Nursing Homes: Complaint Investigation Processes Often Inadequate to Protect Residents

Published by the Government Accountability Office on 1999-03-22.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to the Chairman and Ranking
                 Minority Member, Special Committee on
                 Aging, U.S. Senate

March 1999
                 NURSING HOMES

                 Processes Often
                 Inadequate to Protect

      United States
GAO   General Accounting Office
      Washington, D.C. 20548                                                                           Leter

      Health, Education, and Human Services Division

      B-281767                                                                                  Letter

      March 22, 1999

      The Honorable Charles E. Grassley
      The Honorable John B. Breaux
      Ranking Minority Member
      Special Committee on Aging
      United States Senate

      The 1.6 million elderly and disabled residents confined to nursing homes
      are a highly vulnerable population. They are frequently dependent on
      extensive assistance in basic activities of daily living like dressing,
      grooming, feeding, and using the bathroom, and many require skilled
      nursing or rehabilitative care. The vast majority of nursing homes
      participate in Medicare and Medicaid and are expected to receive nearly
      $39 billion in federal payments from these programs in 1999. For these
      nursing homes, providing adequate care is a federal mandate backed by
      about $210 million in federal funding going to state agencies that inspect
      and certify nursing homes’ compliance with quality standards through
      annual surveys and complaint investigations. About $42 million of this
      goes to fund investigations of complaints that are lodged by various
      sources, including residents, their families, and nursing home employees,
      and incidents of potential abuse or neglect that nursing homes report to

      In our July 1998 report to you, we found that unacceptable care was a
      problem in many California nursing homes, including one in three where
      state surveyors identified serious or potentially life-threatening care
      problems. We also reported that federal and state oversight is not
      sufficient to guarantee the safety and welfare of nursing home residents. 1
      In a companion report issued last week, we further found that current
      federal enforcement efforts cannot ensure sustained compliance with
      federal standards for nursing home care.2

      Concerned that annual surveys alone are inadequate to meet the federal
      goal of ensuring nursing home residents’ health and safety, you asked us to
      examine how states implement the federal requirement that states

      1California Nursing Homes: Care Problems Persist Despite Federal and State Oversight (GAO/HEHS-98-
      202, July 27, 1998).

       Nursing Homes: Additional Steps Needed to Strengthen Enforcement of Federal Quality Standards
      (GAO/HEHS-99-46, Mar. 18, 1999).

      Page 1                                            GAO/HEHS-99-80 Nursing Home Complaints

                   establish a process for nursing home complaint investigations. Complaint
                   investigations offer a unique opportunity to identify and correct potential
                   care problems because they can provide a more timely alert than annual
                   inspections, and they target specific areas of potential problems identified
                   by residents, their families, the concerned public, and even the facility
                   itself. Specifically, this report assesses the effectiveness of (1) state
                   complaint investigation practices as a component of the system to ensure
                   sustained compliance with federal nursing home quality-of-care standards
                   and (2) the Health Care Financing Administration’s (HCFA) role in
                   establishing standards and conducting oversight of states’ complaint
                   investigation practices and in using information about the results of
                   complaint investigations to ensure compliance with nursing home
                   standards. We assessed complaint investigation practices in Maryland,
                   Michigan, and Washington State; reviewed state auditors’ reports from
                   11 other states;3 and examined HCFA’s policies and procedures for
                   overseeing state complaint investigation activities. Appendix I provides
                   more details about our scope and methodology.

Results in Brief   Federal and states’ practices for investigating complaints about care
                   provided in nursing homes are often not as effective as they should be.
                   Among many of the 14 states we examined, we found numerous problems,

                   • procedures or practices that may limit the filing of complaints,
                   • understatement of the seriousness of complaints, and
                   • failure to investigate serious complaints promptly.

                   Serious complaints alleging that nursing home residents are being harmed
                   can remain uninvestigated for weeks or months. Such delays can prolong
                   situations in which residents may be subject to abuse, neglect resulting in
                   serious care problems like malnutrition and dehydration, preventable
                   accidents, and medication errors.

                   Although federal funds finance over 70 percent of complaint investigations
                   nationwide, HCFA plays a minimal role in providing states with direction

                     The state reports examined Iowa, Kansas, Kentucky, Louisiana, New York, North Carolina, Ohio,
                   Pennsylvania, Tennessee, Texas, and Wisconsin. These reports were produced by either the state
                   auditor or similar organizations, such as the Office of Inspector General. In this report, we refer to
                   these reports as state auditor reports.

                   Page 2                                                 GAO/HEHS-99-80 Nursing Home Complaints

             and oversight regarding these investigations. HCFA has left it largely to the
             states to decide which complaints potentially place residents in immediate
             jeopardy and must be investigated within the federally mandated 2
             workdays. If a serious complaint that could harm residents is not classified
             as potentially placing residents in immediate jeopardy, there is no formal
             requirement for prompt investigation. More generally, HCFA’s oversight of
             state agencies that certify federally qualified nursing homes has not
             focused on complaint investigations. We found that

             • a HCFA initiative to strengthen federal requirements for complaint
               investigations was discontinued in 1995, and resulting guidance
               developed for states’ optional use has not been widely adopted;
             • federal reviews of state nursing home inspections are primarily intended
               to focus on the annual surveys of nursing homes, and very few reviews
               are conducted of complaint investigations;
             • since 1998, HCFA has required state agencies to develop their own
               performance measures and quality improvement plans for their
               complaint investigations, but for several of the 14 states we reviewed,
               such assessments addressed complaint processes superficially or not at
               all; and
             • HCFA reporting systems for nursing homes’ compliance history and
               complaint investigations do not collect timely, consistent, and complete

             We are recommending stronger federal requirements for states to promptly
             investigate serious complaints alleging situations that may harm residents
             but are not classified as immediate jeopardy, increased federal monitoring
             of states’ performance in responding to complaints, and improved tracking
             of the substantiated findings of complaint investigations. Such steps can
             strengthen the ability of federal and state regulators to use complaint
             investigations to protect and improve the care nursing home residents

Background   Nearly all nursing homes accept residents with either Medicare or Medicaid
             and are projected to receive nearly $39 billion in federal payments from
             these programs in 1999. The federal government, through HCFA, has
             responsibility for establishing requirements that nursing homes must meet
             to participate in the Medicare and Medicaid programs and ensuring that
             these standards are met. HCFA carries out this responsibility by
             contracting with states to monitor nursing homes. As part of these

             Page 3                                  GAO/HEHS-99-80 Nursing Home Complaints

contracts, the states agree to comply with regulations and other general
instructions that HCFA prescribes.

The Omnibus Budget Reconciliation Act of 1987 revised the standards for
homes’ participation in these federal programs and defined federal and
state roles for ensuring that nursing homes meet these standards. In this
regulatory framework, states (1) license nursing homes to do business in
the state, (2) certify to the federal government, by conducting reviews of
nursing homes, that homes are eligible for Medicare and Medicaid
payment, and (3) investigate complaints about care provided in the homes.
As part of their oversight, the states are required to conduct annual surveys
of homes. While the annual surveys seek to provide a nationally uniform
process to evaluate whether nursing homes meet a comprehensive range of
federal standards, they are often predictable in their timing. 4 Complaint
investigations can be less predictable than annual surveys and generally
provide a unique opportunity for more frequent state inspections that
assess conditions at the nursing home while focusing on specific concerns
raised by residents, their families, or other observers. HCFA oversees
states’ performance by monitoring at least 5 percent of states’ surveys and
by requiring states to develop a quality improvement program that
incorporates performance goals and measures in seven required core
performance areas--including complaint investigations--and other optional
state-identified areas.5

In addition to the requirement that states establish a complaint
investigation process, HCFA requires that states investigate the most
serious complaints that allege situations immediately jeopardizing the
health or safety of residents within 2 workdays, but leaves the timing,
scope, duration, and conduct of other complaint investigations to the
discretion of the state survey agency. Thus, states establish their own
priorities and time frames for investigating complaints that they determine
do not represent immediate jeopardy to resident health and safety. In
addition, states require nursing homes to report and investigate incidents
such as injuries that might signal neglect or abuse. The state then
determines whether it will further investigate the incident.

4HCFA has recently initiated efforts intended to reduce the predictability of the timing of annual
surveys, such as doing some during evenings or weekends.

  A forthcoming GAO report will examine federal oversight of state agencies’ nursing home certification
activities, including the federal monitoring surveys and the State Agency Quality Improvement

Page 4                                                GAO/HEHS-99-80 Nursing Home Complaints

When states conduct a complaint investigation, they attempt to
substantiate whether the allegations are valid. If a complaint is
substantiated, the state may cite the nursing home for violating either
federal or state standards. In such cases, the state agency will require the
home to develop an approved plan of correction. The state may choose to
take action under the state’s licensing authority, using applicable state
remedies and sanctions. If the deficiency relates to federal standards,
information regarding the deficiency is also to be reported to HCFA.
Serious deficiencies require that the home attain compliance within a set
time frame or face enforcement sanctions, such as civil monetary penalties,
by HCFA or the state.

Both federal and state funds finance the costs state agencies incur in
inspecting nursing homes and investigating complaints. In 1998, the federal
government paid states about $210 million for the nursing home survey and
certification process, including about $42 million (20 percent) for
investigating complaints. States contributed an additional $17 million for
complaint investigations. On average, federal funds account for 71 percent
of states’ complaint investigation expenditures. Table 1 compares these
expenditures for the states visited. Appendix II includes additional
expenditure information for all states and further discusses the allocation
of federal and state shares. Generally, the federal government finances
states’ complaint investigation costs for nursing homes in the same
proportion that it finances annual and other surveys.

Table 1: Federal and State Expenditures for Complaint Investigations, 1998

                              Percentage Percentage
                      Total       of total   of total   Average
              expenditures survey and expenditures expenditures       Average
              for complaint certification  federally  per on-site expenditures
             investigations expenditures     funded investigation    per home
Maryland        $    232,666            8            60        $1,199         $885
Michigan            1,204,179          16            71         1,361         2,694
Washington          2,156,161          30            59          664          7,592
U.S. total      $58,833,689            20            71        $1,430        $3,397

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Some States’               Although investigations of complaints filed against nursing homes can
                           provide a valuable opportunity for determining whether the health and
Complaint Practices        safety of residents are threatened, complaint investigation practices do not
Are Limited in             consistently achieve this goal. Some states use procedures that may
                           discourage the public from filing complaints. Furthermore, some states fail
Protecting Nursing         to recognize and promptly respond to complaints that may pose immediate
Home Residents             jeopardy to a resident’s health, safety, or life. Likewise, some states do not
                           require that other serious complaints, including those that allege harm to
                           residents, be investigated for months after the complaint’s receipt.
                           Additionally, many complaints are not investigated within states’ required
                           time frames for conducting an investigation. Consequently, we found
                           several instances in which, after an extended delay, the complaint
                           investigators substantiated that residents had been harmed and other cases
                           in which the state was unable to determine whether the allegations were
                           true partly because so much time had elapsed since the complaint was

Procedures and Practices   Because nursing home residents and the public need an effective and
May Limit the Public’s     expedient means to seek correction of problems that they perceive
                           endanger the health and safety of nursing home residents, the process of
Filing of Complaints
                           filing a complaint should not place an unnecessary burden on the
                           complainant. Nevertheless, some states we reviewed have procedures or
                           practices that may limit the number of complaints. For example, when a
                           person calls with a complaint, Maryland and Michigan encourage him or
                           her to submit the complaint in writing.

                           • Michigan requires that either complainants write a complaint or the
                             state will provide assistance in writing the complaint. About 95 percent
                             of publicly reported6 complaints were submitted in writing between July
                             1997 and June 1998.
                           • Maryland’s policy is to accept and act on a complaint by phone even
                             though callers are encouraged to submit a written complaint. However,
                             state officials provided us conflicting information as to whether calls
                             would be consistently documented and investigated when callers agreed
                             to submit a written complaint but did not do so. Over 70 percent of

                               In this report, publicly reported complaints are those from residents, family, or friends.

                           Page 6                                                    GAO/HEHS-99-80 Nursing Home Complaints

                            Maryland’s publicly reported complaints that the state investigated were
                            identified as written complaints between July 1997 and June 1998.7
                          • In contrast, Washington readily accepts complaints by phone and nearly
                            all complaints are received by phone. This contributes to Washington
                            receiving a considerably higher number of complaints than Michigan or

                          See table 2 for a comparison of the total number of nursing home
                          complaints received in a year by these states.

                          Table 2: Complaints Received Between July 1, 1997, and June 30, 1998

                                                          Number of complaints          Number of complaints per 1,000
                                                                      received                     nursing home beds
                          Maryland                                               642                                        21
                          Michigan                                            2,243                                         45
                          Washington                                          8,748                                        336

States Establish Widely   When a complaint is received, the state agency ascertains its potential
Varying Categories for    seriousness. HCFA requires that complaints that may involve immediate
                          jeopardy of a resident’s health, safety, or life be investigated by states
Prioritizing Complaints
                          within 2 workdays of receipt.8 For other complaints, states are permitted
                          to establish their own categories and time frames for investigation. States
                          have established varying time requirements for complaint responses and
                          varying criteria for prioritizing these complaints, including criteria for
                          complaints that may involve a significant risk of actual harm to nursing
                          home residents. Some states permit relatively long periods of time to pass
                          between the receipt of all such complaints and their investigation. For
                          example, for complaints that may involve significant risk of actual harm to

                          • Michigan’s statute allows 30 days, but in 1998 Michigan’s operating
                            practice was to allow 45 days;

                          7The percentage is based on the total number of complaints that have information about whether the
                          complaint was in writing or by telephone.

