. The director of nursing replied, "maybe she fell on a broomstick."

Verbal abuse:

Staff told residents, "If you hadn't sh*t all over yourself, I wouldn't have to clean your ass" and "I . . . am sorry you were born," and called residents "a blob," "stupid," and "bitch."

Abuse violations are among the most serious violations that can occur in nursing homes. The elderly and disabled residents of nursing homes cannot protect themselves from physical attack or sexual assault. Sometimes they cannot even communicate to family members that they have suffered from abuse. Residents and their families are almost entirely dependent upon nursing homes to ensure the safety of residents.

A recent report by the Inspector General of the Department of Health and Human Services, for example, found that there were thousands of reported complaints of abuse and neglect of nursing home residents in just one year in 11 states. Another series of reports has investigated staffing levels in nursing homes, finding that many nursing homes are severely understaffed, impeding their ability to effectively care for patients. These reports for members of Congress documented many instances where nursing homes were cited for serious abuse violations. They suggested that the problem of abuse in nursing homes may be far more prevalent than the public generally recognizes.

Federal law requires that states maintain a registry that includes documented findings of resident abuse by nursing assistants. 42 U.S.C. § 1396r(e)(2). In 1996, however, the Institute of Medicine, a branch of the National Academy of Sciences, found that the registries have had a "limited effect" because of difficulties in verifying information in the registries and delays in entering information.

There are approximately 17,000 nursing homes in the United States with approximately 1.5 million residents. An analysis of the results of two years of state inspection and complaint investigation reports for these facilities reveals that abuse of nursing homes residents is a widespread and serious problem.

The most frequent abuse violation was the failure to properly investigate and report allegations of resident abuse, neglect, or mistreatment or to ensure that nursing home staff do not have a documented history of abusing, neglecting, or mistreating residents.

In total, 3,797 nursing homes were cited by state inspectors for this abuse violation.

The second most common abuse violation was the failure to develop and implement written policies that prohibit abuse, mistreatment, and neglect of residents and the misappropriation of residents' property. In total, 2,314 homes were cited by state inspectors for this abuse violation.

The third most common abuse violation was the failure to protect residents from sexual, physical, or verbal abuse, corporal punishment, or involuntary seclusion. In total, 1,009 nursing homes -- almost 20% of all homes cited for an abuse violation -- were cited for this violation.

Many of the abuse violations cited by state inspectors were for serious violations that caused actual harm to residents. In total, 1,345 nursing homes were cited for an abuse violation that actually harmed residents. An additional 256 homes were cited for abuse violations that resulted in death or serious injury or placed residents in immediate jeopardy of death or serious injury. Overall, 1,601 nursing homes -- over 9% of all U.S. nursing homes -- were cited for abuse violations that caused actual harm or placed residents in immediate jeopardy.

Nursing Home Conditions in Texas

Many Nursing Homes Fail to Meet Federal Standards for Adequate Care

Many families are becoming increasingly concerned about the conditions in nursing homes. Federal law requires that nursing homes "provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident." But recent studies by the U.S. General Accounting Office and others have indicated that many nursing homes fail to meet federal health standards.

There are 1,148 nursing homes in Texas that accept residents covered by Medicaid or Medicare. These facilities serve almost 85,000 residents. Eighty-six percent of Texas nursing homes violated federal health standards during recent state inspections. Over one-third of the nursing homes had violations that caused actual harm to residents or placed them at risk of death or serious injury. Moreover, over 90% of the nursing homes in Texas did not meet the recommended minimum staffing levels identified by the U.S. Department of Health and Human Services (HHS).

