Resources of Record

Carole L. Farace
Katherine D. Johnson
P.O. Box 771774
Orlando, FL 32877
407-856-6949
904-672-9569
866-856-7705 (Fax)
info@healthcarelegalconsultants.com
healthcarelegalconsultants.com

DEFINITIONS
Dehydration
Malnutrition
Pressure Sores
Starvation

Nursing Homes:
Licensed to Kill?

“If I ever need to go to a nursing home, just shoot me.”

Who hasn’t said or heard this from a loved one?  Nursing home horror stories abound. As a former police officer who had recently lost his father in a nursing home told a U.S. Senate Committee hearing in Florida, in his opinion nursing homes have a license to commit murder.

The tragic truth is that the nursing home industry, for the most part, behaves as just that: an industry that houses our elderly loved ones at the lowest cost possible. This means: 

• Minimal qualifications
• Inadequate staffing
• Insufficient training
• Low wages and high turnover

It would be tragic enough if it affected only a few nursing homes in a few localities, but the problem is nationwide and involves millions of patients in thousands of nursing homes.

A dramatic report prepared by the House Committee on Government Reform for Rep. Henry A. Waxman (D-CA) found that between January 1999 and January 2001 more than 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. That is almost one out of every three nursing homes, and many of these abuse violations were discovered only after the filing of a formal complaint. (View the Waxman report. Downloading time and Adobe Acrobat Reader required.)

Nursing Home Numbers

In 1997, about 1.5 million elderly residents – most of them white, widowed women who were functionally dependent – lived in the nation’s 16,995 nursing facilities on any given day. 

The numbers, however, mask the sobering truth that residents are being shuttled out as rapidly as they are being admitted.  According to the National Center for Health Statistics (NCHS) of the U.S. Department of Health and Human Services, 2.1 million elderly were discharged from nursing homes from October 1996 to September 1997, mostly to be hospitalized or because they had died.  This was an increase of about 900,000 over the previous year.

A little more than half of the homes are owned or leased as part of a chain.  Another 13 percent are hospital-based, and the remainder are individually owned and operated.

We want to believe that the professionals who take care of our elderly in these homes are qualified, caring and compassionate.  We equate their white uniforms with quality. But is it true?

Minimally Qualified

Even car mechanics in television commercials wear white coats to indicate how qualified they are to care for your car.  Unfortunately, although those who work in nursing homes are generally dedicated and compassionate, their white uniforms and quality care do not necessarily equate.

Registered nurses (RNs), licensed practical nurses (LPNs) and nursing assistants in nursing homes must meet minimum professional qualifications.  Each state has its own requirements, but a few generalizations can be made.

Administrators:  No state requires a nursing home administrator to have any clinical background or extensive experience in health care management.  Most require at least a bachelor’s degree, but some still do not require even an associate’s degree.  Generally, all that is required is internship-like experience in long term care, under the direct supervision of another administrator, and completion of national and state-specific exams. 

Directors of Nursing:  The person responsible for overseeing all clinical procedures and operations may or may not be required to have a four-year college degree and generally is not required to be experienced in acute (hospital) care, even though today’s nursing home residents typically arrive with multiple diagnoses. 

In most cases, minimal experience in long-term care – as little as two years in some states – is all that is required. Acceptance of this inadequacy tends to trickle down to lower staff. 

This generally means that RNs and LPNs are unable to evaluate accurately their residents’ clinical needs and are not motivated to acquire those skills. They in turn are promoted to the responsibilities of nursing directors without the skills they should have to assess residents’ needs thoroughly, perpetuating the cycle of inadequate qualifications.

The problem is compounded by serious under-staffing in order to maximize nursing home profits. 
 

Inadequate Staff

Researchers report a direct link between the number of direct nursing care hours a resident receives each day and the number of facility deficiencies and patient problems.  The equation is simple:  the more staff time per resident, the fewer the problems.  Under-staffing contributes to most reports of severe pressure ulcers, malnutrition, abnormal weight loss, infection and other problems all too common among nursing home residents.

An eight-year study of 1,786 nursing homes in three states calculated that staffing levels permit the average nursing home resident only 12 minutes of care a day from an RN, and 45 minutes a day from total licensed staff (RNs and LPNs combined).  Twelve minutes of nursing care a day is hardly sufficient to assess comprehensively and accurately a resident’s clinical needs, given that the average nursing home resident has multiple diagnoses.

Patients are also cared for by certified nursing assistants, each typically responsible for 15 to 20 residents per 7.5-hour shift.  This means at best an average of a half hour per resident.  All daily and individual daily activities that residents need help performing must be completed within this time frame.

•	Most residents need help with at least three routine daily activities:  bathing, dressing, eating, moving between bed and chair, and using the toilet.
•	Most also need help with individual activities:  using the telephone, taking care of and securing personal possessions, money management, etc.

It is little wonder that residents of facilities that fall below these staffing levels experience significantly more problems.
 

For-Profits vs. Not-for-Profits

Staffing shortages are greater in the two-thirds of nursing homes that are operated for profit than among the 27 percent that are nonprofit and the 7 percent that are government-run.  To maximize revenues, the for-profits maintain on average 20 percent lower staffing.  The result is that these homes have 30 percent more deficiencies in both quality-of-care and quality-of-life.

