Nursing Homes
Many Shortcomings Exist in Efforts to Protect Residents from Abuse Gao ID: GAO-02-448T March 4, 2002Often suffering from multiple physical and mental impairments, the 1.5 million elderly and disabled Americans living in nursing homes are a highly vulnerable population. These individuals typically require extensive help with daily living, such as such as dressing, feeding, and bathing. Many require skilled nursing or rehabilitative care. In recent years, reports of inadequate care, including malnutrition, dehydration, and other forms of neglect, have led to mounting scrutiny from state and federal authorities. Concerns have also been growing that some residents are abused--pushed, slapped, or beaten--by the very individuals to whom their care has been entrusted. GAO found that allegations of physical and sexual abuse of nursing home residents are not reported promptly. Local law enforcement officials said that they are seldom summoned to nursing homes to immediately investigate allegations of abuse and that few allegations are ever prosecuted. Some agencies use different policies when deciding whether to refer allegations of abuse to law enforcement. As a result, law enforcement agencies were never told of some incidents or were notified only after lengthy delays. GAO found that federal and state safeguards intended to protect nursing home residents from abuse are inadequate. No federal statute requires criminal background checks for nursing home employees. Background checks are also not required by the Centers for Medicare and Medicaid Services, which sets the standards that nursing homes must meet to participate in the Medicare and Medicaid programs. State agencies rarely recommend that sanctions be imposed on nursing homes. Although state agencies compile lists of aids who have previously abused residents, which can prevent an aide from being hired at another nursing home, GAO found that delays in making these identifications can limit the usefulness of these registries. This testimony summarizes a March report (GAO-02-312).
GAO-02-448T, Nursing Homes: Many Shortcomings Exist in Efforts to Protect Residents from Abuse
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United States General Accounting Office:
GAO:
Testimony:
Before the Special Committee on Aging, U.S. Senate:
For Release on Delivery:
Expected at 1:30 p.m.
Monday, March 4, 2002:
Nursing Homes:
Many Shortcomings Exist in Efforts to Protect Residents from Abuse:
Statement of Leslie G. Aronovitz:
Director, Health Care”-Program Administration and Integrity Issues:
GAO-02-448T:
Mr. Chairman and Members of the Committee:
I am pleased to be here today as you discuss the issue of abuse in
nursing homes. The 1.5 million elderly and disabled individuals
residing in U.S. nursing homes constitute a population that is highly
vulnerable because of their physical and cognitive impairments.
Residents typically require extensive assistance in the basic
activities of daily living, such as dressing, feeding, and bathing,
and many require skilled nursing or rehabilitative care. Residents
with dementia may be irrational and combative. This combination of
impairments heightens the residents' vulnerability to abuse and
impedes efforts to substantiate allegations and build cases for
prosecution.
Our work for this committee on nursing home care quality has found
that oversight by federal and state authorities has increased in
recent years.[Footnote 1] During these years, however, the number of
homes cited for deficiencies involving actual harm to residents or
placing them at risk of death or serious injury remained unacceptably
high--30 percent of the nation's 17,000 nursing homes. Concerns exist
that too many nursing home residents are subjected to abuse-”such as
pushing, slapping, beating, and sexual assault-”by the individuals
entrusted with their care. You therefore asked us to examine efforts
by nursing home oversight authorities to protect residents against
physical and sexual abuse. My remarks today will focus on (1) inherent
difficulties in measuring the extent of the abuse problem, (2) gaps in
efforts to prevent and deter resident abuse, and (3) the limited role
of law enforcement in abuse investigations. My comments reflect the
findings of a report we are issuing today. The report is based on our
visits to three states with relatively large nursing home populations
and discussions with officials at the Centers for Medicare and
Medicaid Services (CMS)-”the federal agency charged with oversight of
states' compliance with federal nursing home standards.[Footnote 2]
In brief, the ambiguous and hidden nature of abuse in nursing homes
makes the prevalence of this offense difficult to determine. CMS
defines abuse in its nursing home regulations and the states we
visited maintain definition consistent with the CMS definition.
