Express-News investigates Texas nursing homes
Filed under: Hospitals, Hot Health Headline, Public records
San Antonio Express-News reporters Karisa King, John Tedesco and Melissa Fletcher Stoeltje took advantage of a number of tools to assemble a broad investigation into the city’s nursing homes.
Slow action on nursing home problems
In the package’s centerpiece, the reporters plowed through 2,200 claims filed against the town’s 55 licensed nursing homes from 2006 to 2009 and found that investigators arrived long after the incidents in question and marked so many claims “unsubstantiated” that the state attorney general posted a notice advising residents that they should take even unsubstantiated claims into account when evaluating nursing homes. They also consulted ratings and visited 10 local nursing homes.
With the ratings as a guide, the newspaper examined more than 3,000 pages of abuse and neglect investigations and annual inspections of 10 nursing homes with the lowest scores. It also reviewed dozens of wrongful-death lawsuits filed against local nursing homes to examine how Texas watches over its elderly.
In addition to a few dangerous homes and some disquieting anecdotes, the reporters found an unenforced reporting law:
(Department of Aging and Disability Services) also is failing to enforce a state law that requires nursing homes to report details about every resident who dies. State officials are supposed to analyze the fatality reports to publicize problems and trends, but that research isn’t being done.
To top off this tale of dysfunction, they also unearthed at least five cases in which would-be nursing home whistle blowers were fired.
Stoeltje added a sidebar on nursing home rating systems, their utility and their shortcomings. She addresses both the local Texas system and the federal Nursing Home Compare database. She talks to both nursing home operators and patient advocates; the operators tend to dwell on ratings’ weaknesses while advocates spoke on their strengths.
LIST: Examples of problems found at nursing homes
Six more examples culled from complaints and often backed with interviews.
MAP: Quality of nursing homesA Yahoo! map linking nursing home location, size and rating.
Texas Public Radio
Terry Gildea, host of a news discussion program called “The Source,” interviewed all three Express-News reporters about their investigation.
Slim guide:
Covering the Health of Local Nursing Homes
This reporting guide gives a head start to journalists who want to pursue stories about one of the most vulnerable populations – nursing home residents. It offers advice about Web sites, datasets, research and other resources. After reading this book, journalists can have more confidence in deciphering nursing home inspection reports, interviewing advocacy groups on all sides of an issue, locating key data, and more. The book includes story examples and ideas.
AHCJ publishes these reporting guides, with the support of the Robert Wood Johnson Foundation, to help journalists understand and accurately report on specific subjects.
• More investigations of nursing homes
• Aging Nation: Troublesome Health Care Issues
• Headlines an advocate for seniors would like to see
• The impact of aging upon health care
• Covering nursing homes and other issues of aging
• How will retiring boomers affect the national health agenda?
• You Can Run, but You Can’t Hide: Policy and Problems in Long-Term Care
• Biology of Aging: Sources and Resources
1 in 5 nursing homes pull consistently bad ratings
USA Today’s Jack Gillum crunched the numbers and found that one-fifth of U.S. nursing homes have received two consecutive poor (one- or two-star) ratings in the federal Nursing Home Compare database since its launch in 2008.
Gillum looked for homes that started with a poor rating, then received at least one more within the past year. Among other things, Gillum found that “Nearly all homes that repeatedly received few overall stars — one or two stars — were owned by for-profit corporations,” and that “the lowest-rated homes had an average of 14 deficiencies per facility.” Consistent poor-performers can be found in all 50 states.
Gillum found that one of the reasons homes weren’t improving from year to year is that they’re often given little incentive to improve their ratings unless consumers are actively using Nursing Home Compare to inform their decisions.
Medicare spokeswoman Mary Kahn says a one-star nursing home is not necessarily a terrible facility. Even the lowest-rated homes must still meet baseline Medicare conditions, she says.
…
“If homes are not motivated to get better, chances are they won’t, and you’ll wind up in homes in poor-quality purgatory,” (Larry Minnix, CEO of American Association of Homes and Services for the Aging) says. “There should be two types of homes: the excellent and the non-existent.”
Slim guide:
Covering the Health of Local Nursing Homes
Check out AHCJ’s latest volume in its ongoing Slim Guide series. This reporting guide gives a head start to journalists who want to pursue stories about one of the most vulnerable populations – nursing home residents. It offers advice about Web sites, datasets, research and other resources. After reading this book, journalists can have more confidence in deciphering nursing home inspection reports, interviewing advocacy groups on all sides of an issue, locating key data, and more. The book includes story examples and ideas.