                            Some states have a more stringent requirement than the federal requirement. For example, Michigan,
                          Louisiana, and Kansas require immediate jeopardy complaints to be investigated within 24 hours.

                          Page 7                                              GAO/HEHS-99-80 Nursing Home Complaints

                         • Tennessee allows 60 days; and,
                         • Kansas allows 180 days.

                         Some states have established other priority categories with similar time
                         frame classifications, but their criteria for determining which complaints to
                         include in these classifications differ substantially. Maryland and
                         Washington both have classification schemes that include categories for
                         complaints to be investigated within 2, 10, or 45 workdays or at the next on-
                         site investigation.9 Similarly, Pennsylvania classifies complaints to be
                         investigated within 2, 5, 10, or 45 workdays or at the next on-site survey.
                         Criteria for complaints to be included in the 10-day category for
                         Washington and Pennsylvania are similar. Washington’s 10-day category
                         includes complaints alleging significant potential harm to a resident’s
                         physical and/or mental health or safety. Similarly, Pennsylvania
                         characterizes 10-day complaints as those in which residents’ needs,
                         including medical, nursing, and dietary, are not being met. Maryland’s 10-
                         day time frame states that complaints in this category are those that appear
                         to be especially significant, sensitive, or could attract broad public
                         attention; those forwarded from a government or public official; and those
                         where the provider has a history of poor performance relative to the

Complaints May Receive   States sometimes place complaints in an inappropriately low investigation
an Inappropriately Low   category, thus postponing a prompt review. The infrequent use of high-
                         priority levels in some states raises a question as to whether complaints are
Investigation Priority
                         being appropriately categorized. Some states have explicit procedures or
                         operating practices that result in the downgrading of a complaint’s severity.
                         We found several instances of complaints that, in our opinion, were
                         inappropriately placed in a low-priority category.

                         As shown in table 3, two of the three states we visited seldom placed
                         complaints in the immediate jeopardy category for the 1-year period we
                         analyzed. Maryland did not identify a single complaint as potentially

                           Washington specifies that the next on-site investigation is within 90 days, whereas Maryland does not
                         have a maximum time frame for the next on-site investigation, other than the maximum 15-month time
                         frame allowed for the annual survey. Washington also has four other categories that do not require an
                         on-site investigation. Priority 5 includes cases where the nursing home has investigated an incident and
                         found that no further action is required. In such cases, the home must retain records for possible future
                         audit by the state agency. Priority 6 cases require no further action beyond recording the complaint,
                         priority 7 cases are resident-to-resident noninjury incidents reported by the home, and priority 8 cases
                         are those not requiring the state to record the complaint.

                         Page 8                                                GAO/HEHS-99-80 Nursing Home Complaints

representing immediate jeopardy. Michigan did prioritize some complaints
as immediate jeopardy, but they accounted for only 2 percent of total
complaints received. The Pennsylvania state auditor also noted that the
number of complaints considered immediate jeopardy in that state had
dropped considerably during the first quarter of 1998 in comparison to
earlier years, raising the auditor’s skepticism and concern.

Table 3: State-Investigated Complaints That Were Considered Potential Immediate
Jeopardy, July 1997 Through June 1998

                           Number of                                           Immediate jeopardy
                          complaints           Number of immediate                 complaints as a
                         classified as          jeopardy complaints             percentage of total
State              immediate jeopardy                per 1,000 beds         complaints investigated
Maryland                                  0                             0                           0
Michigan                                24                            0.5                           2
Washington                             223                            8.6                           8

Some states also categorized relatively few complaints in other high-
priority categories, such as those that should be investigated within 10
days. For example, Maryland placed most complaints in its lowest-priority
category–to be investigated at the next on-site survey. This contrasts with
Washington, which categorized nearly 90 percent of its complaints to be
investigated within either 2 or 10 workdays. Table 4 compares the use of
similar priority time frames among the states visited.

Table 4: Percentages of State-Investigated Complaints in Maryland, Michigan, and
Washington, by Priority Category, July 1997 Through June 1998

Priority time framea                          Maryland               Michiganb         Washington
Within 2   daysc                                      0                         2                   8
Within 10 days                                      22                       N/A                   81
Within 45 days                                      34                        92                    9
Next   surveyd                                      44                       N/A                    3
Note: Percentages may not add to 100 because of rounding.
  Maryland and Washington define their time frames as workdays, whereas Michigan defines its time
frames as calendar days.
 About 5 percent of Michigan’s complaints were placed in other miscellaneous categories or their
priority was unknown.
cMichigan’s   highest priority category requires an investigation within 24 hours.

Page 9                                                    GAO/HEHS-99-80 Nursing Home Complaints

dAlthough  Michigan’s policy includes a priority level that permits complaints to be investigated at the
next survey, none of the complaints we reviewed was categorized at this priority level. Maryland
defines this category as “the next on-site survey,” whereas Washington defines it as being within 90
days or at the next on-site survey, whichever is sooner.

Several states have explicit procedures or operating practices that place
serious complaints in lower-priority categories. A Maryland official, for
example, acknowledged reducing the priority of some complaints because
the state recognized that it could not meet shorter time frames because of
insufficient staff. Similarly, a Michigan official also told us that her office
gives a complaint low priority if the resident is no longer at the nursing
home when the complaint is received--even if the resident died or was
transferred to a hospital or another nursing home.10 The state may
investigate these complaints during the home’s next survey or not at all.
Failure to investigate such a complaint in a timely manner may
compromise the health and safety of other residents who may also be
affected by problems cited in the complaint. We identified several cases in
which a resident had died or been transferred from the nursing home that
were assigned to Michigan’s lower-priority (45-day) category, were
uninvestigated for several months, or had not yet been investigated at the
time of our visit. For example, a complaint in Michigan alleged in July 1998
that a resident died because the home did not properly manage his insulin
injections or perform blood sugar tests. Because the resident died, the
state had not investigated the complaint as of January 1999. We question
why the state agency would not have concerns that this situation might
affect other diabetic residents in the home.11

Michigan also delays investigating certain nonimmediate jeopardy
complaints against nursing homes that are undergoing federal enforcement
action. Officials told us that they adopted this practice to avoid potential
confusion that may result from having two enforcement actions pending

10In reviewing our draft, Michigan stated that its policy is to investigate complaints whether or not a
resident is still in the home.

  In its comments on a draft of this report, Michigan provided additional information about this
complaint. It stated that the state did not investigate this complaint because state investigators had
investigated the home shortly before the complaint was received and found that previous problems
related to treatment of diabetic residents had been resolved. About 8 months after the complaint was
received (Mar. 12, 1999), state investigators conducted the most recent annual survey of the home and
found no problems relating to the monitoring of diabetic residents. However, we still question why the
state did not more immediately investigate the complaint given that (1) the resident died, (2) the state
had identified previous problems with this home’s treatment of diabetic residents, and (3) the attorney
general’s office had been notified. This appears to violate Michigan’s policy that complaints should be
investigated within 24 hours if the incident involves “injury or . . . death or potential criminal activity
under investigation by a state or local law enforcement agency.”

Page 10                                                GAO/HEHS-99-80 Nursing Home Complaints

simultaneously. We believe this practice could unreasonably delay the
investigation of serious complaints at nursing homes already identified as
violating federal standards.

In reviewing complaints from the states visited, we identified several
complaints in two states that raise questions about why they were not
considered as potentially immediate jeopardy. Examples of these
allegations include the following:

• The complaint alleged that a resident was found dead with her head
  trapped between the mattress and the side rail of the bed, with her body
  lying on the floor. The state categorized this complaint as one needing
  to be investigated within 45 days. The state investigated this complaint
  within 13 days and determined that 11 of 24 sampled beds had similar
  side rail violations. Our concern about whether this complaint was
  appropriately classified is supported by another HCFA region’s
  interpretation of HCFA’s guidance to states. The Denver region would
  have considered this situation to be an immediate jeopardy complaint to
  be investigated within 2 workdays, noting that “an unexplained resident
  death related to a medical device, side rails, or other restraints
  exemplifies a possible immediate jeopardy situation requiring an on-site
  investigation within two workdays.”
• Another complaint alleged that an alert resident who was placed in a
  nursing home for a 20-day rehabilitation stay to recover from hip
  surgery was transferred in less than 3 weeks to a hospital because of
  what the complainant termed an “unprecedented rapid decline [in the
  resident’s condition].” One of the members of the ambulance crew
  transporting the resident to the hospital filed a written report stating
  that the resident “had dried . . . blood in his fingernails and on his hands
  . . . sores all over his body . . . smelled like feces and [was] unable to
  walk or take care of himself. Patient is in very poor condition as far as
  his hygiene. I personally feel he was not being properly cared for.” The
  state categorized this complaint as needing an investigation at the next
  on-site inspection, took more than 4 months to begin its investigation,
  and determined that the nursing home had harmed the resident.
• Another complaint alleged that the home’s staff would not send a
  resident with maggots in the sores on his feet to the hospital because the
  home’s director of nursing did not want the state agency to be notified
  by the hospital and investigate the home. The state categorized this
  complaint, received 105 days before our visit, as needing to be
  investigated within 45 days, but it had not yet been investigated.

Page 11                                 GAO/HEHS-99-80 Nursing Home Complaints

                           • In another instance, the police reported suspected abuse and neglect to
                             the state survey agency after a resident was brought twice to the
                             hospital emergency room because of falls. The resident’s first
                             hospitalization identified a broken elbow, and the second found a
                             contusion on the resident’s cheek. The police did not believe the
                             nursing home staff’s account of how the resident had sustained these
                             injuries. This complaint, filed 13 workdays before our visit, was being
                             held by the state until the next on-site investigation.

                           State auditors’ reports identified additional complaints that the auditors
                           found should have been placed in a higher category. Examples follow:

                           • Kansas’ auditors said that about 10 percent of 213 complaints reviewed
                             were classified too low, given their potential seriousness. Among the
                             complaints categorized as not requiring an investigation until the earlier
                             of the home’s next annual survey or within 6 months of receipt was one
                             alleging that a resident had skin tears, purple lesions, feces and food on
                             his clothing, broken eyeglasses, and was not being fed regularly.
                             Another complaint charged that a nurse’s aide abused several residents.
                           • Pennsylvania’s auditors identified several complaints as categorized too
                             low, including one filed by a licensed practical nurse recently employed
                             by the home. The nurse alleged that there had been at least 12 deaths at
                             the home over a 2-week period, including a resident who choked to
                             death because she had mistakenly been given solid food; a resident who
                             was sent to the emergency room because her feeding tube had become
                             dislodged and was entirely within her stomach; and a resident who had
                             received 10 times the prescribed dosage of a medication. This nurse’s
                             complaint was placed in the lowest category, delaying its investigation
                             until the home’s next annual survey.

States Frequently Do Not   States often do not conduct investigations of complaints within the time
Investigate Complaints     frames they assign, even though some states frequently place complaints in
                           lower investigation categories to increase the time available to investigate
Within Required Time
                           them. Some of these complaints, despite alleging serious risk to resident
Frames                     health and safety, remained uninvestigated for several months after the
                           deadline for investigation. These delays may contribute to investigators
                           being unable to determine whether the allegations are true because, by the
                           time the investigation starts, evidence needed to establish validity may no
                           longer be available.

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To determine whether states investigate complaints within state-required
time frames, we reviewed state data covering 1 year from July 1997 through
June 1998. Table 5 shows the percentage of complaints that met the
assigned time frame for investigation.

Table 5: Percentage of State-Investigated Complaints Meeting Time Frame for
Investigation, July 1997 to June 1998

                                                                Percentage investigated within
Time frame                        Number of complaints                             time frame
2 workdays                                                 0                                     N/A
10 workdays                                              47                                        21a
45 workdays                                              72                                        69a
24 hours                                                 24                                        21b
45   daysc                                            1,273                                        26
2 workdays                                              223                                        78
10 workdays                                           2,331                                        47
45 workdays                                             252                                        89
90 workdays                                              78                                      100
Note: N/A = not applicable.
 Maryland’s data provide information on the last date of the investigation, but not when the
investigation was initiated. Based on our review of complaints received in early 1998, only 1 of 18
complaints was initiated within the assigned time frame of 10 workdays, and only 4 of 11 complaints
were initiated within the assigned time frame of 45 workdays.
bWhen  using the federal requirement of 2 workdays to investigate immediate jeopardy complaints,
Michigan investigated 42 percent of these complaints on time.
  About 5 percent of Michigan’s complaints were identified as those to be investigated within
miscellaneous time frames. Although state law requires serious complaints other than immediate
jeopardy to be investigated within 30 days, Michigan’s Department of Consumer and Industry Services
changed the 30-day requirement to a 45-day requirement in 1998. As shown, Michigan did not meet
even the 45-day time frame in most cases.

We asked each state visited to provide copies of all complaints in the
Baltimore, Detroit, and Seattle areas that had not yet been investigated and
that exceeded the assigned time frame. Baltimore and Detroit each had

Page 13                                             GAO/HEHS-99-80 Nursing Home Complaints

                                                over 100 such complaints, while Seattle had 40.12 From the complaints
                                                provided, we identified those for homes having at least three outstanding
                                                complaints not investigated within the states’ prioritized time frames, and
                                                we summarized the allegations of each complaint. Many of these
                                                complaints alleged potential resident abuse by staff; resident neglect,
                                                including malnutrition and dehydration; preventable accidents; medication
                                                errors; and understaffing. See appendix III for this summary.