86% of Nursing Homes in Texas Did Not Meet Federal Standards Governing Quality of Care

The vast majority of nursing homes in Texas violated federal standards governing quality of care. State inspectors consider a nursing home to be in full compliance with federal health standards if no violations are detected during the inspection. They will consider a home to be in "substantial compliance" with federal standards if the violations at the home do not have the potential to cause more than minimal harm. Of the 1,148 nursing homes in Texas, only 161 facilities (14%) were found to be in full or substantial compliance with the federal standards. In contrast, 987 nursing homes (86%) had at least one violation with the potential to cause more than minimal harm to residents or worse. On average, each of these 987 nursing homes had 9.8 violations of federal quality of care requirements. Many nursing homes in Texas had violations that caused actual harm to residents. Of the 1,148 nursing homes in Texas, 443 facilities, 39% of all facilities, had a violation that caused actual harm to nursing home residents or placed them at risk of death or serious injury. The 443 nursing homes with actual harm violations or worse serve 37,417 residents and are estimated to receive over $440 million each year in federal and state funds.

Most nursing homes in Texas did not provide adequate staffing. During their most recent annual inspections, the vast majority of nursing homes in Texas,1,060 of the 1,124 facilities for which staffing data was available (94%), did not meet minimum staffing levels identified by HHS in a recent report to Congress. Compared to other states, Texas nursing homes rank 43rd in the nation in hours of nursing care provided to residents each day. Texas nursing homes that failed to meet the minimum staffing levels were over three times as likely to have violations that caused actual harm to residents compared to nursing homes that met all minimum staffing levels.

Individuals who are admitted receive very inadequate, sometimes shockingly deficient care that is likely to hasten the deterioration of their physical, mental, and emotional health. They are also likely to have their rights ignored or violated, and may even be subject to physical abuse.

NURSING HOME CONDITIONS IN TEXAS

There are 1,148 nursing homes in Texas that accept residents whose care is paid for by Medicaid or Medicare. These nursing homes have 121,187 beds that were occupied by 84,859 residents during the most recent round of inspections. The majority of these residents, 60,809, rely on Medicaid to pay for their nursing home care. Medicare pays the cost of care for 8,097 residents. Eighty-two percent of the 1,148 nursing homes in Texas are private, for-profit facilities. The results of this investigation indicate that the conditions in these nursing homes fall below federal standards. Many residents are not receiving the care that their families expect and that federal law requires. This report also finds that the vast majority of the nursing homes do not meet the minimum staffing levels identified by HHS as necessary for adequate care.

Prevalence of Violations

Only 161 of the nursing homes in Texas were found by the state inspectors to be in full or substantial compliance with federal health requirements. The remaining 987 nursing homes, 86% of all facilities in Texas, had at least one violation that had the potential to cause more than minimal harm to their residents or worse.

Many nursing homes had multiple violations. State inspectors found a total of 9,624 violations in facilities that were not in complete or substantial compliance with federal requirements, an average of 9.8 violations per noncompliant home.

Additional Steps Needed

Some of the greatest safety concerns are posed by nursing homes with violations that cause actual harm to residents or have the potential to cause death or serious injury. 79 nursing homes were cited for violations that caused or had the potential to cause death or serious injury. An additional 364 nursing homes were cited for violations that caused actual harm to residents. In total, 443 nursing homes in Texas, 39% of all facilities, had serious violations that caused actual harm to residents or had the potential to cause death or serious injury. These 443 nursing homes serve 37,417 residents and are estimated to receive over $440 million in federal and state funds each year. Many of these facilities had multiple, actual harm violations. The 443 facilities had 1,160 violations that caused actual harm to residents or had the potential to cause death or serious injury. Over half of the nursing homes, 238 of 443 facilities, had two or more actual harm or worse violations. Fifty-eight facilities had five or more such violations.

Some of the most common actual harm violations included:

  • Failing to prevent physical or sexual abuse of residents or other forms of mistreatment and neglect (209 violations);
  • Failing to prevent or properly treat pressure sores (156 violations);
  • Failing to prevent falls and accidents, such as failing to provide proper supervision or assistance devices to residents (155 violations);
  • Improper or inadequate medical care, such as failing to provide proper treatments or drugs to residents (136 violations); and
  • Failing to provide adequate nutrition and hydration to residents (111 violations).

NURSING HOME STAFFING IN TEXAS

There are 1,148 nursing homes in Texas that receive Medicaid or Medicare payments. For 1,124 of these facilities (98%), there is sufficient data in the OSCAR database to evaluate staffing levels. The vast majority of these nursing homes, over 90%, fail to provide adequate staffing to residents. Compared to other states, Texas ranks 43rd in the median number of daily hours of nursing care provided to residents.