AHCJ publishes these reporting guides, with the support of the Robert Wood Johnson Foundation, to help journalists understand and accurately report on specific subjects.
Other resources
- Aging Nation: Troublesome Health Care Issues
- Headlines an advocate for seniors would like to see
- The impact of aging upon health care
- Covering nursing homes and other issues of aging
- How will retiring boomers affect the national health agenda?
- You Can Run, but You Can’t Hide: Policy and Problems in Long-Term Care
- Biology of Aging: Sources and Resources
GAO looks into why nursing home evals are flawed
Filed under: Government, Health data, Hot Health Headline, Public health, Studies
The Government Accountability Office has followed up its May 2008 report that found a high level of inconsistency in nursing home evaluations (PDF) with a blockbuster sequel: Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment (PDF).
In this report, the GAO seeks to figure out exactly what’s causing state inspectors to miss serious violations on at least 15 percent of their surveys. The answers? Bad survey methodology, workforce shortages, inexperienced surveyors, bad survey documentation, odd state practices and, most interestingly, outside pressure from stakeholders like those in the nursing home industry.
The entire report deserves a close review, but for now we’ll settle for a few cherry-picked highlights. Keep in mind that while the federal government sets and enforces standards, much of the process, including hiring, training and review of surveyors, is left up to the discretion of the states. For the report, the GAO surveyed 98 percent of state agency directors (Pennsylvania’s Deputy Secretary for Quality Assurance asked that state’s surveyors not respond) and 61 percent of eligible nursing home surveyors.
Practices vary, as do the reasons behind them
“Forty percent of surveyors in five states and four directors reported that their state had at least one practice not to cite certain deficiencies.”
“… over 40 percent of surveyors in four states reported that their states’ informal dispute resolution processes favored concerns of nursing home operators over resident welfare.”
“… directors from seven states reported that pressure from the industry or legislators may have compromised the nursing home survey process, and two directors reported that CMS’s support is needed to deal with such pressure.”
“If surveyors perceive that certain deficiencies may not be consistently upheld or enforced, they may choose not to cite them.”
“Fifty-four percent of surveyors nationwide reported on our questionnaire that supervisors at least sometimes removed the deficiency that was cited, and 53 percent of surveyors noted that supervisors at least sometimes changed the scope and severity level of cited deficiencies. Of the surveyors, who reported that supervisors sometimes removed deficiencies, 13 percent reported that supervisors always or frequently removed deficiencies — including 12 states with 20 percent or more of their surveyors reporting that deficiencies were removed.”
The survey – the length and complexity of which was cited as a contributor to incorrect deficiency reporting – includes 200 standards grouped into 15 categories, which are then rated based on a scope and severity grid.
Scale is always an issue
About 1.5 million Americans live in nursing homes. That’s more than live in Maine, Hawaii, South Dakota or any one of eight other states. Combine this with state budget issues, and you can see how scale would be a serious obstacle to consistency.
“More than two-thirds of state agency directors reported on our questionnaire that staffing posed a problem for completing complaint surveys, and more than half reported that staffing posed a problem for completing standard or revisit surveys. In addition, 46 percent of state agency directors reported that time pressures always, frequently, or sometimes contributed to understatement in their states.”
Does CMS new survey system fix anything?
When the GAO sent out its questionnaires, eight states had begun adopting QIS, which is CMS’ new, and theoretically improved, nursing home survey method (PDF). While the sample size is small, early returns aren’t promising:
There was no consensus among the eight state agency directors who had started implementing the QIS as of November 2008 about how the new survey methodology would affect understatement.44 Three directors reported that the QIS was likely to reduce understatement; three directors reported that it was not likely to reduce understatement; and two directors were unsure or had no opinion… Similarly, there was no evidence that the QIS resulted in higher-quality documentation or improved surveyor efficiency.
Slim guide:
Covering the Health of Local Nursing Homes
Check out AHCJ’s latest volume in its ongoing Slim Guide series. This reporting guide gives a head start to journalists who want to pursue stories about one of the most vulnerable populations – nursing home residents. It offers advice about Web sites, datasets, research and other resources. After reading this book, journalists can have more confidence in deciphering nursing home inspection reports, interviewing advocacy groups on all sides of an issue, locating key data, and more. The book includes story examples and ideas.