However, the states vary in their interpretation and application of
the definitions. For example, nurse aides in two of the states we
visited who struck residents were not considered abusive by state
survey agency officials under certain circumstances, whereas the third
state's nurse aides under similar circumstances were consistently
cited for this offense. Incidents of abuse often remain hidden,
moreover, because victims, witnesses, and others, including family
members, are unable to file complaints or are reluctant for several
reasons, including fear of reprisal. When complaints and incidents are
reported, they are often not reported immediately, thus harming
efforts to investigate cases and obtain necessary evidence.
Despite certain measures in place at various levels to prevent or
deter resident abuse, certain gaps undermine these protections. For
instance, states use a registry to keep records on nurse aides within
the state, but these state registries do not include information about
offenses committed by nurse aides in other states. Unlicensed or
uncertified personnel, such as laundry aides and maintenance workers,
are not listed with a registry or with a licensing or certification
body, allowing those with a history of abuse to be employed without
detection, unless they have an established criminal record. In
addition, in the states we visited, nursing homes often did not notify
state authorities immediately of abuse allegations. Moreover, states'
efforts to inform consumers about available protections appeared
limited, as the government agency pages in telephone books of several
major cities we visited lacked explicitly designated phone numbers for
filing nursing home complaints with the state.
Local and state enforcement authorities have played a limited role in
addressing incidents of abuse. Several local police departments we
interviewed had little knowledge of the state survey agencies'
investigation activities at nursing homes in their communities. Some
noted that, by the time the police are called, others may have begun
investigations, hampering police efforts to collect evidence. Even the
involvement of Medicaid Fraud Control Units (MFCU)”the state law
enforcement agencies with explicit responsibility for investigating
allegations of patient neglect and abuse in nursing homes”is not
automatic. MFCUs get involved in resident abuse cases through
referrals from state survey agencies. However, as demonstrated in the
states we visited, the extent to which a state's MFCU investigates
cases varies according to the referral policies at each state's survey
agency. Our review of alleged abuse cases suggests that the early
involvement of the state MFCU can be productive in obtaining criminal
convictions.
In its federal oversight role, CMS could do more to ensure that
nursing home residents are protected from abuse. Requirements for
screening and hiring prospective employees, involving local law
enforcement promptly when incidents of abuse are alleged, and ensuring
the public's access to designated telephone numbers are among the
protections that CMS could strengthen. Our report makes
recommendations addressing these requirements.
Background:
To help ensure that nursing homes provide proper care to their
residents, a combination of federal, state, and local oversight
agencies and requirements is in place. At the heart of nursing home
oversight activities are state survey agencies, which, under contract
with the federal government, perform detailed inspections of nursing
homes participating in the Medicare and Medicaid programs. The purpose
of the inspections is to ensure that nursing homes comply with
Medicare and Medicaid standards. CMS, in the Department of Health and
Human Services (HHS), is the federal agency with which the states
contract and is responsible for oversight of states' facility
inspections and other nursing-home-related activities.[Footnote 3] By
law, CMS sets the standards for nursing homes' participation in
Medicare and Medicaid.
State survey agencies also investigate complaints of inadequate care,
including allegations of physical or sexual abuse. Once aware of an
abuse allegation, nursing homes are required by CMS to notify the
state survey agency immediately. They must also conduct their own
investigations and submit their findings in written reports to the
state survey agency, which determines whether to investigate further.
Certain federal and state requirements focus on the screening of
prospective nursing home employees. CMS requires nursing homes to
establish policies prohibiting employment of individuals convicted of
abusing nursing home residents. Although this requirement does not
include offenses committed outside the nursing home, the three states
we visited”Georgia, Illinois, and Pennsylvania”do not limit offenses
to those committed in the nursing home setting and have broadened the
list of disqualifying offenses to include kidnapping, murder, assault,
battery, or forgery.