Delayed Investigations of                       Failure by states to investigate complaints promptly can delay the
Complaints Prolong Harm                         identification of serious problems in nursing homes and postpone needed
                                                corrective actions. Furthermore, delayed investigations can prolong, for
to Residents
                                                extended periods, situations in which residents are harmed. Table 6
                                                identifies complaints received in early 1998 in which the state’s complaint
                                                investigation concluded that the resident had been harmed. In Maryland
                                                and Michigan, a large percentage of such cases was not investigated for
                                                extended periods.

Table 6: Complaints in Which Investigation Substantiated Federal Deficiency and Resulted in Home Being Cited for Actual Harm
to One or More Residents

                                                                                                                  Days until
                                                                                                               investigation      Scope of harm
Description of allegations                                                                                           started      founda
Nurse charted that resident’s intravenous fluid was flowing well; however, fluid was going under                          139     Isolated
the resident’s skin and not into a vein. Resident had to be hospitalized.
Resident had caked feces all over his body, dried blood under his fingernails and on his hand,                                    Isolated
and pressure sores all over his body. A member of the ambulance team that transported the                                 130
resident to the hospital questioned whether the home properly cared for the resident.
Inadequate supervision led to falls. One resident suffered a dislocated jaw and could not chew.                             54    Isolated
A feeding tube was inserted into the resident. The resident later developed pneumonia, was
hospitalized, and was put on life support.
Three residents were hospitalized with several pressure sores. One resident had a sore that                                 39    Isolated
was exposed to the bone. Another resident had four sores; a third resident had three sores.
The state noted that the home did not ensure proper nutrition for one of these residents to
prevent the development of the sores.

                                                  As discussed in app. I, this includes only the unassigned complaints in Baltimore. Other assigned
                                                complaints were also uninvestigated.

                                                Page 14                                              GAO/HEHS-99-80 Nursing Home Complaints

                                                                                                                 Days until
                                                                                                              investigation      Scope of harm
Description of allegations                                                                                          started      founda
Resident had multiple pressure sores and multiple fractures caused by falls, resulting in                                228     Pattern
Resident had swelling and bruising on chest, shoulder, and forearm. The emergency room                                   216     Isolated
diagnosed fractured ribs.
Resident was verbally abused by an aide, who told resident to go to the bathroom in her diaper                           152     Isolated
after resident asked for a bedpan. The home failed to draw a conclusion about the incident,
but suspended the aide. The state noted the home had a history of not being able to draw
conclusions about abuse incidents.
Aide was rough in transferring resident from wheelchair, resulting in laceration needing 25                              146     Isolated
Resident with history of 13 altercations with other residents hit a resident who suffered a                              112     Isolated
laceration. The home had not implemented safeguards to prevent such occurrences.
Resident’s weight and fluids were not monitored. Also, resident’s foot was swollen, possibly                               99    Pattern
requiring amputation. Resident also found sitting in urine, not clean, and missing personal
property. Resident rushed to emergency room.
Male aide slapped a female resident and squeezed her hand causing a bruise. Another                                        88    Isolated
resident struck a home employee, who slapped the resident’s face in response.
Resident sustained a fractured nose and laceration of her forehead as a result of improper                                 45    Isolated
positioning in her wheelchair. Resident sent to hospital for stitches.
Resident, who had blood drawn, was noted to have a badly bruised hand and elbow.                                           37    Isolated
Complainant alleged that a laboratory representative stated that sometimes they “have to get
rough” in order to draw blood from residents.
Home failed to monitor resident’s condition; resident became unresponsive and was                                          33    Pattern
hospitalized for dehydration and a urinary tract infection. Home failed to use bed side rails for
seven residents, resulting in lacerations/injuries to four residents who fell out of bed.
A resident’s leg was fractured three different times, possibly due to rough handling of resident                           33    Pattern
during transfer by aide. Allegation also stated that aides are not properly trained to transfer
residents who have fragile bones.
Resident hit another resident.                                                                                             17    Isolated
Resident found dead with head between mattress and bed side rail, with body lying on the                                   13    Isolated
Resident had repeatedly developed pressure sores while in the nursing home.                                                27    Isolated
Resident fell while being transferred from wheelchair to toilet, and as a result, re-broke hip.                             9    Isolated
Quadriplegic left the home in an electric wheelchair and died of hypothermia after the battery                              3    Isolated
ran out.
Inadequate staffing resulting in deteriorated care of many residents. Medications were late,                                1    Widespread
and a diabetic’s blood was not tested for sugar level.
Resident suffered a hairline fracture of the foot while being transferred from wheelchair to bed.                           0    Isolated
                                                 Note: Data include a complete chronological sample of complaints received in early 1998 that were
                                                 investigated and resulted in a violation indicating that actual harm had occurred. In Maryland, we
                                                 reviewed 102 complaints received between January 1 and February 28, 1998; in Michigan, we

                                                 Page 15                                             GAO/HEHS-99-80 Nursing Home Complaints

                             reviewed 59 complaints received between January 1 and January 15, 1998; and in Washington, we
                             reviewed 132 complaints received between January 1 and January 7, 1998.
                               Isolated, pattern, and widespread are terms that state investigators must use to classify the scope of
                             a violation. In general, isolated violations affect one or a limited number of residents and/or occur only
                             occasionally; pattern violations affect more than a limited number of residents and/or have occurred
                             repeatedly; widespread violations are pervasive, affecting a large number of residents and occurring

HCFA’s Complaint             Although HCFA funds, on average, 71 percent of state agencies’ complaint
                             investigation costs, HCFA has established minimal standards for
Investigation                investigating complaints and has conducted little monitoring of states’
Standards Are Minimal,       complaint practices. HCFA provides limited guidance to states on
                             complaints beyond the 2-workday requirement for allegations classified as
and Its Oversight of         posing immediate jeopardy to resident health and safety.13 HCFA
States’ Complaint            established a taskforce in 1993 to develop more stringent federal policies
Practices Is Weak            for complaint investigations, but it was disbanded in 1995, and formal
                             policies were not revised. Finally, HCFA’s ability to oversee states’
                             performance in handling complaints is limited because major monitoring
                             efforts are focused instead on annual surveys; it primarily relies on states
                             to develop performance measures for complaint investigations; and it has
                             inadequate reporting systems for capturing the results of complaint

Previous HCFA Efforts to     Between 1993 and 1995, a HCFA task force worked to develop formal
Strengthen Federal           complaint guidance for states and a complaint investigation manual to help
                             state investigators. The task force activities included consideration of
Standards for Nursing Home
                             additional minimum federal priority and time frame classifications,
Complaint Investigations     including requirements that time frames be set for complaints alleging
Were Abandoned               serious care issues but at levels less than immediate jeopardy. However,
                             the formal guidance and the manual were never finalized or released.
                             HCFA attributes the decision to discontinue this initiative to a shift in
                             HCFA’s focus toward revising enforcement regulations and its concern that
                             some states that exceeded the proposed federal standards might weaken
                             their standards.

                             Instead of formal guidance, HCFA sent a portion of the task force’s work to
                             its 10 regional offices as a set of optional protocols. These were released as

                               HCFA’s request for state budget proposals for fiscal year 1999 noted that “in some cases, it may be
                             appropriate for the complaint to be investigated during the next scheduled visit to the facility.”

                             Page 16                                                GAO/HEHS-99-80 Nursing Home Complaints

                        “tools, not rules” for specific situations an investigator may encounter
                        while conducting an on-site complaint investigation. These protocols did
                        not address the prioritization and timeliness aspects of complaint
                        investigations. This optional guidance has not been widely used. Officials
                        at several HCFA regional offices did not recall receiving these on-site
                        investigative protocols. Another HCFA regional office reported that it did
                        not release the document to states in its area because the document
                        appeared to be in draft form. HCFA does not provide additional guidance
                        to states on ways to manage complaint workloads efficiently, how to
                        categorize complaints, or when to expand a review beyond the residents
                        involved with the original complaint.

                        In contrast, the HCFA regional office in Boston established its own task
                        force to enhance the protocols. The region adopted its own guidance for
                        how state agencies should classify complaints. This guidance suggests that
                        “at a minimum, your [state] agency should have at least three action levels
                        based on the degree of safety or health hazard alleged: high-level action,
                        mid-level action, and low-level action.”

                        Although HCFA had not established a priority and timeliness scheme for
                        complaints other than those alleging immediate jeopardy to residents, the
                        form it uses for states to report the results of investigations includes four
                        priority and timeliness categories. The form asks states to specify whether
                        an investigation was conducted within 2, 10, or 45 workdays or at an annual
                        survey. It is intended for reporting state agencies’ investigation results for
                        all types of health care facilities--including home health agencies and
                        clinical laboratories–as well as nursing homes. Thus, the form does not
                        formally establish additional time frames for nursing home investigations.
                        However, some states have interpreted the categories included on the
                        HCFA form as suggested priority and timeliness categories and have
                        modeled their standards after them. For example, officials in Maryland and
                        Washington indicated that they adopted their priority categories in part to
                        conform with the categories on the HCFA form. Other states, however,
                        maintain complaint priority levels and time frames that are distinct, and
                        often less stringent, than those identified on the HCFA form.

Federal Monitoring of   HCFA’s major efforts to monitor states’ performance in surveying and
States’ Complaint       certifying nursing homes are largely focused on annual surveys–not on
                        complaint investigations. HCFA requires its regional investigators to
Practices Is Limited
                        replicate or observe a 5-percent sample of state investigators’ nursing home
                        inspections and requires states to develop performance measures and

                        Page 17                                 GAO/HEHS-99-80 Nursing Home Complaints

                                 quality improvement programs. However, nearly all of the state nursing
                                 home inspections that HCFA monitors are annual surveys rather than
                                 complaint investigations. Even though HCFA has begun requiring states to
                                 include complaint investigations as part of their performance measurement
                                 and improvement programs, some states have not yet begun to do so. For
                                 states that have developed quality improvement programs, some programs
                                 have not identified or focused on concerns that state auditors and we have

Few Federal Monitoring Surveys   HCFA’s principal method for monitoring state agencies’ performance in
Are Performed for Complaint      certifying nursing homes is through the statutory requirement that HCFA
Investigations                   staff conduct monitoring surveys of at least 5 percent of the states’ nursing
                                 home investigations. This process allows HCFA either to repeat a state’s
                                 survey of a nursing home and compare findings or to observe state
                                 investigators while they perform a nursing home survey. However, these
                                 federal monitoring surveys are largely intended to focus on annual surveys
                                 rather than on complaint investigations, and few federal monitoring
                                 surveys are conducted of complaint investigations.

                                 In 1998, of the 824 federal monitoring surveys that HCFA conducted
                                 nationwide, only 39 were of complaint investigations. Furthermore, 25 of
                                 the 39 were conducted by HCFA’s Chicago regional office, which oversees 6
                                 states, and 10 were conducted in Illinois. Therefore, in the remaining 44
                                 states and the District of Columbia, only 14 federal monitoring surveys
                                 focused on complaint investigations. Thus, federal monitoring surveys
                                 provide HCFA with little insight into state agencies’ performance in
                                 conducting nursing home complaint investigations.

                                 As of October 1, 1998, HCFA had revised its requirements for federal
                                 monitoring surveys, allowing its regions to include only a small number of
                                 complaint investigations in each state to meet the requirement that 5
                                 percent of surveys be monitored. Under this revision, HCFA may assess
                                 only one complaint investigation as part of its quota for most states, while
                                 even in the largest states, HCFA may include no more than four complaint
                                 investigations as part of the 5-percent requirement. As a result, it is clear
                                 that HCFA intends that federal monitoring surveys principally should be a
                                 method to oversee state agencies’ performance in conducting annual
                                 surveys, resulting in minimal oversight of states’ complaint investigations.

                                 Page 18                                 GAO/HEHS-99-80 Nursing Home Complaints

Initial State Quality          HCFA requires each state to evaluate its performance in complaint
Improvement Reports Identify   investigations beginning in 1998 as part of the State Agency Quality
Few Problems With Complaint    Improvement Program. However, our review of the 1998 reports submitted
Practices                      to HCFA by states that either we visited or had a recent state auditor’s
                               report14 indicated that several states had not yet developed performance
                               measures or improvement plans related to nursing home complaints, and
                               that the states that had evaluated complaint processes ignored concerns
                               that we and the state auditors raised. Furthermore, under the new Quality
                               Improvement Program, HCFA regional offices appeared to be less directly
                               involved in evaluating state agencies’ performance in complaint handling
                               than with previous oversight approaches.

                               Among the states visited,

                               • Maryland had not developed a Quality Improvement Program or
                                 baseline performance measures for nursing home complaints.15
                               • Michigan’s final 1998 quality improvement report noted that staff
                                 turnover had delayed its ability to begin evaluating whether all
                                 complaints were investigated and processed within the time frames but
                                 stressed that the state agency “feels confident that this [performance
                                 standard] will be (and currently is) met.” This statement conflicts with
                                 our findings that most investigations in Michigan were conducted later
                                 than the 45-day time frame adopted by the state agency.
                               • Although Washington’s quality improvement program includes
                                 performance measures related to training staff in conducting complaint
                                 investigations and properly documenting the results, it did not evaluate
                                 the timeliness of complaint investigations. As noted above, we found
                                 that Washington categorizes its complaints at a higher priority level than
                                 do Maryland and Michigan and is more timely in investigating them.
                                 Nevertheless, Washington met its time frames in only about 55 percent
                                 of the complaints investigated.