AHCJ publishes these reporting guides, with the support of the Robert Wood Johnson Foundation, to help journalists understand and accurately report on specific subjects.
Other resources
Scripps finds inequalities in nursing home care
Lee Bowman and Thomas Hargrove of Scripps Howard News Service looked into nursing homes around the country and found the quality of care to be quite uneven, highlighting the difficulty of finding a good nursing home.
Despite the differences in care, Bowman and Hargrove were able to draw some conclusions from their analysis of the Nursing Home Compare data:
- Institutions run by for-profit corporations generally get lower scores than those run by nonprofits.
- Homes with more nursing staff per patient generally do better in the ratings.
- Homes with more than 100 beds tend to get lower scores
- Ratings are lowest in South and highest for homes in the Northeast.
- Slightly more than 20 percent of nursing homes nationwide have been regularly given the lowest ratings, and 12 percent to 13 percent have received the top rating.
Bowman found that, because of medical concerns, many families are forced to choose a nursing home on a very tight timetable, usually related to a loved one’s hospital discharge date. Concerns like expedience and geographic proximity, then, often end up trumping nursing home quality. To help better direct this process, Bowman offered “Ten things to consider in nursing home care,” only one of which directly relates to the Nursing Home Compare database.
For ideas on how to localize stories on this general theme, check out the rest of the Scripps package.
Slim guide:
Covering the Health of Local Nursing Homes
Check out AHCJ’s latest volume in its ongoing Slim Guide series. This reporting guide gives a head start to journalists who want to pursue stories about one of the most vulnerable populations – nursing home residents. It offers advice about Web sites, datasets, research and other resources. After reading this book, journalists can have more confidence in deciphering nursing home inspection reports, interviewing advocacy groups on all sides of an issue, locating key data, and more. The book includes story examples and ideas.
AHCJ publishes these reporting guides, with the support of the Robert Wood Johnson Foundation, to help journalists understand and accurately report on specific subjects.
Recent workshop
AHCJ’s Aging in the 21st Century workshop, held Oct. 16 and 17 in Miami, addressed many topics raised by the Tribune’s reports, as well as the changing picture of aging Americans and key research and issues related to this growing population. Tip sheets and presentations from that workshop are available to AHCJ members, as are these related tip sheets:
- Aging Nation: Troublesome Health Care Issues
- Headlines an advocate for seniors would like to see
- The impact of aging upon health care
- Covering nursing homes and other issues of aging
- How will retiring boomers affect the national health agenda?
- You Can Run, but You Can’t Hide: Policy and Problems in Long-Term Care
- Biology of Aging: Sources and Resources
600-plus Ill. patients drugged without consent
After a review of 40,000+ inspection reports for Illinois nursing homes, the Chicago Tribune’s Sam Roe reports that the paper found 1,200 violations (affecting 2,900 patients) involving psychotropic drugs since 2001. More than 600 patients were drugged without their consent. According to Roe, “The actual numbers are likely far higher because regulators inspect some facilities just once every 15 months, and even then they usually check only a small sample of residents for harm.”
The violations, many of which were caused by a desire to make patients easier to deal with, were “for ‘chemical restraint’ and ‘unnecessary drugs’ as well as cases involving dosages that exceeded safety standards or falls in which psychotropics possibly played a role.”
While some nursing home residents suffer from major mental illnesses, such as schizophrenia, the inspection reports show that many patients harmed by antipsychotic drugs had not been diagnosed with psychosis. They were disabled by Alzheimer’s disease, cancer or Parkinson’s disease. Some were blind or so frail that they could not breathe without the aid of an oxygen tank.
In a follow-up story, Roe reveals that doctors responsible for these dubious prescriptions are not held accountable, even when cited by government entities.
The Chicago Tribune’s full series on nursing home safety can be found here.
Recent workshop
AHCJ’s Aging in the 21st Century workshop, held Oct. 16 and 17 in Miami, addressed many topics raised by the Tribune’s reports, as well as the changing picture of aging Americans and key research and issues related to this growing population. Tip sheets and presentations from that workshop are available to AHCJ members.
Related tip sheets
Aging Nation: Troublesome Health Care Issues
Headlines an advocate for seniors would like to see
The impact of aging upon health care
Covering nursing homes and other issues of aging
How will retiring boomers affect the national health agenda?