As another protective measure, federal law requires states to maintain
a registry of nurse aides”specifically, all individuals who have
satisfactorily completed an approved nurse aide training and
competency evaluation program.[Footnote 4] This requirement is
consistent with the fact that nurse aides are the primary caregivers
in these facilities. Before employing an aide, nursing homes are
required to check the registry to verify that the aide has passed a
competency evaluation.[Footnote 5] Aides whose names are not included
in a state's registry may work at a nursing home for up to 4 months to
complete their training and pass a state-administered competency
evaluation. CMS' nursing home regulations require states to add to the
registry any findings of abuse, neglect, or theft of a resident's
property that have been established against an individual. The
inclusion of such a finding on a nurse aide's record constitutes a
lifetime ban on nursing home employment, as CMS regulations prohibit
homes from hiring individuals with these offenses. As a matter of due
process, nurse aides have a right to request a hearing to rebut the
allegations against them, be represented by an attorney, and appeal an
unfavorable outcome. Other nursing home professionals who are
suspected of abuse and who are licensed by the state, such as
registered nurses, are referred to their respective state licensing
boards for review and possible disciplinary action.
Among the local and state law enforcement agencies that may
investigate nursing home abuse cases are the MFCUs. MFCUs are state
agencies charged with conducting criminal investigations related to
Medicare and Medicaid. Generally, MFCUs are located in the state
attorney general's office, although they can be located in another
state agency, such as the state police. Part of their mission is to
investigate patient abuse in nursing homes. MFCUs typically receive
abuse cases from referrals by state survey agencies. If criminal
charges are brought, prosecuting attorneys within the MFCU or
attorneys representing the locality take charge of the case.
Ambiguous and Hidden Nature of Nursing Home Abuse Makes Extent of
Problem Difficult to Measure:
The problem of nursing home abuse is difficult to quantify and is
likely understated for several reasons. First, states differ in what
they consider abuse, with the result that some states do not count
incidents that CMS or other states would count as abuse. Second,
powerful incentives exist for victims, their families, and witnesses
to keep silent or delay the reporting of abuse allegations. Third,
some research focuses on citations of nursing homes for abuse-related
violations, which are maintained in a CMS database, but these data
reflect only the extent to which facilities fail to comply with
federal or state regulations. Abuse incidents that nursing homes
handle properly are not counted, because no violation has been
committed that warrants a citation.
States Do Not Share Common View of Resident Abuse:
Some states may not be citing nurse aides for incidents that other
states would consider abuse. Based on the definition of abuse in the
Older Americans Act of 1965,[Footnote 6] CMS defines abuse as "the
willful infliction of injury, unreasonable confinement, intimidation,
or punishment with resulting physical harm, pain or mental anguish."
[Footnote 7] States maintain their own definitions that are consistent
with the CMS definition. Our review of case files showed that states
interpret and apply these definitions differently.
For example, on the basis of the abuse cases reviewed, we noted that
Georgia survey agency officials were less likely to determine that an
aide had been abusive if the aide's behavior appeared to be
spontaneous or the result of a "reflex" response. The Georgia
officials told us that, to cite an aide for abuse, they must find that
the individual's actions were intentional. They said they would view
an instance in which an aide struck a combative resident in
retaliation after being slapped by the resident as an unfortunate
reflex response rather than an act of abuse. Among the Georgia case
files we reviewed, we found 5 cases in which the aides struck back
after residents hit them or otherwise made physical contact. In all
five cases, Georgia officials had determined that the aides' behavior
was not abusive because the residents were combative and the aides did
not intend to hurt the residents.
In Pennsylvania, officials emphasized other factors to determine a
finding of abuse. They said that establishing intention was important,
but they would be unlikely to cite an aide for abuse unless the aide
caused serious injury or obvious pain. Our review of Pennsylvania
files indicated that most of the aides that were found to have been
abusive had, in fact, clearly injured residents or caused them obvious
pain. In several cases reviewed in which residents were bumped or
slapped and reported being in pain as the result of aides' actions,
the survey agency officials decided not to take action against the
aides because, in their view, the residents had no apparent physical
injuries.