                               For the states reviewed by state auditors, our review of the quality
                               improvement reports submitted to HCFA showed that several states had

                               14We  reviewed the reports submitted by the 11 states reviewed by state auditors and the 3 states we

                                 While not reflected as a part of HCFA’s quality improvement program, Maryland’s director of the
                               survey and certification unit indicated that the unit has implemented some improvements and is
                               planning others. For example, the unit has hired three additional staff persons and is planning to merge
                               the complaint and survey units.

                               Page 19                                               GAO/HEHS-99-80 Nursing Home Complaints

                               not yet initiated quality improvement programs while few others identified
                               concerns regarding complaints. Examples follow:

                               • New York had not yet established performance standards for nursing
                                 home complaints.
                               • Tennessee reported that it planned to begin implementing new
                                 complaint performance standards in October 1998.
                               • Wisconsin cited the implementation of a new data system as the cause
                                 of its delay in tracking complaints as part of quality improvement efforts
                                 but stressed that “our belief is that we are fine, but we have no data to
                                 support or refute this belief.”

                               North Carolina’s 1998 quality improvement report acknowledged that the
                               state agency “has fallen behind significantly on investigating complaints
                               within 60 days for nursing homes due to [a] shortage in nursing staff and
                               the large number of complaints.” As remedial actions, North Carolina
                               reported that it intended to reevaluate its hiring practices, increase salaries
                               to attract and retain qualified staff, improve training, and request that the
                               state legislature either provide additional funds or repeal the 60-day
                               statutory requirement.

                               The relatively new process relies largely on self-measurement of
                               performance, resulting in less direct involvement by the HCFA regional
                               offices than previous approaches to evaluating state agencies’
                               performance. For example, HCFA regional offices are no longer required
                               to review state procedures for complaint investigations and other types of
                               nursing home oversight. Based on our interviews, some HCFA regional
                               offices have had very little involvement in developing or monitoring states’
                               quality improvement plans, even though this involvement is a HCFA

Inadequate Reporting Systems   An effective complaint reporting system is important to support both
Hamper Effective               federal and state efforts to maintain an accurate and complete record of a
Federal and State Management   nursing home’s federal compliance history as well as to track the state
of Complaint Investigations    agencies’ performance in complaint investigations. Tracking of complaints
                               is integral to identifying the status of complaint investigations and to
                               managing complaint workloads to appropriately protect residents’ health.
                               In particular, a full compliance history is key to several parts of the survey
                               and certification process, such as HCFA’s enforcement and oversight of
                               standards, states’ prioritization of complaints, and HCFA’s ability to provide

                               Page 20                                  GAO/HEHS-99-80 Nursing Home Complaints

full information to consumers via its Internet page and other sources.16 We
found that inadequacies in HCFA’s data system and the linkage between
state and federal systems hinder HCFA’s and states’ ability to adequately
track the status of complaint investigations and for HCFA to maintain a full
nursing home compliance history. In short, one HCFA official stated that
the complaint system is “not used as a management tool.”17

HCFA requires states to develop tracking systems and to submit summary
information about all complaint investigations. For monitoring purposes,
HCFA maintains a database of nursing home complaint investigation
information. Although HCFA standards require states to report this
information, the process for collecting it results in inaccurate and
incomplete information. For example, HCFA collects summary
information for on-site complaint investigations with a form that was
created for recording information about a single complaint. Some states,
including Maryland and Michigan, use the form for multiple complaints.
Therefore, timeliness, prioritization, and other important tracking
information that relates to multiple complaints is reported as though it
applies to one complaint. In this situation, states typically record the
highest priority level assigned to any of the individual complaints and are
limited to choosing timeliness dates reflective of only one of the
complaints. As a result, HCFA is unable to effectively monitor states’
performance on prioritization and timeliness.18

In our report on California nursing homes, we determined that the results
of complaint inspections are often cited as state, not federal, deficiencies. 19
Thus, the results of complaint investigations may not appear in federal
databases. Furthermore, state officials reported that complaints might
appear to be unsubstantiated in federal databases when the state has
actually substantiated the complaint. In contrast, Washington and
Michigan report that they record most violations they identify in both

  HCFA recently has begun posting results of nursing homes’ most recent annual survey on the Internet,
available at http://www.medicare.gov/nursing/home.asp. Results of complaint investigations are not
publicly available from the Internet.
  For an assessment of the weaknesses of HCFA’s management information systems and the impact
those weaknesses have on HCFA’s enforcement activities, see GAO/HEHS-99-46, Mar. 18, 1999.

18HCFA  regional offices are also required to maintain a complaint log with the information reported by
states. We spoke with all HCFA regions, and none indicated that it had any additional tracking system
for complaints other than the central HCFA tracking system.

     GAO/HEHS-98-202, July 27, 1998.

Page 21                                              GAO/HEHS-99-80 Nursing Home Complaints

                  federal and state information systems. For example, Washington has
                  developed a crosswalk between its state licensing and federal regulations
                  to assist providing full information in both federal and state information

                  Overall, there is also a time lag on states reporting data to HCFA.
                  Washington, for example, estimated that its input into the federal data
                  system was 3 months behind. HCFA estimated that some states might lag
                  by as much as 6 months in entering complaint investigation information
                  into federal management systems.

Conclusions       Our work in selected states reveals that serious complaints alleging harm
                  to residents often remain uninvestigated for extended periods. Such delays
                  do not provide this vulnerable population the protections intended by the
                  federally mandated complaint investigation process. Some practices, such
                  as Washington’s ready acceptance of phone complaints and its relatively
                  prompt investigation, as well as the HCFA Boston office’s guidance to
                  states recommending improved prioritization of complaints, merit
                  replication. Despite these positive efforts, we identified frequent systemic
                  weaknesses in HCFA’s and many states’ practices that can leave nursing
                  home residents in poor care and unsafe conditions for extended periods.
                  The combination of inadequate state practices and limited HCFA guidance
                  and oversight have too often resulted in extensive delays in investigating
                  serious complaints alleging harmful situations, a lack of careful review of
                  states’ policies and practices, and incomplete reporting on nursing homes’
                  compliance history and states’ complaint investigation performance.

Recommendations   To make complaint investigations a more effective tool for protecting
                  nursing home residents’ health and safety, we recommend that the HCFA
                  Administrator revise federal guidance and ensure state agency compliance
                  through the following actions:

                  • Develop additional standards for the prompt investigation of serious
                    complaints alleging situations that may harm residents but are
                    categorized as less than immediate jeopardy. These standards should
                    include maximum allowable time frames for investigating serious
                    complaints and for complaints that may be deferred until the next
                    scheduled annual survey. States may continue to set priority levels and
                    time frames that are more stringent than these federal standards.

                  Page 22                                GAO/HEHS-99-80 Nursing Home Complaints

                     • Strengthen federal oversight of state complaint investigations, including
                       monitoring states’ practices regarding priority-setting, on-site
                       investigation, and timely reporting of serious health and safety
                     • Require that the substantiated results of complaint investigations be
                       included in federal data systems or be accessible by federal officials.

Agency, State, and   We obtained comments on our draft report from HCFA and the three states
                     we visited. (See apps. IV through VII for their written comments.) In
Industry Comments    general, HCFA and the states concurred with our recommendations and
and Our Response     highlighted efforts being taken to improve complaint investigations. They
                     also suggested clarification on certain findings and technical changes,
                     which we included in the report where appropriate.

                     HCFA, in concurring with our recommendations, also immediately
                     announced several initiatives to address issues we raise. These include

                     • a new interim requirement that states should investigate complaints
                       alleging actual harm to residents within 10 workdays, and a complaint
                       improvement project with the intention of developing additional
                       minimum standards for complaint investigations;
                     • increased federal oversight of complaints, including allowing HCFA
                       regional offices to conduct additional monitoring surveys based upon
                       complaints and new state agency performance measures relating to
                       complaints; and
                     • improved reporting on complaint information, including a review of the
                       form states use to report complaint information to HCFA, further
                       direction to states requiring that complaint findings be included in the
                       federal as well as state database in a timely manner, and a review of
                       potential long-term improvements in the federal data system.

                     Maryland, Michigan, and Washington each highlighted resource limitations
                     as contributing to the problems we identify. Specifically, Maryland noted
                     that in recognition of many of the problems we identify, the state has
                     recently hired additional staff and plans additional improvements,
                     including merging its complaint and annual survey investigative staff and
                     improving the tracking of complaints. Maryland also commented that the
                     scope of our work was narrowly focused on complaint investigations and,
                     as only one component of its broader nursing home oversight efforts,
                     should not be used to evaluate the state’s entire regulatory process. While
                     we concentrated this aspect of our work on complaints, we continue to

                     Page 23                                GAO/HEHS-99-80 Nursing Home Complaints

believe that, in coordination with annual surveys, complaint investigations
are an essential component of state efforts to protect residents and ensure
that nursing homes provide adequate care. They afford a unique
opportunity to increase state inspectors’ unexpected presence in homes
and to target specific areas of potential problems identified by residents
and other concerned individuals.

Michigan’s comments noted that prior to the period we examined the state
had experienced a loss of staff and that it has been hiring and training
additional investigators. Michigan also reiterated its criteria for including
complaints in its highest priority level. However, we found several cases
that appear to meet these criteria but were not classified as requiring a 24-
hour visit. Michigan also noted that several state practices we highlight
were developed with guidance from the HCFA regional office, including
investigating complaints concurrently with annual surveys and delaying the
investigation of certain complaints regarding nursing homes nearing the
deadline for enforcement actions. Michigan disputes that its policy or
practice places egregious complaints in a lower priority level. However, we
remain concerned that state investigators we interviewed reported that
some complaints where residents died or left the nursing home would not
be investigated until the next on-site inspection. Furthermore, several
cases we reviewed where a resident had died or had been transferred from
the home were assigned to Michigan’s lower (45-day) category, were
uninvestigated for several months, or had not yet been investigated at the
time of our visit. Michigan indicated that it plans a more thorough review
of its handling of complaints and intends to make recommendations to
address any concerns it identifies by April 1999.

Washington concurred with the importance of an effective complaint
system and stressed attributes of its system, including prioritizing most
complaints at a high level and a highly trained professional staff.
Washington acknowledged that, because of the large volume of complaints
categorized as requiring an investigation within 10 days and the need for
increased resources, the timeliness of complaints within this category
depends on investigators’ determinations of which complaints are the most

We also provided a copy of the report for review by the American Health
Care Association (AHCA) and the American Association of Homes and
Services for the Aging (AAHSA). AHCA officials expressed agreement with
the report’s recommendations. Both AHCA and AAHSA officials noted that
the report summarizes some uninvestigated complaints and that the

Page 24                                 GAO/HEHS-99-80 Nursing Home Complaints

allegations had not yet been substantiated or unsubstantiated. We
acknowledge that many of the complaints summarized reflect allegations
rather than substantiated problems and believe that the report adequately
reflects that many had not yet been investigated at the time of our visit to
determine their validity. We included these allegations to reflect the
information that a state agency would have as it determines the priority
level to assign complaints and how promptly to investigate them.

We are making copies of this report available to the honorable Nancy-Ann
Min DeParle, the HCFA Administrator; appropriate congressional
committees; and interested parties upon request.

Please contact me or Kathryn G. Allen, Associate Director, at (202) 512-
7114 if you or your staffs have any further questions. This report was
prepared by Jack Brennan, Mary Ann Curran, C. Robert DeRoy, Gloria
Eldridge, and Chick Walter under the direction of John Dicken.

William J. Scanlon
Director, Health Financing
 and Public Health Issues

Page 25                                 GAO/HEHS-99-80 Nursing Home Complaints

Letter                                                                  1

Appendix I                                                             30
Scope and

Appendix II                                                            34
Nursing Home

Appendix III                                                           40
Summary of
Unassigned or
Complaints for the
Baltimore, Detroit, and
Seattle Metropolitan

Appendix IV                                                            56
Comments From the
Health Care Financing

                          Page 26   GAO/HEHS-99-80 Nursing Home Complaints

Appendix V                                                                                      65
Comments From
Maryland’s Department
of Health and Mental

Appendix VI                                                                                     67
Comments From
Michigan’s Department
of Consumer and
Industry Services

Appendix VII                                                                                    75
Comments From
Washington State’s
Department of Social
and Health Services

Tables                  Table 1: Federal and State Expenditures for Complaint
                          Investigations, 1998                                                 5
                        Table 2: Complaints Received Between July 1, 1997, and June 30, 1998   7
                        Table 3: State-Investigated Complaints That Were Considered Potential
                          Immediate Jeopardy, July 1997 Through June 1998                      9
                        Table 4: Percentages of State-Investigated Complaints in Maryland,
                          Michigan, and Washington, by Priority Category, July 1997 Through
                          June 1998                                                            9
                        Table 5: Percentage of State-Investigated Complaints Meeting Time
                          Frame for Investigation, July 1997 to June 1998                     13
                        Table 6: Complaints in Which Investigation Substantiated Federal
                          Deficiency and Resulted in Home Being Cited for Actual Harm to
                          One or More Residents                                               14
                        Table II.1: Estimated Expenditures for Nursing Home Complaint
                          Investigations, by State, Fiscal Year 1998                          36

                        Page 27                              GAO/HEHS-99-80 Nursing Home Complaints

Table II.2: Expenditure Rates by Home, Visit, and Bed, Fiscal
  Year 1998                                                              38
Table III.1: Unassigned Complaints for Nursing Homes in Baltimore
  With Three or More Such Complaints                                     40
Table III.2: Uninvestigated Complaints for Nursing Homes in Detroit
  With Three or More Such Complaints                                     45
Table III.3: Uninvestigated Complaints for Nursing Homes in Seattle
  With Three or More Such Complaints                                     53


AAHSA      American Association of Homes and Services for the Aging
AHCA       American Health Care Association
HCFA       Health Care Financing Administration

Page 28                               GAO/HEHS-99-80 Nursing Home Complaints
Page 29   GAO/HEHS-99-80 Nursing Home Complaints
Appendix I

Scope and Methodology                                                                                    AppIexndi

                          To develop this report, we examined state nursing home complaint
                          investigation practices in Maryland, Michigan, and Washington. We
                          selected these three states as case studies because they are geographically
                          diverse and have different approaches to investigating complaints. For
                          each state, we reviewed laws, regulations, and policies and interviewed
                          leading state agency officials and complaint investigators.