HHS Minimum Staffing Levels

Nursing homes cannot provide a high level of care unless they have enough well-trained staff to care for their residents. However, the staffing requirements under the 1987 federal nursing home law are minimal. In general, the law allows each nursing home to decide for itself how many hours of nursing care to provide to residents each day. The 1987 federal law recognizes three types of nursing staff: registered nurses; licensed nurses; and nursing assistants.

Different standards apply for each type of nursing staff:

Registered nurses, who are often in a supervisory position, are nurses who have gone through two to four years of nursing education.

Under the 1987 law, all nursing homes must have a registered nurse on duty for at least eight hours per day.

This standard applies regardless of the size of the nursing home or the number of residents. The law does not specify a minimum registered nurse-to-resident ratio.

Licensed professional nurses provide a level of care between the nursing assistant and the registered nurse. Licensed nurses generally undergo a 12 to 18 month period of training

The 1987 federal nursing home law requires that nursing assistants receive 75 hours of training and testing for competency within four months of employment. Nursing assistants must also receive 12 hours of additional training annually. IOM Report,

Under the 1987 law, nursing homes must have a licensed nurse on duty 24 hours a day.

Again, this standard applies regardless of the size of the nursing home or the number of residents and does not specify a minimum licensed nurse-to-resident ratio.

Nursing assistants provide the majority of care in most facilities. Federal law requires that nursing assistants receive a minimal amount of special training.

The law does not, however, contain any requirements regarding the level of staffing by nursing assistants. Rather, each nursing home is permitted to determine for itself how many hours of nursing assistant care it will provide residents each day. There is a widespread consensus among nursing home experts that current federal staffing requirements need to be improved. To assess the need for new staffing standards, HHS released the final results of a ten-year study, entitled Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes , in April 2002.

In order to determine whether minimum nursing home staffing ratios could be identified, researchers analyzed detailed staffing and resident data from over 5,000 nursing homes. The analysis examined the ratio of nursing assistants, licensed nurses, and registered nurses to nursing home residents, and assessed whether staffing ratios affected resident outcomes, such as the risk of hospitalization or the risk of developing pressure sores.

The report found that there are minimum staffing levels below which nursing homes are at substantially greater risk for quality of care problems. The report found that facilities that fell below these standards were significantly more likely to have high numbers of residents with problems such as urinary tract infections, respiratory infections, pressure sores, and unexpected weight loss.

Based on these findings, the HHS report identified minimum staffing levels necessary to provide adequate care for residents. For nursing homes that predominantly housed residents with long-term stays of 90 days or more, the staffing levels identified by HHS would require that each resident receive at least 4.1 hours of individual care per day, including at least 2.8 hours of individual care by nursing assistants and 1.3 hours of individual care by registered or licensed nurses.

The HHS report also identified minimum staffing levels for a nursing home with a mix of residents that are predominantly in the facility for short-term stays. The HHS report found that these nursing homes must have sufficient staff to provide each short-term resident at least 3.55 hours of individual care per day, including at least 1.15 hours of individual care by registered or licensed nurses, and at least 0.55 hours of care by registered nurses, in order to meet the minimum staffing level.

Texas Ranks Near the Bottom in Staffing

It is difficult to compare rates of violations of health standards among states because the thoroughness of state inspections can vary considerably from state to state. In the case of nursing home staffing, however, state comparisons are feasible because all nursing homes report hours of daily nursing care using the same criteria. Such a comparison shows that Texas ranks near the bottom of the 50 states in nursing home staffing. The median nursing home in Texas provided just 3.19 hours of daily nursing care per resident. This figure ranks 43rd in the nation in the number of hours of daily nursing care per resident The median nursing home in Texas provided just 21 minutes of daily care by registered nurses for each resident, less than half of the HHS minimum. This ranks 46th in the nation.