In contrast, the Illinois survey agency considers any nonaccidental
injury to be abuse. Thus, incidents not considered abusive in Georgia
and Pennsylvania”reflex actions and incidents not involving serious
injury or obvious pain”could be considered abusive in Illinois. In the
17 Illinois case files we reviewed involving either combative
residents or residents who did not suffer serious injury, officials
found that aides had been abusive. When Illinois handled a case
similar to a Georgia case in which a nursing home employee witnessed a
nurse aide strike a combative resident, the state not only included
this information in the individual's nurse aide registry file, it also
referred the matter to the state's MFCU, resulting in a criminal
conviction.[Footnote 8]
CMS officials indicated that states may use different definitions of
abuse, as long as the definitions are at least as inclusive as the CMS
definition. The officials agreed that intent is a key factor in
assessing whether an aide abused a resident but argued that intent can
be formed in an instant. In their view, an aide who slaps a resident,
regardless of whether it was a reflexive response, should be
considered abusive. In light of these different perspectives, we have
recommended that CMS clarify the definition of abuse to ensure that
states cite abuse consistently and appropriately.
People May Be Unable or Reluctant to Report Abuse Allegations:
The physical and mental impairments typical of the nursing home
population handicap residents' ability to respond to abuse. Some
residents lack the ability to communicate or even realize that they
have been abused, while others are reluctant to report abuse because
they fear reprisal. For these reasons, elder abuse in nursing homes is
likely underreported or often not reported immediately. In some cases,
residents are unable to complain about what was done to them. In other
cases, family members may hesitate to report their suspicions because
they fear retribution or that, if reported, the resident will be asked
to leave the home. In still other cases, facility staff fear losing
their jobs or recrimination from coworkers, while facility management
may not want to risk adverse publicity or sanctions from the state. In
our file reviews, we saw evidence that family members, staff, and
management did not immediately report allegations of abuse. (See
figure.)
Figure: Examples of Allegations Not Immediately Reported:
[Refer to PDF for image: text box]
* A resident reported to a licensed practical nurse that she had been
raped. Although the nurse recorded this information in the resident's
chart, she did not notify the facility's management. The nurse also
allegedly discouraged the resident from telling anyone else. About 2
months later, the resident was admitted to the hospital for unrelated
reasons and told hospital officials she had been raped. Once hospital
officials notified the police, an investigation was conducted and
revealed that the resident had also informed her daughter of the
incident, but the daughter dismissed it. The resident later told
police that she did not report the incident to other staff because she
did not want to cause trouble. The case was closed because the
resident could not describe the alleged perpetrator. However, the
nurse was counseled about the need to immediately report such
incidents.
* An aide, angry with a resident for soiling his bed, threw a pitcher
of cold water on him and refused to clean him. Another aide witnessed
the incident. Instead of informing management, the witness confided in
a third employee, who reported the incident to the nursing home
administrator 5 days after the abuse took place. The aide who threw
the water on the resident was fired and was cited for resident abuse
in the state's nurse aide registry.
* Nursing home management failed to promptly notify the state survey
agency of an incident in which an aide slapped a resident and visibly
bruised the victim's face. Although the home investigated the
situation and took appropriate action by quickly suspending and
ultimately firing the aide, it did not notify the state survey agency
until 11 days after the abuse took place.
Source: Case files from state survey agencies in Georgia and
Pennsylvania.
[End of figure]
Data on States' Nursing Home Citations Provide Little Information
About Resident Abuse:
Data from states' annual inspections of nursing homes, while a source
of information about facility compliance with nursing home standards,
provide little precision about the extent of care problems, of which
resident abuse-related problems are a subset. Abuse-related violations
committed by nursing homes include failure to protect residents from
sexual, physical, or verbal abuse; failure to properly investigate
allegations of resident abuse or to ensure that nursing home staff
have been properly screened before employment; and failure to develop
and implement written policies prohibiting abuse.
In 2000, we reported on the wide variation across states in surveyors'
identification and classification of serious deficiencies”conditions
under which residents were harmed or were in immediate jeopardy of
harm or death.[Footnote 9] The extent to which abuse-related
violations are counted as serious deficiencies depends on how the
surveyor classifies the severity of the deficiency identified. In our
analysis, the problem of "interrater reliability"”that is, individual
differences among surveyors in citing homes for serious deficiencies”
was one of several factors contributing to the difference of roughly
48 percentage points across states in the proportion of homes cited in
1999 and 2000 for serious deficiencies. The variation ranged from
about 1 in 10 homes cited in one state to more than 1 in 2 homes cited
in another.