                          In each of the three states visited, we

                          • interviewed state officials and complaint investigators and obtained
                            documentation of each state’s complaint investigation procedures and
                          • analyzed computerized data on all complaints the states had received
                            from July 1997 through June 1998,
                          • obtained and reviewed the files of complaints that each state received
                            and investigated in early 1998, and
                          • obtained and reviewed the files of complaints that the states had not yet
                            investigated at the time of our visits in late 1998 and early 1999.

                          For each of the 14 states included in our work, we reviewed the state
                          agency quality improvement program report that was submitted to HCFA at
                          the end of 1998. In addition, we interviewed HCFA officials, including
                          representatives of each of HCFA’s 10 regions, regarding federal guidance to
                          and oversight of state agencies. We also obtained from HCFA data on
                          federal and state expenditures on nursing home complaint investigations
                          for all states.

State Auditors’ Reports   We also reviewed reports from 11 states whose state auditor (or similar
                          organization such as the Office of Inspector General) had performed
                          reviews of the state’s long-term-care activities and whose investigation
                          reports were issued between December 1995 and April 1998. Each of these
                          reports addressed some aspect of the state’s nursing home complaint
                          process. The 11 states were Iowa, Kansas, Kentucky, Louisiana, New York,
                          North Carolina, Ohio, Pennsylvania, Tennessee, Texas, and Wisconsin.

Data Analysis             Each of the three states we visited provided us with electronic databases
                          on complaints received in 1997 and 1998. These data include information
                          such as the number of complaints received and investigated, the priority
                          category assigned, and when the complaint was received and investigated.

                          Page 30                                   GAO/HEHS-99-80 Nursing Home Complaints
                          Appendix I
                          Scope and Methodology

                          Recognizing that there may be a lag in recording information regarding
                          complaints, we excluded data on complaints received after June 30, 1998,
                          and report data for the 1-year period from July 1, 1997, to June 30, 1998. We
                          also only included complaints related to federally certified nursing homes.
                          For data on timeliness, we report data only for state-investigated
                          complaints, excluding any complaints that were either not investigated at
                          all or were investigated only by another entity, such as the ombudsman,
                          local law enforcement agencies, or the nursing home itself. We excluded
                          any complaint that either did not have all dates in the database or would
                          have resulted in a negative number of days between receipt and
                          investigation of the complaint.

Complaints Received       We asked each state to give us access to its file of complaints received in
                          early 1998.
in Early 1998
                          • In Maryland, we reviewed 102 complaints that the state received
                            between January 1, 1998, and February 27, 1998.
                          • In Michigan, we reviewed the 59 complaints the state received between
                            January 1, 1998, and January 15, 1998.
                          • In Washington, we reviewed the 133 complaints received between
                            January 1, 1998 and January 7, 1998.

                          We reviewed the nature of complaints received, the priority levels assigned,
                          whether the complaint resulted in an investigation and the timeliness of the
                          investigation, and whether an investigation substantiated the allegations
                          and resulted in any federal or state deficiencies. Table 6 summarizes all
                          complaints received in the three states during these periods in early 1998
                          that resulted in the state identifying a violation of federal standards and
                          that were of a severity level that actual harm to residents was found.

Uninvestigated            Each of the three states visited had a backlog of uninvestigated complaints
                          and we asked each state to give us the files for these complaints. For the
Complaints in             Baltimore, Detroit, and Seattle metropolitan areas, the tables in appendix
Baltimore, Detroit, and   III summarize the uninvestigated complaints that (1) had already exceeded
                          the state’s assigned time frame at the time of our visit and (2) were lodged

                          Page 31                                 GAO/HEHS-99-80 Nursing Home Complaints
                   Appendix I
                   Scope and Methodology

                   against nursing homes with at least three such pending complaints.1 In
                   Baltimore, these include only complaints that had not yet been assigned to
                   an investigator; they do not include additional uninvestigated complaints
                   assigned to an investigator. For Detroit and Seattle, appendix III includes
                   any uninvestigated complaint (whether unassigned or uninvestigated)
                   meeting these criteria.

HCFA Oversight     We contacted each of HCFA’s 10 regional offices and requested

Efforts            • the number of federal monitoring surveys the region conducted during
                     1996, 1997, and 1998, and how many of these represented reviews of
                     complaint investigations;
                   • State Agency Quality Improvement Program reports for the 14 states we
                     or state auditors had reviewed and that the states had submitted to
                     HCFA at the end of 1998; and
                   • any additional guidance or oversight methods for complaint
                     investigations that the regional office had developed.

Complaint          To estimate 1998 expenditures by state for nursing home complaints, we
                   collaborated with HCFA to develop a method to distinguish expenditures
Investigation      associated with (1) nursing homes for the elderly and physically disabled
Expenditure Data   from other types of facilities, including those serving individuals with
                   mental health disabilities, and (2) complaint investigations from annual
                   surveys and other state certification and licensing activities. These
                   estimates are based in large part on survey hours for complaint
                   investigations compared with all survey hours as reported to HCFA by the
                   states. Expenditure data are from 1998, except in some states where the
                   information was not yet available for the fourth quarter of the federal fiscal
                   year.2 In addition, 1997 survey hours were used because 1998 data were
                   not complete at the time of the analysis. In addition to Medicare and
                   Medicaid expenditures, the expenditures include state licensing activities
                   of federally certified nursing homes in all states where federal certification
                   and state licensing activities are conducted as part of the same process.

                   1In Baltimore, complaints that were assigned a priority classification of next on-site investigation were
                   included if they were not investigated within 45 working days.
                     For these states, expenditure data from the fourth quarter of 1997 and the first three quarters of 1998
                   were used.

                   Page 32                                                GAO/HEHS-99-80 Nursing Home Complaints
Appendix I
Scope and Methodology

Appendix II further discusses, by state, how these costs are allocated
between federal and state governments and reports expenditures for all
types of surveys; complaint investigations; federal and state shares;
complaint expenditures per visit, nursing home, and bed; and the number
of complaint visits per home and per thousand beds.

We conducted our work between October 1998 and March 1999 in
accordance with generally accepted government auditing standards.

Page 33                              GAO/HEHS-99-80 Nursing Home Complaints
Appendix II

Nursing Home Complaint Investigation
Expenditures                                                                                                                  ApIpexndi

              In fiscal year 1998, about $300 million was spent by the federal and state
              governments to certify and perform state licensing functions of federally
              certified nursing homes, with the federal government contributing about 70
              percent ($210 million) of these costs. The federal government pays the
              states for costs associated with certifying that nursing homes meet
              Medicare’s standards and pays for 75 percent of the costs associated with
              certifying that they meet Medicaid’s standards. States contribute the
              remaining share of the costs associated with Medicaid standards, and they
              also pay additional costs related to ensuring that nursing homes meet state-
              established licensing standards. States generally conduct these licensing
              reviews concurrently with their federal certification activities. HCFA and
              each of the states agree on the share of total costs that corresponds to the
              effort spent for state licensure during federal certification. Most nursing
              homes (77 percent) are dually certified for both the Medicare and Medicaid
              programs. The expenditures for these homes are split evenly between the
              Medicare and Medicaid programs after deducting the portion to be paid by
              the state for its licensing activities.

              Nearly $60 million, about 20 percent of total nursing home certification and
              licensing expenditures, was spent on complaint investigations. The federal
              government contributed about $42 million, or 71 percent, of the costs
              associated with investigating complaints. The proportion of federal and
              state expenditures for annual surveys is similar to that for complaints.
              Table II.1 shows the total expenditures by state for the federal certification
              and state licensing activities for federally certified nursing homes, the
              percentage dedicated to complaint investigations, and federal and state
              shares of complaint investigations. 1

                The information presented in tables II.1 and II.2 was developed by HCFA in collaboration with GAO. It
              is based on Medicare and Medicaid certification expenditure data, workload data and state licensure
              percentages reported by states to HCFA. When states investigate a complaint as part of annual
              inspections, HCFA requires states to separate work hours between complaint and annual surveys, but
              some states may neglect to distinguish complaint hours. Therefore, complaint expenditures may be
              understated in some states. The estimates are based on certification expenditures only, so that if a state
              places any portion of its certification responsibilities within other noncertification-related Medicaid-
              administered expenditures, this portion will not be reflected in the expenditure amounts. Also, the
              state licensing percentages were reported by the HCFA regional offices after verification by the states.
              While 77 percent of federally certified nursing homes participate in both the Medicare and Medicaid
              programs, there are some homes that participate solely in one or the other. The state licensing
              percentage is affected slightly by this mix of facilities’ certification in each state. Some, but not all, of
              the state licensing percentages reflect a mix of facilities. This may slightly vary the federal and state
              shares in those states where mix of facilities was not reflected in the state licensing percentage. Data
              on U.S. territories are reflected in the national numbers.

              Page 34                                                 GAO/HEHS-99-80 Nursing Home Complaints
Appendix II
Nursing Home Complaint Investigation

The total expenditures include those for Medicare, Medicaid, and state
licensing activities related to federally certified nursing homes. 2

The amount spent on complaint investigations was estimated by HCFA and
GAO on the basis of the staff time dedicated to complaints. The
distribution of federal and state shares varied depending on

• the share of costs that are attributed to state licensing activities and not
  shared by the federal government and
• the proportion of nursing homes that are Medicare certified, Medicaid
  certified, and dually certified for Medicare and Medicaid.

Table II.2 presents complaint investigation expenditures, by state, per on-
site investigation, nursing home, and federally certified bed, as well as the
number of complaint investigations per home and per 1,000 beds.


  The total expenditures also include activities for federal life-safety certification, which are separate
reviews generally performed by local fire departments that ensure safety of nursing homes.

Page 35                                                 GAO/HEHS-99-80 Nursing Home Complaints
                                            Appendix II
                                            Nursing Home Complaint Investigation

Table II.1: Estimated Expenditures for Nursing Home Complaint Investigations, by State, Fiscal Year 1998

                                                                         Federal complaint             State complaint
                                                                           expenditures                 expenditures
                                                     Nursing home
                       Nursing home federal              complaint
                       certification and state    expenditures as a
                                     licensing   percentage of total
State                            expenditures         expenditures           Dollars   Percentage          Dollars   Percentage
National                        $300,923,161                   19.6     $41,851,120          71.1     $16,982,569          28.9
Alabama                             4,513,957                  25.8         915,584          78.7          247,381         21.3
Alaska                               718,294                   10.6          44,929          59.1           31,132         40.9
Arizona                             2,974,070                  16.4         326,283          67.0          161,001         33.0
Arkansas                            4,572,890                  23.5         864,920          80.5          209,945         19.5
California                        32,295,110                   22.3       5,371,302          74.5       1,834,312          25.5
Colorado                            4,411,078                  16.4         604,763          83.7          117,878         16.3
Connecticut                         6,513,868                  13.1         501,715          58.8          351,886         41.2
Delaware                            1,571,149                  14.0         123,536          56.3           96,028         43.7
District of Columbia                 884,804                   10.0          54,461          61.3           34,340         38.7
Florida                           10,074,324                   11.4         886,421          77.1          263,636         22.9
Georgia                             5,129,227                  20.2         698,176          67.3          339,661         32.7
Hawaii                               904,436                   11.4          72,672          70.2           30,814         29.8
Idaho                               1,717,627                  11.9         128,585          62.7           76,334         37.3
Illinois                          20,141,264                   20.3       2,361,634          57.6       1,735,050          42.4
Indiana                             7,221,142                  24.6       1,252,656          70.6          522,195         29.4
Iowa                                3,680,882                  20.9         483,649          62.9          284,659         37.1
Kansas                              5,795,741                  19.5         760,129          67.1          371,992         32.9
Kentucky                            2,990,823                  27.9         615,417          73.8          218,894         26.2
Louisiana                           2,620,308                    6.3        137,827          83.6           27,128         16.4
Maine                               1,786,290                  24.9         335,846          75.6          108,512         24.4
Maryland                            2,980,394                    7.8        140,614          60.4           92,053         39.6
Massachusetts                       8,009,692                  11.6         723,255          77.9          205,546         22.1
Michigan                            7,627,160                  15.8         858,315          71.3          345,864         28.7
Minnesota                           7,011,762                  10.7         538,930          71.6          213,828         28.4
Mississippi                         2,396,923                  17.5         298,351          71.2          120,824         28.8
Missouri                            9,585,434                  30.2       2,112,904          73.1          778,952         26.9
Montana                             2,615,725                  15.6         328,038          80.5           79,519         19.5
Nebraska                            2,783,633                  18.6         342,063          66.0          176,260         34.0
Nevada                              1,628,137                  15.7         143,965          56.2          112,089          43.8