Inadequate Staffing Is Linked to Inadequate Care

There was a direct correlation between inadequate staffing and inadequate care. The nursing homes that did not meet the minimum staffing levels identified by HHS were more likely to have serious violations of federal health standards than nursing homes that met the minimum staffing levels. There are 64 nursing homes in Texas that met all of the minimum staffing levels identified by HHS. Only eight of these facilities that met the minimum staffing levels (13%)

430 of the 1,060 facilities (41%) that failed to meet at least one of the minimum staffing levels were cited for a violation that caused actual harm to residents. Thus, nursing homes that failed to meet at least one of the minimum staffing levels were over three times as likely to have violations that caused actual harm to residents

As discussed above, 917 nursing homes in Texas did not provide the recommended 4.1 hours of daily nursing care per resident. Forty-two percent of these nursing homes, 384 of 917, were cited during recent annual inspections or complaint investigations for a violation that caused actual harm to residents. In contrast, of the 207 facilities that met the minimum staffing level of 4.1 hours, 54 facilities (26%) had violations that caused actual harm to residents. Thus, nursing homes that did not meet the minimum hourly staffing level were over 60% more likely to have violations that caused actual harm to residents.

CONDITIONS REMAIN POOR IN TEXAS NURSING HOMES

There appears to have been little change in nursing home conditions since October 2000. Since the release of the October 2000 report, there has been a slight increase in the percentage of Texas nursing homes violating federal health standards (from 84% in the October 2000 report to 86% in this report) and a slight decrease in the percentage of nursing homes cited for violations that caused or had the potential to cause death or serious injury (from 8% in the October 2000 report to 7% in this report).

Staffing levels have also not changed measurably between reports. The October 2000 report found that Texas ranked 40th among the 50 states in the median number of daily hours of nursing care provided to residents; the current report finds that Texas ranks 43rd. In terms of the number of hours of daily nursing care provided to individual residents, the median nursing home in Texas in the October 2000 report provided 3.14 hours of care, compared to 3.19 hours in this report.

Thus, over the past two years, Texas facilities have added only three minutes to the amount of daily nursing care provided to residents. Moreover, there has been a 5% decrease in the number of hours of care by registered nurses provided by nursing homes in Texas from the October 2000 report to this report. In one area, however, there has been a more significant change. The percentage of nursing homes cited for violations that caused actual harm to residents dropped from 47% in the October 2000 report to 32% in this report.

The 1987 nursing home law was intended to stop abuses in nursing homes by establishing stringent federal standards of care. Although the law and its implementing regulations require appropriate standards of care, compliance by the nursing homes in Texas has been poor.

Many nursing homes in Texas are failing to provide the care that the law requires and that families expect. Furthermore, most nursing homes in Texas did not meet the minimum staffing levels identified by HHS as necessary to provide adequate care to residents.

Stop Nursing Home Abuse

The best way to stop nursing home abuse is to make sure violations are adequately punished. If a loved one has been injured by nursing home abuse, or by nursing home negligence, contact a lawyer experienced in nursing home abuse cases as soon as possible. [click here for a list of nursing home abuse attorneys]

Nursing Home Abuse Links

http://www.medicare.gov/nhcompare/home.asp
Tool that provides detailed information about the past performance of every Medicare and Medicaid certified nursing home in the country.

Medicare.gov - Nursing Home Overview

Medicare.gov - Nursing Home Resident Rights

Guide to Choosing a Nursing Home

Finding the Right Nursing Home

Texas Assoc. of Homes & Services for the Aging

Texas Department of Human Services, Long-Term Care Policy

DHS Long-Term Care Policy Nursing Facilities

Texas Department of Protective and Regulatory Services

About Adult Protective Services

How to Report Abuse and Neglect

Elder Abuse Prevention

Find a Long-term Care Facility or Home Health Agency in Texas

Should you consider a nursing home?

What kinds of services can a nursing home offer?

Who are the providers of primary services in a nursing home?

Who pays for nursing home care?

What does every good nursing home have?

Additional information

Consumer Guides to Nursing and Assisted Living

Administration on Aging

Eldercare Web

Nursing Home Compare

Senior Net

A Consumer Guide to Choosing a Nursing Home

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