We also found that one state's tally of nursing homes with serious
deficiencies would have been highly misleading as an indicator of
serious care problems. Of the homes the state surveyed during the 1999-
2000 period, it found 84 to be "deficiency free." However, when we
crosschecked the annual inspection results for these homes with the
homes' history of complaint allegations, we found that these
deficiency-free homes had received 605 complaints and that significant
numbers of these complaints were substantiated when investigated. This
discrepancy illustrates the difficulty of estimating the extent of
resident abuse using nursing home inspection data.
Gaps Exist in Efforts to Prevent or Deter Resident Abuse:
Nursing home residents' inability to protect themselves accentuates
the need for strong preventive measures to be in place in both nursing
homes and the agencies overseeing them. Although certain measures are
in place, we found them to be, in some cases, incomplete or
insufficient. In the states we visited, efforts to screen employees
and achieve prompt reporting fell short of creating a net sufficiently
tight to protect residents from potential offenders.
Sources Used to Screen Prospective Employees Do Not Contain Complete
or Up-to-Date Information:
Nursing homes have available three main tools to screen prospective
employees: criminal background checks conducted by local law
enforcement agencies, criminal background checks conducted by the
Federal Bureau of Investigation (FBI), and state registries listing
information on nursing home aides, including any findings of abuse
committed in the state's facilities. The information included in these
sources, however, is often not complete or up to date.
State and local law enforcement officials in the three states we
visited conduct background checks on prospective nursing home
employees, but these checks are made only state wide. Consequently,
individuals who have committed disqualifying crimes”including
kidnapping, murder, assault, battery, and forgery”may be able to pass
muster for employment by crossing state lines. On request, the FBI
will conduct background checks outside the prospective employee's
state of residence, but in some states these requests are rarely made,
according to an FBI official.
Some states allow individuals to begin working before facilities
complete their background checks. Pennsylvania permits new employees
to work for 30 days and Illinois, for 3 months, before criminal
background checks are completed. In contrast, Georgia requires that
background checks be completed within 3 days of the request and
interprets this requirement to mean that the checks must be completed
before prospective employees may assume their duties.
Of the three states we visited, only Illinois requires that the
results of criminal background checks on prospective nurse aides be
reported to the state survey agency, which enters the information in
the registry. A 1998 survey conducted by BIB' Office of Inspector
General reported that Illinois was the only state with this
requirement.[Footnote 10] Nursing homes in Illinois checking the state
registry are able to determine if an aide has a disqualifying
conviction well before an offer of employment is made and a criminal
background check is initiated. Alternatively, the survey agencies in
states without this requirement do not have the information necessary
to warn their respective nursing home communities about inappropriate
individuals seeking employment.
Nurse aide registries, designed to maintain background information on
nursing home aides, also contain information gaps that can undermine
screening efforts. To cite an individual in the state's registry for a
finding of abuse, authorities must first establish a finding, notify
the individual of the intent to "annotate" the registry, and if the
individual requests, hold a hearing to consider whether the finding is
warranted. Specifically, the individual must be notified in writing of
the state's intent to annotate the registry and be given 30 days from
the date of the state's notice to make a written request for a
hearing. Because the hearing may not be completed for several months
after it is requested and decisions may not be rendered immediately,
additional time may elapse. As with background checks, state
registries do not track an aide's offenses committed at nursing homes
in other states.
Our analysis of nurse aide records from 1999 indicated that hearings
to reconsider an abuse finding added, on average, 5 to 7 months to the
process of annotating an individual's record in the state registry.
During this time, residents of other nursing homes were at risk
because, even if an aide was terminated from one home, the individual
could find new employment in other homes before the state's registry
included information on the individual's offense. Thus, because of the
amount of time that can elapse between the date a finding is
established and the date it is published, the use of nurse aide
registries as a screening tool alone is inadequate.