                                            Page 36                                     GAO/HEHS-99-80 Nursing Home Complaints
                                      Appendix II
                                      Nursing Home Complaint Investigation

                                                                   Federal complaint             State complaint
                                                                     expenditures                 expenditures
                                               Nursing home
                 Nursing home federal              complaint
                 certification and state    expenditures as a
                               licensing   percentage of total
State                      expenditures         expenditures           Dollars   Percentage         Dollars   Percentage
New Hampshire                  891,682                     4.7         32,665          78.1           9,134         21.9
New Jersey                    8,701,678                  11.5         569,847          57.1         428,978         42.9
New Mexico                    1,315,590                  15.9         177,305          85.0          31,284         15.0
New York                    17,089,866                   17.1       1,613,194          55.3       1,303,696         44.7
North Carolina                5,751,723                  24.4       1,029,176          73.3         374,173         26.7
North Dakota                  1,393,939                    7.2         73,931          73.4          26,745         26.6
Ohio                        15,592,087                   17.7       2,129,053          77.1         632,731         22.9
Oklahoma                      2,809,476                  12.1         262,191          77.4          76,718         22.6
Oregon                        3,467,206                    2.9         76,050          76.9          22,874         23.1
Pennsylvania                15,295,820                   13.8       1,097,780          52.2       1,005,789         47.8
Rhode Island                  2,113,621                  12.4         195,587          74.4          67,243         25.6
South Carolina                1,548,950                  24.1         328,645          87.9          45,184         12.1
South Dakota                  1,260,880                    7.2         73,517          80.9          17,347         19.1
Tennessee                     3,863,975                  14.0         363,191          67.1         178,414         32.9
Texas                       29,270,138                   35.5       8,638,940          83.1       1,761,302         16.9
Utah                          1,551,866                  17.3         236,563          88.2          31,702         11.8
Vermont                        603,018                     5.5         26,204          78.8           7,068         21.2
Virginia                      3,454,394                  15.5         299,591          56.0         235,466         44.0
Washington                    7,245,469                  29.8       1,278,506          59.3         877,655         40.7
West Virginia                 1,762,342                  16.3         163,071          56.8         123,803         43.2
Wisconsin                     9,895,572                  15.7       1,048,376          67.4         507,816         32.6
Wyoming                        879,581                   16.0         110,802          78.8          29,732         21.2


                                      Page 37                                     GAO/HEHS-99-80 Nursing Home Complaints
                                           Appendix II
                                           Nursing Home Complaint Investigation

Table II.2: Expenditure Rates by Home, Visit, and Bed, by State, Fiscal Year 1998

                                                                                                    Number of
                           Nursing home          Complaint         Number of          Complaint      complaint       Complaint
                               complaint       expenditures    complaint visits     expenditures      visits per   expenditures
State                       expenditures          per home          per home            per visit   1,000 beds          per bed
National                     $58,833,689              $3,397                2.4           $1,430           23.7             $34
Alabama                        1,162,965               5,215                1.4            3,716           12.7              47
Alaska                            76,061               5,071                0.8            6,338           16.7             106
Arizona                          487,284               2,901                2.0            1,463           19.4              28
Arkansas                       1,074,865               3,894                2.1            1,844           22.2              41
California                     7,205,614               5,074                3.7            1,353           41.7              56
Colorado                         722,641               3,156                1.9            1,684           22.3              38
Connecticut                      853,601               3,296                0.9            3,632            7.4              27
Delaware                         219,564               4,990                0.9            5,778            8.4              48
District of Columbia              88,801               4,036                1.5            2,691           10.6              28
Florida                        1,150,057               1,542                1.2            1,333           11.1              15
Georgia                        1,037,837               2,859                2.7            1,061           25.0              27
Hawaii                           103,486               2,407                0.8            2,957            9.4              28
Idaho                            204,919               2,440                1.2            2,029           17.8              36
Illinois                       4,096,684               4,655                3.7            1,256           32.4              41
Indiana                        1,774,851               3,097                2.6            1,203           27.0              32
Iowa                             768,308               1,645                1.8              936           23.7              22
Kansas                         1,132,120               2,795                3.8              739           57.8              43
Kentucky                         834,312               2,649                2.5            1,057           32.5              34
Louisiana                        164,955                 501                0.6              805            5.7               5
Maine                            444,357               3,392                2.5            1,351           36.2              49
Maryland                         232,666                 885                0.7            1,199            6.5               8
Massachusetts                    928,801               1,647                1.1            1,553           10.5              16
Michigan                       1,204,179               2,694                2.0            1,361           17.8              24
Minnesota                        752,759               1,680                0.8            2,057            8.2              17
Mississippi                      419,175               2,065                1.8            1,145           21.7              25
Missouri                       2,891,856               5,100                4.4            1,159           49.3              57
Montana                          407,557               3,881                0.8            4,739           11.4              54
Nebraska                         518,323               2,160                2.3              953           31.2              30
Nevada                           256,054               5,226                2.1            2,510           23.4              59
New Hampshire                     41,799                 504                1.1              475           11.5               5
New Jersey                       998,825               2,782                2.7            1,032           19.4               20

                                           Page 38                                       GAO/HEHS-99-80 Nursing Home Complaints
                                 Appendix II
                                 Nursing Home Complaint Investigation

                                                                                        Number of
                 Nursing home         Complaint         Number of         Complaint      complaint       Complaint
                     complaint      expenditures    complaint visits    expenditures      visits per   expenditures
State             expenditures         per home          per home           per visit   1,000 beds          per bed
New Mexico            208,589               2,513                 2.5            993           29.4             29
New York             2,916,890              4,406                 2.2          1,978           12.5             25
North Carolina       1,403,349              3,482                 1.7          2,013           17.7             36
North Dakota          100,677               1,144                 0.4          3,248            4.4             14
Ohio                 2,761,784              2,732                 1.5          1,802           16.2             29
Oklahoma              338,909                 823                 1.1            762           13.2             10
Oregon                  98,924                607                 0.2          3,805            1.9              7
Pennsylvania         2,103,569              2,626                 0.9          2,827            7.8             22
Rhode Island          262,830               2,602                 2.3          1,143           22.5             26
South Carolina        373,829               2,124                 1.8          1,194           18.9             23
South Dakota            90,864                797                 0.4          1,893            6.0             11
Tennessee             541,605               1,517                 1.5          1,028           13.5             14
Texas               10,400,242              8,006                 4.5          1,772           50.7             90
Utah                  268,265               2,885                 1.8          1,597           22.7             36
Vermont                 33,272                739                 0.5          1,512            5.9              9
Virginia              535,057               1,891                 0.7          2,585            6.8             18
Washington           2,156,161              7,592               11.4             664          124.6             83
West Virginia         286,874               1,938                 0.4          4,347            5.4             24
Wisconsin            1,556,191              3,662                 2.0          1,839           17.8             33
Wyoming               140,534               3,513                 1.3          2,703           16.5             45

                                 Page 39                                     GAO/HEHS-99-80 Nursing Home Complaints
Appendix III

Summary of Unassigned or Uninvestigated
Complaints for the Baltimore, Detroit, and
Seattle Metropolitan Areas                                                                                                                       AIpIexndi

Baltimore                                 As of December 14, 1998, there were 101 complaints, received between
                                          January and November 1998, filed against 56 nursing homes in the
                                          Baltimore metropolitan area that had not yet been assigned to an
                                          investigator and that also exceeded Maryland’s investigation timeframes.1
                                          The following table summarizes the complaints filed against 12 of these
                                          homes that received three or more such complaints.

Table III.1: Unassigned Complaints for Nursing Homes in Baltimore With Three or More Such Complaints

                Calendar days
                (workdays) since
                complaint was
Priority        receiveda            Summary of allegation(s)
Maryland Home 1
Next on-site    189 days (130        A nurse allowed a respite resident with Alzheimer’s disease to leave the nursing home; family
                workdays)            disputes nurse’s belief that resident was aware of where she was going. Family requested that
                                     a physician examine resident; however, a nurse examined her instead. Family was also
                                     unaware that home ordered a psychiatric consultation resulting in medication being ordered,
                                     and disputes home’s claim that family was notified. Family alleges that the resident's medical
                                     records were falsified.
Next on-site    152 days (104        Blind resident does not get needed assistance—such as identifying food provided her, or help
                workdays)            leaving room.
Next on-site    123 days (83         Understaffing, with 64 residents and only 3 to 4 aides.
Next on-site    120 days (81         Understaffing, with 64 residents and only 3 to 4 aides.
Maryland Home 2
10 workdays     249 days (171        Nurse aide struck resident in the chest.
Next on-site    230 days (158        Nursing home and complainant agreed on a time to discharge a 91-year-old resident with
                workdays)            dementia. Home discharged the resident earlier, and the new nursing home was unprepared
                                     for resident's arrival. The family was not notified that resident was transferred early and arrived
                                     to help the resident move to find that resident had already been transferred.
10 workdays     229 days (157        Visitor overheard a nurse aide verbally abusing a resident.
10 workdays     125 days (85         Resident alleged that a nurse aide verbally abused her. Aide was suspended pending
                workdays)            investigation.

                                            For complaints designated to be investigated during a home’s next on-site survey, we included only
                                          those received 45 or more workdays before December 14.

                                          Page 40                                              GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

               Calendar days
               (workdays) since
               complaint was
Priority       receiveda          Summary of allegation(s)
Next on-site   96 days (65        No hot water for several weeks or months at a time, so resident was not bathed or cleaned
               workdays)          properly. Inadequate supply of diapers, towels, washcloths, resulting in resident sitting in urine
                                  for extended periods of time. Lack of staff, resulting in resident not being adequately hydrated,
                                  fed, turned, or kept clean. Unskilled nursing assistants attended resident. Charting of intake
                                  and bowel movements was false. It was charted that resident had a bowel movement, but
                                  resident was severely impacted and needed immediate medical intervention. Scales and
                                  thermometers did not always function properly. Fluids were not routinely offered and time was
                                  not taken to make sure that the resident drank enough. If feeding took too long, the staff would
                                  not wait to ensure that the resident ate enough. Resident was admitted to the hospital 4 times
                                  in 10 years with dehydration and a urinary tract infection.
Maryland Home 3
Next on-site   147 days (101      Complainant visited resident on a Saturday and Sunday and found resident dirty with dried
               workdays)          feces and no sheet on the bed. On Sunday, resident was wet. When complainant asked aide
                                  for a towel, wash cloth, and soap, she was given paper towels and told the home did not have
                                  any soap. The complainant asked the home's staff for a water pitcher and was told that the
                                  home does not use water pitchers, only cups in the utility closet. Complainant could not find a
                                  cup in the closet and the aide told her that none was available. Call lights unanswered on both
Next on-site   137 days (93       Staff does not stay to ensure that resident takes medications. Resident in same clothes for 3
               workdays)          days. Resident received no medications for 10 days; family not notified.
45 workdays    70 days (47        Resident sent to emergency room with diagnosis of possible infection. Hospital staff found
               workdays)          resident’s intravenous line dirty and clogged because nursing home staff did not flush the line.
Maryland Home 4
Next on-site   236 days (162      Physical, verbal, and emotional abuse of a resident by nursing home staff and resident’s
               workdays)          physician who is part of the home’s staff.
10 workdays    223 days (153      Resident feeds self with a special spoon but is dependent in all other activities of daily living.
               workdays)          On two shifts, aides refused to help the resident out of bed. Resident’s supper tray was
                                  delivered but the resident was not provided any assistance to eat. Aide grabbed the resident’s
                                  shoulder after the resident told the aide that her shoulder hurt. Pressure sores have worsened
                                  since admission to the home.
45 workdays    116 days (78       Resident developed contractures because the home did not provide range-of-motion exercises
               workdays)          as ordered.
Next on-site   101 days (67       Management’s treatment of employees is affecting care. Promised pay raise never came.
Next on-site   97 days (66        Nursing home staff did not answer call lights. A resident with infection was not given an
               workdays)          antibiotic as ordered.
10 workdays    67 days (44        Nursing home offered no explanation to family for resident’s leg fracture, so the family moved
               workdays)          resident to another home. Home told state survey agency that it would investigate; however,
                                  no indication as of December 1998 that agency had received the home’s report.
Maryland Home 5
Next on-site   115 days (77       Understaffing: unit has 1 nurse and 7 aides for 52 residents, including 2 with stage III and IV
               workdays)          pressure sores, 13 with stomach feeding tubes, and 13 requiring injections. The nurse is
                                  unable to complete what she needs to do.