The problems caused by having too few staff to serve residents’ needs is compounded by lack of staff training in diagnosing patients health needs.  Training and continuing education of professional staff might remedy this.  It, too, is seriously lacking.
 

Insufficient Training

Compliance with state and federal training regulations amounts to little more than satisfying minimum requirements. 

Training is typically provided in-service and only offered in reaction to a discovered problem.  Typically, this means RNs and LPNs are trained “on the fly.”  They receive remedial in-service training only after a problem has been identified:  a resident had to suffer before the training was offered.

Coupled with under-staffing and inadequate training, low wages typically paid by nursing homes means high turnover, which makes the need for training all the more critical.
 

Low Wages, High Turnover

In 1998, the average U.S. hourly wage for nursing assistants was $6.58, but wages in nursing facilities are substantially lower than those paid by hospitals.  Many nursing home employees also receive only limited health benefits, if any.

High staff turnover is the natural result of the frustrations born of inadequate training, inadequate time to serve residents who need care, and inadequate wages.  This turnover contributes to further declines in care and increased need for quality training.

Turnover averaged 93 percent for nursing assistants in 1997 and 51 percent for RNs.  Serious staff shortages resulted nationwide.  Increased wages and benefits, and improved working conditions, are urgently needed for nursing facility employees in order to build a strong, stable, well-trained and reliable workforce. 

For these failures, the resident-patients of nursing homes, their families, and society at large pay a high price. 
 

The High Cost of Nursing Care

Each year U.S. families spend $490 million out-of-pocket for nursing home care, but the majority of nursing facility services are paid for by taxpayers, through Medicare and Medicaid.

Most nursing homes provide three levels of care – subacute (most residents need rehabilitative services for only a limited time); skilled (more intensive than traditional long-term care but less than hospital care); and long-term (for residents with chronic diseases).

A one-year stay in a Florida nursing home, for example, can cost more than $38,000, but care for persons with chronic conditions can run as high as $200 to $500 per day in south Florida – up to $15,000 a month, $180,000 a year.

Medicare and Medicaid funding gives the federal government authority to regulate those nursing homes that accept such funds, which most do.  Regulation, however, is not uniform.

The Regulators

Each year survey teams make "unannounced" visits to inspect nursing homes that receive Medicare and Medicaid funds, but their inspections yield inconsistent and inadequate results, not only because staffing and training standards are so low, but also because:

•	Visits are usually anticipated:  each nursing home is surveyed 9-15 months from thedate it is licensed by Centers for Medicare and Medicaid Services (CMS) formerly Health Care Finance Administration (HCFA), so most homes prepare for its initial unannounced survey knowing it will happen within that window and annually thereafter.
•	Each team decides what violations to cite and the severity of citations and fines. Homes in violation also can be required to stop admitting new residents until corrections are made.  The process is subjective, however; a different team may or may not cite the same violations.

The surveys and certification of homes are done by the federal, which administers Medicare and Medicaid funding.  Survey teams generally include a nurse, a social worker, an activity person and, sometimes, a dietitian. They examine records, visit 10 percent of the residents, and inspect a range of things, from hallway cleanliness to specific care.

Their greatest value may be that their findings are required to be posted prominently in the nursing home, giving the public at least one tool in shopping for a nursing home. 

The shortcomings of the nursing home industry has not gone unnoticed by politicians, but reform efforts are slow in producing results.

Reform Efforts

Nursing facility needs were placed on the national policy agenda in the fall of 2000 when President Clinton proposed $1 billion in aid to help states address nursing home staffing shortages.  Also, legislation was introduced in the U.S. Senate to require CMS to establish minimum nurse staffing requirements and to boost staffing levels in nursing facilities by $1 billion over two years.

Further, during the past two years 17 states have enacted legislation to increase staffing requirements.  California, for example, now requires a minimum of 3.2 direct care hours per resident per day.  Delaware requires at least three direct care hours per resident each day beginning this year, increasing to 3.67 hours daily in 2003.  Florida, however, still lags at 1.7 hours per day, despite a nursing home population with higher than average diagnosed health problems.  Eighteen states require more than Florida’s 10 minutes of licensed nurse care per patient each day.

Continued public outcries and pressure on lawmakers are needed if nursing homes are to improve.  By permitting the profiteering of “big business” approaches to care for the elderly, we literally give investor-owned facilities a license to kill our loved ones.  The only ones who benefit from the nation’s nursing homes will continue to be their owners.

Looking for a Home

When shopping for a nursing home, most families look first at the aesthetic qualities of the home’s exterior – its yard and other “home-like” amenities.  Cautious shoppers will look beyond these outward appearances and consider:
 

•	What is the facility’s survey history? A copy of the latest inspection must be posted conspicuously inside the facility.
•	Are staff members aware of the survey results?  If so, have they corrected deficiencies that were found?  All homes are required to produce a correction plan after each survey.
•	How many staff members are on each shift?  The facility will meet minimum staffing requirements, but these may not be adequate to address residents’ medical needs around the clock.
•	Are top administrators accessible?  Ask residents and family members how long they have been at the home and if they know the administrator and director of nursing.  If someone has been in a facility for longer than three months and doesn’t know the administrator and director of nursing, it may signal that not enough interaction occurs between supervisors and staff to ward off medical complications.