Facilities can screen licensed personnel, such as nurses and
therapists, by checking the records of licensing boards for
disciplinary actions, but screening other facility employees, such as
laundry aides, security guards, and maintenance workers, is limited to
criminal background checks. Unless such employees are convicted of an
offense, problems with their prior behavior will not be detected. No
centralized source contains a record of substantiated abuse
allegations involving these individuals. Even when abuse violations
identified through nursing home inspections are cited, they result in
sanctions against the homes and not the employees. We identified 10
uncertified and unlicensed employees in the 158 cases we reviewed who
allegedly committed abuse. One of the 10 pled guilty in court, thus
establishing a criminal record. However, the disposition of five of
these cases left no way to track the individuals through routine
screening channels. Three of the nine”all of whom were dismissed from
their positions”were investigated by law enforcement but were not
prosecuted. Two others were also terminated by their nursing home
employers but were not the subject of criminal investigations. (In
these cases, physical abuse was alleged but the residents did not
sustain apparent injuries.) The remaining four cases involved
instances in which the allegations proved unfounded or the evidence
was inconsistent; the individuals were thus not tracked, as
appropriate.
In 1998, the HHS Office of the Inspector General recommended
developing a national abuse registry and expanding state registries to
include not only aides but all other nursing home employees cited for
abuse offenses.[Footnote 11] A firm that CMS (then the Health Care
Financing Administration) contracted with in September 2000 is
currently conducting a feasibility study regarding the development of
a national registry that would centralize nurse aide registry
information and include information on all nursing home employees. The
contractor intends to report its findings in March 2002.
Efforts to Alert Authorities of Abuse Incidents and Allegations Lack
Sufficient Rigor:
Enlisting the help of the facilities and the public to report
incidents and allegations of abuse can supplement other efforts to
protect nursing home residents. However, in the states we visited,
nursing homes' performance in notifying the survey agencies promptly
was well below par. In addition, access to information on phone
numbers the public could use for filing complaints was limited.
In the three states we visited, nursing homes are required to notify
their state survey agencies of abuse allegations immediately, which
the agencies define as the day the facility becomes aware of the
incident or the next day. Using this standard, we examined 111 abuse
allegations filed by the three states' nursing homes. We found that,
for these allegations, the homes in Pennsylvania notified the state
late 60 percent of the time; in Illinois, late almost half of the
time; and in Georgia, late about 40 percent of the time. Each state
had several cases for which homes notified the state a week or more
late and in each state at least one home notified the state more than
2 weeks late. Such time lags delay efforts by the survey agencies to
conduct their own prompt investigations and ensure that nursing homes
are taking appropriate steps to protect residents. In these
situations, residents remain vulnerable to additional abuse until
corrective action is taken.
As a nursing home resident's family and friends are another essential
resource for reporting abuse to the state authorities, increasing
public awareness of the state's phone number for filing complaints
should be a high priority. CMS requires nursing homes to post phone
numbers for making complaints to the state. However, in major cities
of the states we visited, phone numbers specifically for lodging
complaints to the state survey agency were not listed in the telephone
book. This was the case in Chicago and Peoria, Illinois; in Athens and
Augusta, Georgia; and in Philadelphia and Pittsburgh, Pennsylvania.
At the same time, the telephone books we examined listed numbers in
the government agency pages for organizations that appeared to be
appropriate for reporting abuse allegations but did not have authority
to take action. In the telephone books of selected cities in the three
states we visited, we identified listings for 42 such entities that
were not affiliated with the state survey agencies. Of these, six
entities said they were capable of accepting and acting on abuse
allegations. These included long-term care ombudsmen and adult
protective services offices. The other 36 either could not be reached
or could not accept complaints, despite having listings such as the
"Senior Helpline" or the "Fraud and Abuse Line." Sometimes these
entities attempted to refer us to an appropriate organization to
report abuse, with mixed success. For example, calls we made in
Georgia resulted in four correct referrals to the state survey
agency's designated complaint intake line but also led to five
incorrect referrals. Five entities offered us no referrals.