                                       Page 41                                          GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

               Calendar days
               (workdays) since
               complaint was
Priority       receiveda          Summary of allegation(s)
Next on-site   113 days (76       Understaffing: only 1 nurse on the 7 a.m. to 3 p.m. shift with 8 aides for 52 residents, including
               workdays)          2 residents requiring treatment, others requiring injections, and 13 stomach tube feedings.
10 workdays    47 days (31        Resident alleged caregiver at the home bruised her right forearm and later threw the resident
               workdays)          onto the bed. The hospital emergency room report indicated that the arm had soft tissue injury.
                                  Pictures of the resident show a “badly bruised arm.”
10 workdays    35 days (23        Complainant not satisfied with the home’s investigation of an incident report that a resident had
               workdays)          fallen about 13 times in 4 months. The last fall resulted in laceration of the resident’s forehead.
Maryland Home 6
Next on-site   245 days (169      Understaffing—call lights not answered in a timely manner; residents not bathed as scheduled;
               workdays)          and residents not turned and changed as needed. One aide for 15 residents requiring total
                                  care on 7 a.m. to 3 p.m., and 3 p.m. to 11 p.m. shift.
Next on-site   179 days (122      Discharge planning at home is not done appropriately, for example, a hospital-style bed was
               workdays)          not ordered until resident’s Friday discharge, so was not delivered until Monday. Residents not
                                  given choices of home health agencies or equipment companies. Residents' medical records
                                  do not indicate discharge planning. Discharge planning form usually is not completed and
                                  given to families to inform them of arrangements.
Next on-site   167 days (114      Family requested restraints for resident because of falls, but home refused.
Next on-site   145 days (99       Understaffing. Resident lost 22 lbs. in 5 months. Resident's feet have sores and are
               workdays)          bandaged, but not always changed as ordered. Sores are beginning to smell. Complainant
                                  found resident's face swollen, but staff was unable to explain what happened.
Maryland Home 7
Next on-site   287 days (199      Resident told therapist that an aide verbally abused her. Home was to investigate and report to
               workdays)          the state survey agency. However, as of December 1998, the state did not have the home’s
                                  investigative report.
10 workdays    270 days (186      Aide smokes in the home and around residents. Same aide mishandled residents—threw
               workdays)          them into bed and used nasty language. Home was to investigate and report to the state;
                                  however, as of December 1998, there was no indication home had done an investigation.
10 workdays    88 days (59        After contacting home about its investigation of physical abuse of a resident, ombudsman was
               workdays)          uncomfortable with the home’s inconsistent responses.
Maryland Home 8
10 workdays    182 days (125      Resident had discoloration of chest that family believed was bruise caused by physical abuse.
               workdays)          Home to investigate and report to the state; but, as of December 1998, there was no indication
                                  home had investigated.
45 workdays    103 days (69       Understaffing, resulting in the dining room being closed for 2 days. During this time, there were
               workdays)          only 3 aides for 70 to 80 residents.
10 workdays    69 days (46        Complainant saw a nursing home employee shaking resident. Employee terminated by home.
Maryland Home 9
10 workdays    160 days (110      Hygiene inadequate--resident was not bathed, teeth not cleaned, and hair not combed.
               workdays)          Weight loss from April to June, was 134 lbs. to 120 lbs. Home said resident spit food out and
                                  that home had recommended a stomach tube.

                                       Page 42                                          GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

               Calendar days
               (workdays) since
               complaint was
Priority       receiveda          Summary of allegation(s)
Next on-site   157 days (107      Resident was not provided food from Monday night until Wednesday at 3:00 p.m. Resident was
               workdays)          sent to hospital after complainant insisted. At hospital, the resident was found to have infected
                                  sacral decubitus ulcer, was dehydrated, and had urinary tract infection. Nursing home staff
                                  said they had not sent resident to the hospital because resident was dying.
45 workdays    147 days (101      New aide tried to transfer resident without another aide to assist, although the care plan called
               workdays)          for two people for transfers. Aide said she could not get timely help, so attempted to do it by
                                  herself. Five days later, resident was found to have two fractured legs. Home wrote incident
                                  report, but did not interview new aide as required until ombudsman opened a case as a result
                                  of family's concern about home misrepresenting circumstances of resident's fall. Family called
                                  doctor, who ordered X-rays. It is unclear whether home also called doctor simultaneously, or
                                  earlier—as home reported.
Maryland Home 10
45 workdays    181 days (124      Resident was blind, intelligent, and sociable. Complainant has found resident alone, begging
               workdays)          for help, screaming “ . . .help, where am I?”, or “please, someone get me a drink of water,” or
                                  “please take me to the bathroom." No one responded or reassured resident that she was not
                                  alone. On one occasion, resident was found still in bed at 3:00 p.m.—urine-soaked, hungry,
                                  and thirsty. She had no breakfast or lunch. Nurse said home was short of staff that day.
10 workdays    145 days (99       Aide spoke to resident in a very poor manner--told resident to “shut up” and if she kept ringing
               workdays)          her call bell, she would be the last one to be answered. Administrator spoke with other staff
                                  who noted that the aide’s attitude was poor toward residents and some staff had seen him in
                                  altercations with residents. They indicated that the aide appeared to be “fired/wired up.”
10 workdays    119 days (81       Aide was verbally abusive to resident in presence of the family.
45 workdays    68 days (45        When admitted to home from hospital in July, resident could bathe, walk, and feed self. After 1
               workdays)          month in home, these activities stopped. Family met with home's staff about three times on
                                  quality-of-care issues, but problems persisted. Resident readmitted to hospital three times in
                                  her 2-month stay--a result of poor care at the home. Resident had series of falls. Home said
                                  no injuries resulted, but the resident suffers pain to the touch of bruised areas. As organ
                                  transplant recipient, needs sufficient fluids, but had not been getting, as evidenced by hospital
                                  diagnosis of dehydration. Hospital staff questioned whether resident had been receiving
                                  medications as prescribed. Staffing ratio at home was sometimes 1 aide to 20 residents on
                                  evening shift, so family had to bathe resident and put to bed. Resident placed on a toileting
                                  program by the home, but family has found her with a saturated diaper on, indicating resident
                                  was not being toileted on a regular basis.
Maryland Home 11
10 workdays    243 days (167      Caregiver handled resident roughly causing her to “suffer all night.” The resident was in a
               workdays)          rehabilitation unit receiving treatment for a fractured hip. Resident’s roommate witnessed the
10 workdays    243 days (167      Aide was verbally abusive: called resident a “witch” and threatened to throw water on the floor
               workdays)          and make her walk in it, hoping she would slip; said he would put her out of the unit because he
                                  was the boss on the floor; put a pillowcase over his head to try to disguise himself as resident’s
                                  doctor; threatened to unplug another resident’s call bell. Police were notified.
Next on-site   231 days (159      Resident had two bruises on her arms. Ombudsman found no documentation of the bruises in
               workdays)          records.

                                       Page 43                                          GAO/HEHS-99-80 Nursing Home Complaints
                                      Appendix III
                                      Summary of Unassigned or Uninvestigated
                                      Complaints for the Baltimore, Detroit, and
                                      Seattle Metropolitan Areas

              Calendar days
              (workdays) since
              complaint was
Priority      receiveda          Summary of allegation(s)
Maryland Home 12
10 workdays   112 days (76       A resident diagnosed with schizophrenia alleged someone in the home was sexually abusing
              workdays)          her. Complaint investigated by nursing home, but no formal report generated.
10 workdays   81 days (54        Resident alleged an aide placed a pillow over the resident’s face; resident removed pillow, and
              workdays)          aide did it again.
10 workdays   81 days (54        Resident said a nurse aide yanked the bed covers off and grabbed resident’s hand real hard.
              workdays)          Ombudsman noted resident’s hand had a discolored area.
                                       This column represents the number of days from the date the complaint was received to the day GAO
                                      visited the state agency.

                                      Page 44                                            GAO/HEHS-99-80 Nursing Home Complaints
                                          Appendix III
                                          Summary of Unassigned or Uninvestigated
                                          Complaints for the Baltimore, Detroit, and
                                          Seattle Metropolitan Areas

Detroit                                   As of January 11, 1999, there were 129 complaints, received between
                                          February and November 1998, filed against 62 nursing homes in the Detroit
                                          metropolitan area that had not been investigated and that exceeded the
                                          state’s 45-day investigation time frame. The following table summarizes the
                                          complaints filed against 17 of these homes that received three or more such

Table III.2: Uninvestigated Complaints for Nursing Homes in Detroit With Three or More Such Complaints

               Calendar days
               since complaint
Priority       was receiveda      Summary of allegation(s)
Michigan Home 1
45 days        262 days           The nursing home changed its billing formula resulting in a large increase in fees.
45 days        160 days           The air conditioning does not work properly in one of the wings of the home.
45 days        144 days           Questionable infection control practices. Two roommates died within days of each other of
                                  complications of infections. One roommate was admitted to the home with gangrene between two
                                  toes and an ulcer on her foot, but with no oozing or infection. Despite being diabetic, which
                                  required close monitoring of her feet, the home did not change the dressings as her physician
                                  ordered. The resident’s foot began to ooze and became swollen. A culture was taken and the
                                  resident was moved to another room without explanation. Twenty-five days after being admitted to
                                  the nursing home, she was returned to the hospital where she died 6 days later. The resident’s
                                  roommate, who entered the home 11 days after the resident, was a diabetic with open wounds on
                                  her feet and legs when she was admitted. Twelve days after being admitted, the roommate had
                                  an elevated temperature. Despite her family’s request to have her hospitalized, her doctor
                                  prescribed liquid Tylenol. That same day, she experienced breathing problems, was given
                                  antibiotics for an infection, and died.
Michigan Home 2
45 days        122 days           Resident was not repositioned timely, developed pressure sores, and was neglected, resulting in
                                  dehydration requiring hospitalization.
45 days        111 days           Resident’s condition declined visibly in a short period of time resulting in her becoming lethargic,
                                  weak, and listless. The complainant suspected dehydration even though she was taken to the
                                  hospital and not treated for dehydration. Later that week, the home advised the complainant that
                                  the resident had “perked up” and that she would have dressings applied to her feet because of
                                  skin breakdowns. During a 4-hour visit 2 days later, the complainant contends that staff did not
                                  reposition the resident during this 4-hour period and that the dressings promised earlier had not
                                  been applied.

                                          Page 45                                          GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

             Calendar days
             since complaint
Priority     was receiveda     Summary of allegation(s)
45 days      73 days           Complaint discussed treatment of several different residents over the past several years. One
                               resident was dropped on the floor during the middle of the night, suffered knee damage, and was
                               placed back in bed. She moaned with severe pain until the day shift nurse found her at 7:00 a.m.
                               She was sent to the hospital where her knee, although severely damaged, could only be
                               bandaged. She died days later. A second resident received the wrong medication that burned
                               her mouth, throat, and lower regions causing discomfort for many weeks. She was later dropped
                               while being weighed. A third resident entered the home with no visible skin problems but
                               developed bedsores that led to the amputation of a limb.
45 days      54 days           Resident’s feeding tube was running and vomit was evident in her mouth and on her hands and
                               face. She was found lying in a urine-soaked sheet, and a pressure sore was also urine soaked.
                               She also had skin tears, but no wound care was performed. On the day she was admitted, she
                               received no insulin as scheduled. The staff reportedly said that there was no insulin in the nursing
                               home at that time.
Michigan Home 3
45 days      139 days          The home failed to assess a resident’s injury in a timely manner. The resident fell at 12:30 p.m.
                               suffering a broken left hip, but was not transferred to the hospital until the next day.
45 days      67 days           A resident sustained a fracture of unknown origin to the right hip. Neglect is alleged.
45 days      63 days           A resident sustained a fracture of her wrist while taking a shower without supervision.
Michigan Home 4
45 days      195 days          Family member found a portable X-ray company taking X-rays of resident without an explanation.
                               The floor nurse said the resident’s knee was swelling. X-rays revealed a fracture in the knee.
                               Family questions if resident was properly restrained. The hospital physician felt the resident was
                               either dropped or fell down. The home staff stated they thought the resident might have bumped
                               the side rail. The family also felt the resident was not receiving required assistance with eating.
45 days      119 days          During lunchtime an employee of the nursing home slapped a resident who needs assistance with
45 days      96 days           A resident was not adequately groomed (soiled clothing), did not receive services ordered by a
                               physician, was harmfully neglected, and suffered a preventable injury.
Michigan Home 5
45 days      293 days          Resident fell sometime during the evening or the early morning of the next day. The facility put her
                               back in bed without ordering X-rays, even though she complained of pain in her leg. X-rays were
                               not taken for 3 days and then were taken only upon the family’s insistence. The resident was
                               transferred to the hospital where it was determined that she had a shattered hip.
45 days      255 days          A resident fell from her bed and suffered injuries including a skin tear on her hand and an abrasion
                               on her left temple. X-rays also revealed a fracture to her left hip.
45 days      140 days          Complainant alleged a series of problems with the care provided to her father: he had no access
                               to water despite being diabetic and was often very thirsty; he frequently slipped down in his
                               cardiac chair but was not offered a wheelchair because the home did not have one that would fit
                               him; the home failed to provide an assessment of the resident’s breast for breast cancer; his
                               oxygen machine was broken but complainant suspects that the home nevertheless bills Medicare
                               for oxygen; resident was advised that his family should come and help to feed him; the resident’s
                               belongings were missing and he was wearing the clothes of other residents; complainant was told
                               by staff that the laundry in the home is done infrequently.