You Can Run, but You Can’t Hide: Policy and Problems in Long-Term Care
Biology of Aging: Sources and Resources
Trib looks into dangerous nursing home residents
The Chicago Tribune’s Gary Marx and David Jackson examined the effectiveness of Illinois regulations implemented in 2006 to protect nursing home residents from potentially dangerous peers. They’ve pulled together some alarming anecdotes and data that show the law is not as effective as hoped.
For example, the reporters focus on the man with a criminal record who attacked by another resident with an ice pick. Just a year after the attack, he ended up in the same facility as his victim again. This time, he slashed him with a box cutter. Obviously, there was a hole somewhere in the new system. Marx and Jackson lay out the facts:
With growing numbers of mentally ill felons entering Illinois nursing homes, the state in 2006 became the first to require criminal background checks as part of an overall risk assessment of new residents. The screenings by state contractors are used to identify high-risk individuals who should live in private rooms and be closely monitored.
But a review of confidential reports in 45 recent cases shows that in many instances the assessments were incomplete, leaving out some criminal convictions and other crucial details.
The project includes a searchable database of safety reports on nursing homes in Illinois, including information not searchable on government sites. Readers can use the database to find out the number of residents at a facility who are convicted felons and sex offenders, crimes reported at Chicago nursing homes and fines levied because of deficiencies in care. Head over to the investigation’s homepage to follow the story and its results.
GAO: Four percent of nursing homes are troubled
A new report from the Government Accountability Office report estimates that 580, or 4 percent, of America’s approximately 16,000 nursing homes are troubled enough to qualify for Centers for Medicare and Medicaid Services “Special Focus Facility” designation. Because of CMS’ limited resources, only 136 are.
Special Focus Facilities, which are evaluated based on deficiencies and revisited to ensure compliance, are chosen from a list of the 15 worst homes in each state. Using more objective criteria based on CMS recommendations, the GAO report found that, in reality, the nation’s worst homes don’t follow such a neat distribution “with 8 states having no such homes and 10 others having from 21 to 52 such homes.”
Legislators, including influential voices like Sen. Herb Kohl, D-Wis. and Sen. Chuck Grassley, R-Iowa, are saying the report shows that the “Special Focus Facility” program should be expanded to include more low-quality homes, Freking reported.
The GAO also released a profile of the most common sort of under-performing nursing home:
The worst-performing ones tend to be for-profit facilities affiliated with a chain of nursing homes. They are more likely to be a larger facility, averaging 102 residents, while other nursing homes not identified as among the worst had 89 residents on average.
Find the full 57-page report here.
Related article
Reporter discovers data missing from federal Nursing Home Compare
Member Duane Schrag of the Salina (Kan.) Journal tells AHCJ how he discovered that certain data was missing from the Nursing Home Compare database and chronicles his efforts to break through the CMS bureaucracy and figure out what was missing and why.
Glitch kept data out of Nursing Home Compare
Filed under: Government, Health data, Health journalism
Duane Schrag of the Salina (Kan.) Journal reports on problems he found in the data behind Nursing Home Compare, the federal government’s online tool to help guide consumers in judging the quality of nursing homes.
Schrag says that an area nursing home announced it was shutting down because it couldn’t comply with a state fire marshal’s requirement to replace its sprinkler system. But a check of the Nursing Home Compare data found no fire safety violations for the facility for 2007 or 2008, despite the fact that it had been cited for several fire code violations in both years.
When the Salina Journal pushed officials to explain why the deficiencies were not showing up, the Centers for Medicare & Medicaid Services discovered a software problem:
But a glitch in the software used by the federal government kept the reports from showing up in Nursing Home Compare. The software blocked more than 1,000 fire code violation reports involving Kansas nursing homes in 2006, a similar number in 2007 and almost 800 in the first six months of 2008.
Nationally, about 21,600 reports were blocked during that same period.
Officials at CMS say the software was fixed on July 23.
Schrag talked to nursing home administrators and found that most of them dispute the rankings that Nursing Home Compare assigns to them; the exception was a nursing home that had a five-star rating.
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Health Journalism 2010, AHCJ's annual conference, features a world-class program with story ideas, sources, stronger reporting skills, chances to meet newsmakers and network with other journalists.
- Health and education: Covering these intersecting beats
- Reporting on the business of health care
- Health reporting resources for journalists on state and local government beats
- Shortened Lives: How location, lifestyle affect health
- Covering a complex story for the long haul
- Aging in the 21st Century: Presentations and tip sheets
- AHCJ calls for better information from Joint Commission Web site