Law Enforcement's Involvement in Protecting Residents Is Limited:
The involvement of law enforcement in protecting nursing home
residents has generally been limited. Owing to the nature of the
nursing home population, developing adequate evidence to investigate
and prosecute abuse cases and achieve convictions is difficult. The
states we visited had different policies for referring cases to law
enforcement agencies.
Residents' Impairments Weaken Law Enforcement's Efforts to Develop
Cases:
Critical evidence is often missing in elder abuse cases, precluding
prosecution. Our review of states' case files included instances in
which residents sustained black eyes, lacerations, and fractures but
were unable or unwilling to describe what had happened. However,
despite what appeared to be signs of abuse, investigators could
neither rule out accidental injuries nor identify a perpetrator.
The cases that are prosecuted are often weakened by the time lapse
between the incident and the trial. Law enforcement officials and
prosecutors indicated that the amount of time that elapses between an
incident and a trial can ruin an otherwise successful case, because
witnesses cannot always retain essential details of the incident. For
example, in one case we reviewed, a victim's roommate witnessed an
incident of abuse and positively identified the abuser during the
investigation. By the time of the trial nearly 5 months later,
however, the witness could no longer identify the suspect in the
courtroom, prompting the judge to dismiss the charges. Law enforcement
officials told us that, without testimony from either a victim or
witness, conviction is unlikely. Similarly, resident victims may not
survive long enough to participate in a trial. A recent study of 20
sexually abused nursing home residents revealed that 11 died within 1
year of the abuse.[Footnote 12]
Local Law Enforcement Authorities in States Visited Not Frequently
Involved With Nursing Home Abuse Incidents:
In the states we visited, local law enforcement authorities did not
have much involvement in nursing home abuse cases. Our discussions
with officials from 19 local law enforcement agencies indicate that
police are rarely summoned to nursing homes to investigate allegations
of abuse. Of those 19 agencies, 15 indicated that they had little or
no contact with their state's survey agency regarding abuse of nursing
home residents in the past year. In fact, several police departments
we interviewed were unaware of the role state survey agencies play in
investigating instances of resident abuse. Several of the police
officials we met with noted that, even when the police are called,
other entities may have begun investigating, hampering further
evidence collection.
Involving law enforcement authorities does not appear to be common for
abuse incidents occurring in nursing homes. Facility residents and
family members may report allegations directly to the facility. There
is no federal requirement compelling nursing homes that receive such
complaints to contact local law enforcement, although some states,
including Pennsylvania, have instituted such requirements.
MFCUs Not as Involved as Their Mission Would Suggest:
The involvement of MFCUs”-the state law enforcement agencies whose
mission is to, among other things, investigate allegations of patient
neglect and abuse in nursing homes”-is not automatic. MFCUs get
involved in resident abuse cases through referrals from state survey
agencies. Each of the states we visited had a different referral
policy. In Pennsylvania, by agreement, the state's MFCU typically
investigates nursing home neglect matters, while local law enforcement
agencies investigate nursing home abuse. In contrast, the survey
agencies in Illinois and Georgia both refer allegations of resident
abuse to their states' MFCUs, but these two states' referral policies
also differ from one another.
Of the cases we reviewed in Illinois, the survey agency consistently
referred all reports of physical and sexual abuse to the state's MFCU,
regardless of whether the source of the report was an individual or a
nursing facility. The Illinois MFCU, in turn, determined whether the
cases warranted opening an investigation. The Georgia survey agency,
on the other hand, screened its allegations before referring cases to
the state's MFCU, basing its assessment of a case's merit on the
severity of the harm done and the potential for the MFCU to obtain a
criminal conviction.
Our review of case files from Illinois and Georgia suggests that the
more the state's MFCU is involved in resident abuse investigations,
the greater the potential to convict offenders.[Footnote 13] (This
case file review consisted of only those cases that were opened in
1999 and closed at the time of our review.) The Illinois MFCU obtained
18 convictions from 50 unscreened referrals. In Georgia, however,
where the survey agency tried to avoid referring weak cases to the
state's MFCU, 14 of 52 cases were referred and 3 resulted in
convictions. The state's small number of convictions from the cases
opened in 1999 was not consistent with the expectation that
prescreened cases would have greater potential for successful
prosecution.[Footnote 14]
In 2000, the Georgia survey agency substantially changed its MFCU
referral policy, leading to a four-fold increase in the state's total
number of referrals from the previous year. The policy change followed
a meeting between survey agency and MFCU officials, at which the MFCU
indicated a willingness to investigate instances that the survey
agency had previously assumed the MFCU would have dismissed”such as
incidents involving nursing home employees slapping residents.
The timeliness of referrals made to the MFCU may also play a role in
achieving favorable results. Of the 64 cases referred in the two
states, we determined that the Illinois survey agency referred its
cases to the MFCU earlier than did Georgia's Illinois referred its
cases, on average, within 3 days after receiving a report of abuse,
whereas Georgia referred its cases, on average, 15 days after learning
about an allegation.
Concluding Observations:
The problem of resident abuse in nursing homes is serious but of
unknown magnitude, with certain limitations in the adequacy of
protections in the states we visited. Nurse aide registries provide
information on only one type of employee, are difficult to keep
current, and do not capture offenses committed in other states. At the
same time, local law enforcement authorities are seldom involved in
nursing home abuse cases and therefore are not in a position to help
protect this at-risk population. MFCUs, which are likely to have
expertise in investigating nursing home abuse cases, must rely on the
state survey agencies to refer such cases. When a state's referral
policy is overly restrictive, the MFCU is precluded from capitalizing
on its potential to bring offenders to justice.
Several opportunities exist for CMS to establish new safeguards and
strengthen those now in place. Our report includes recommendations for
CMS to, among other things, clarify what is included in CMS'
definition of abuse and increase the involvement of MFCUs in examining
abuse allegations. Without such improvements, vulnerable nursing home
residents remain considerably ill-protected.
Mr. Chairman, this concludes my prepared remarks. I will be pleased to
answer any questions you or the committee members may have.
Contact and Acknowledgments:
For further information regarding this testimony, please contact me or
Geraldine Redican-Bigott, Assistant Director, at (312) 220-7600. Sari
Bloom, Hannah Fein, and Lynn Filla-Clark made contributions to this
statement.
[End of section]
Footnote:
[1] U.S. General Accounting Office, Nursing Homes: Sustained Efforts
Are Essential to Realize Potential of the Quality Initiatives,
[hyperlink, http://www.gao.gov/products/GAO/HEHS-00-197] (Washington,
D.C.: 2000).
[2] U.S. General Accounting Office, Nursing Homes: More Can Be Done to
Protect Residents from Abuse, [hyperlink,
http://www.gao.gov/products/GAO-02-312] (Washington, D.C.: 2002).
[3] CMS was formerly the Health Care Financing Administration (HCFA)
and was renamed in June 2001.
[4] In certain instances, some individuals would be exempt from this
training, such as student nurses or nurses trained in another country.
[5] Nursing homes in the states we visited have several means of
checking the nurse aide registries to determine whether aides are in
good standing and eligible for employment. Homes receive quarterly
bulletins listing all disqualified aides in their state. In addition,
they may obtain this information from the survey agency's website or
by calling the survey agency.
[6]] 42 U.S.C. § 2002 (1994).
[7] 42 C.F.R. § 488.301 (2001).
[8] As a result, the aide was sentenced to 2 years probation, directed
to complete 100 hours of community service, and prohibited from
employment that would involve contact with the elderly or people with
disabilities.
[9] [hyperlink, http://www.gao.gov/products/GAO/HEHS-00-197].
[10] HHS Office of Inspector General, Safeguarding Long-Term Care
Residents, A-12-9700003 (Washington, D.C.: Sept. 14, 1998).
[11] HHS Office of Inspector General, A-12-97-00003.
[12] Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky,
"Sexual Abuse of Nursing Home Residents," Journal of Psychosocial
Nursing, Volume 38, No. 6, June 2000.
[13] Because of Pennsylvania's referral policy, its MFCU files, with a
few exceptions, did not include resident abuse cases.
[14] Georgia's conviction results are lower than might be expected
also given the state survey agency's practice of disregarding abuse
allegations in which patient provocation is a factor.
[End of section]