                                       Page 46                                          GAO/HEHS-99-80 Nursing Home Complaints
                                        Appendix III
                                        Summary of Unassigned or Uninvestigated
                                        Complaints for the Baltimore, Detroit, and
                                        Seattle Metropolitan Areas

             Calendar days
             (workdays) since
             complaint was
Priority     receiveda          Summary of allegation(s)
45 days      111 days           During a 16-month period, the resident–who is unable to turn in bed, speak, or move her right
                                side–suffered pneumonia, numerous bruises, cracked ribs, a broken hip, a broken shoulder, and a
                                broken leg.
Michigan Home 6
45 days      252 days           A resident was brought into the hospital and was not breathing, was severely dehydrated, and had
                                acute rib fractures and pneumonia.
45 days      251 days           A resident signed himself out of the home and did not return.
45 days      241 days           The resident had an untreated pressure sore. The complainant indicated that the staff intentionally
                                hid the resident’s condition from her for possibly up to one year.
Michigan Home 7
45 days      292 days           Resident ran a temperature of 100+ degrees for three days without the home contacting the
                                family. The resident died from bronchial pneumonia and a closed-head injury.
45 days      115 days           Nursing staff failed to provide the resident with a breakfast tray. When the resident asked the
                                nursing assistant for the tray, the nursing assistant responded “because of your attitude, no one
                                wants to give it to you. Do it yourself.”
45 days      105 days           The home schedules only one aide per floor on the midnight shift. The home reuses the feeding
                                tube bags between the residents. One resident was found to have maggots in the sores on his
                                feet, but the home would not send him to the hospital because it was afraid the hospital would call
                                the state. The Director of Nursing specifically told the staff that the resident was not to go
                                anywhere “because the state would be called in to investigate and we do not need that right now.”
Michigan Home 8
45 days      116 days           Resident sustained an injury (fracture of the femur) of unknown origin.
45 days      116 days           Resident sustained an injury (femoral neck fracture) of unknown origin.
45 days      116 days           Resident had a hematoma over her left eye, with bruising, as well as a black left eye. The cause
                                of the injuries is unknown.
45 days      103 days           Resident sustained a fracture (left ankle and lower leg) of unknown origin.
Michigan Home 9
45 days      181 days           Home was understaffed; a resident was found sitting in the dining room with wet pants; resident
                                found in a gown with no underwear; resident’s clothing missing; resident not helped to bathroom in
                                a timely manner; no therapeutic activities for residents; meals are inadequate; a dog is allowed to
                                roam through the nursing home; offensive odors in the home; resident has been injured as a result
                                of falls.
45 days      165 days           The resident was not allowed to take a leave of absence from the home; her privacy was not
                                protected; she had a difficult time getting her personal expense money from the administration.
45 days      95 days            The resident fell out of a chair and was sent to the hospital where she received six stitches in the
                                back of her head. This was the fourth time she had fallen. One of the falls resulted in permanent
                                loss of vision in her right eye. The family also alleges that they have been denied access to her
                                clinical records.

                                        Page 47                                         GAO/HEHS-99-80 Nursing Home Complaints
                                        Appendix III
                                        Summary of Unassigned or Uninvestigated
                                        Complaints for the Baltimore, Detroit, and
                                        Seattle Metropolitan Areas

             Calendar days
             (workdays) since
             complaint was
Priority     receiveda          Summary of allegation(s)
Michigan Home 10
45 days      320 days           When resident returned to the home following amputation of part of his leg, the home did not take
                                necessary precautions to ensure that the leg did not become infected. It became infected and
                                more of the leg had to be subsequently amputated. He was also handled roughly, over-
                                medicated, and his feeding tube was not kept clean.
45 days      320 days           Although the resident could not get out of bed without assistance, the home informed the family
                                that he had to be taken to the hospital emergency room because he had gotten out of bed and
                                fallen. When the family saw him, his arm was completely black and blue. He was also constantly
45 days      292 days           The resident was in the home for three months recovering from a stroke. Complainant alleges
                                that the resident was left in soiled clothing for hours and was prescribed a mixture of medication
                                that caused internal bleeding that led to a blood transfusion. The nursing home advised the
                                resident on numerous occasions that insurance would cover all her costs and convinced her to
                                remain in the home for the entire period of Medicare coverage. After leaving the home, she
                                received a bill for $7,000, which a credit agency is attempting to collect from her son.
45 days      292 days           The resident was not properly groomed; food was observed in the heaters; staff did not answer
                                call bells; staff harassed the resident and his family if they complained about care.
45 days      292 days           Resident developed pressure sores on both feet and had to have part of one leg amputated due to
                                improper care of the sores.
45 days      291 days           The home was short of staff and was falsifying the books.
45 days      273 days           Staff would not respond to the resident’s buzzer; resident was often found sitting in urine and
                                feces; a week before he died, he complained of an upset stomach and was vomiting, but staff told
                                the family there was a virus going around and there was nothing to worry about; family was not
                                informed of a change in his condition.
45 days      273 days           Resident was not washed or shaved; his teeth were not brushed and his fingernails were dirty; call
                                lights went unanswered.
45 days      189 days           The certified nursing assistants were not qualified to care for residents; staff failed to follow the
                                care plan that requires two people to move this resident; the resident was left alone in the
                                bathroom, fell down, struck her head, and suffered cracked ribs and various cuts and bruises.
45 days      180 days           Several residents fell out of bed one evening because the side rails were not put up; food was
                                served cold and there was no staff person to help residents eat; the home was very short staffed
                                and on several nights the complainant was the only nonresident adult in the wing; the resident’s
                                roommate was choking but no one responded when the complainant pulled the call light; during a
                                shift change, all the nursing staff was gathered around the nursing station calling in lotto tickets.

                                        Page 48                                            GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

             Calendar days
             since complaint
Priority     was receiveda     Summary of allegation(s)
45 days      178 days          A resident made the following allegations: her telephone was taken away; she did not receive
                               adequate whirlpool baths ordered by her doctor; she did not receive two baths weekly; her food
                               was cold and unpalatable; she was not allowed to attend the church of her choice; her discharge
                               planning was inadequate.
45 days      174 days          The resident had injuries (bruises and swelling) of unknown origin. The home provided conflicting
                               reports as to what may have happened.
45 days      172 days          The food was not palatable; the home was short staffed; physical therapy provided was very
                               limited; money was stolen from the night stand; beds did not raise up and down and the
                               mattresses were very thin.
45 days      168 days          The resident had bed sores on his heels; he was refused readmission to the home following a
                               hospital stay; he was not properly groomed (bathed and shaved); dirty bed linens were not
                               changed; he was not turned; physicians did not visit residents but instead took the word of the
                               nurses concerning residents’ condition; resident was not timely transferred to the hospital for
                               treatment, resulting in his death.
45 days      129 days          A nurse verbally abused the resident.
45 days      76 days           Staff failed to assess and monitor a resident who was later sent to the hospital for treatment of a
                               seizure; they did not take proper precautions for pressure sores; they did not treat the resident
                               with dignity and respect because they forced him to wear diapers.
Michigan Home 11
45 days      178 days          The home did not check the blood sugar level of a diabetic resident for three days following his
                               admission. On the third day he received two units of insulin when he should have received 100
                               units. When brought to the attention of the nurse, she said they were not supposed to check his
                               blood sugar. The resident’s wife insisted that the doctor be called, and it was determined that the
                               resident’s blood sugar was more than six times the normal amount. On the physician’s order, the
                               home gave him potassium pills to normalize his sugar level, but his heart rate went so high that he
                               was taken to the hospital, where he died.
45 days      96 days           Nursing home staff would not permit the resident to leave the home to visit with his family.
45 days      55 days           Resident fell out of bed and suffered a cut on her head. Staff bandaged the cut but because she
                               had no other marks on her body and could move her arms and legs, X-rays were not taken. Three
                               days later she was taken to the emergency room with elevated heart rate, blood pressure, and
                               sugar level. The doctor in the emergency room ordered an X-ray after noticing that she cried and
                               reached for her hip when he tried to turn her. The X-ray confirmed a hip fracture, necessitating hip
                               surgery. The complaint also alleges that the resident previously had experienced dehydration and
                               a urinary tract infection, had two hearing aids and her dentures lost in the home, and was
                               discovered wearing another resident’s dentures, which resulted in a sore mouth and an inability to
Michigan Home 12
45 days      245 days          A resident walked out of the home and was found a block away by a passerby. He had fallen and
                               suffered a swollen eye, a bruised hand, and a knee abrasion.
45 days      217 days          An employee was verbally abusive to a resident.
45 days      137 days          A resident developed a cut on his foot that became infected. It was left unchecked and spread into
                               the bone. The heel had to be amputated.

                                       Page 49                                          GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

             Calendar days
             since complaint
Priority     was receiveda     Summary of allegation(s)
45 days      82 days           The resident had a condition that, if vomiting takes place, dictates that the resident should be
                               taken immediately to the emergency room. Although the resident was suffering spells of vomiting,
                               the nursing home failed to send her to the hospital until she was found unconscious. Following
                               surgery, she improved, but died about a month later. Although peritonitis was listed as the cause
                               of death, a doctor at the hospital told family members that “if she hadn’t been so dehydrated and
                               malnourished, she would have been better able to fight off the infection.”
Michigan Home 13
45 days      102 days          An employee slapped a resident.
45 days      81 days           The resident had bruises on her chin, her stomach, and her arms and legs; the home did not notify
                               family when resident was hurt or sick; she suffered a head injury of unknown origin; the family had
                               to request that she be hospitalized after she was ill for several weeks; she was so over-medicated
                               that the doctor was unable to perform needed gall bladder surgery; she suffered a stroke but was
                               not sent to the hospital until the family observed the problem and insisted on hospitalization.
45 days      55 days           The home failed to provide proper dental care. The dental progress notes were inconsistent and
                               of dubious accuracy. Despite the home’s assurance to the complainant that its dentist was
                               capable of providing care, the resident had to visit an oral surgeon to resolve the problem that had
                               lasted for 15 months.
Michigan Home 14
45 days      145 days          The resident was found on the floor bleeding from an injury to her head that required 17 stitches.
                               In addition to the head injury, the resident had bruises on her face by her mouth and under her ear
                               and her eyes were black and blue. The complainant feels she did not get a satisfactory answer
                               from the home about the reason for the injury.
45 days      115 days          This complaint included 28 separate allegations about the care provided to 17 residents. The
                               allegations include: the administrator would not order needed equipment (such as recliners and
                               geri-chairs) which forced the residents to stay in their beds; 90 percent of the home’s beds are old
                               and faulty (big gaps in the side rails); a resident got her head caught in the side rails, was sent to
                               the hospital, and later died; side rail pads are not put on the beds; the nurses are not passing the
                               medications; the administrator told staff to call EMS (the community emergency medical service)
                               instead of 911 when a resident was nonresponsive, possibly to save money; one resident was
                               gritting her teeth in the dining room and the director of nurses shoved her and her chair out of the
                               dining room because she couldn’t stand the sound; a resident was sent to the hospital due to
                               malnutrition and dehydration and died two weeks later; a resident who entered the home with both
                               legs is now a bilateral amputee because he developed pressure sores when staff failed to turn and
                               reposition him or provide heel protection or foot elevation; a resident frequently complained of leg
                               pains but his complaints were not addressed. It was later determined that he had deep vein
                               thrombosis; a resident was frequently sleeping but no assessment or lab tests were performed to
                               determine the problem; residents are restrained for convenience; as a result of understaffing,
                               residents are not cleaned, changed, or provided oral care; a resident was admitted with no
                               pressure sores, but developed sores on her heels and legs, became septic, and died; a resident
                               with very bad teeth and gums has received no dental care; residents complain that their food trays
                               are removed before they are finished eating.

                                       Page 50                                           GAO/HEHS-99-80 Nursing Home Complaints
                                       Appendix III
                                       Summary of Unassigned or Uninvestigated
                                       Complaints for the Baltimore, Detroit, and
                                       Seattle Metropolitan Areas

             Calendar days
             since complaint
Priority     was receiveda     Summary of allegation(s)
45 days      73 days           The complainant alleges that this home does not care for its residents. His father, a cancer
                               patient, has a radiation machine in his room. Although this machine generates a great deal of
                               heat, the thermostat in his father’s room has not been adjusted accordingly and the room is very
                               hot. The complainant also indicated that the home cannot accommodate its residents and make
                               them comfortable as it would have people believe. The home is not clean and no one seems to
                               care. Complaints are made to the home’s staff, but nothing improves.
Michigan Home 15
45 days      136 days          Staff told complainant that her husband had fallen and that the fall was likely due to his
                               medication. When complainant went to the resident’s room, she found that he was shaking, hot,
                               gasping for air, that his respirations were only 30-38, and that his hands were blue. Complainant
                               indicates that the physician assistant had been in her husband’s room only two minutes earlier
                               and had only ordered a chest X-ray. The resident was taken to the emergency room where it was
                               determined that he had a temperature of 103 degrees and was placed on life support. The
                               emergency room doctor determined the resident had pneumonia.
45 days      109 days          The resident receives cold showers and once went for two weeks without a shower; she lays in
                               urine and feces; staff lost her address book and she cannot contact any of her friends; she has
                               been denied seeing a doctor to explain her pain; no one helps her with her meals; the facility is
                               short staffed.
Not shown    48 days           A nurse aide, thought to be but later determined not to be certified as a nurse aide, was verbally
                               and physically abusive to a resident.
Michigan Home 16
45 days      196 days          Nurse aide was seen striking a resident with a towel.
45 days      152 days          A resident’s personal belongings (clothes and shoes) were missing and the resident had to wear
                               another resident’s shoes to a doctor’s appointment; when she returned from the late-afternoon
                               appointment, she was given cold leftovers as her evening meal; she suffered facial cuts of
                               unknown origin; she was constantly falling but the home failed to notify the legal guardian; the
                               home failed to coordinate transportation for a medical appointment; during visiting hours,
                               residents were being changed in their rooms with the doors left wide open.
45 days      48 days           An employee slapped a resident across the face.
Michigan Home 17
45 days      152 days          The resident was hospitalized for a blood infection and pressure sore; she experienced a
                               significant weight loss; another resident was observed eating the resident’s food and using her
                               comforter; her personal property was missing.
45 days      136 days          A former employee said the home fired her after 3 weeks of employment because she refused to
                               falsify documents; the home is understaffed; wound care is put off for two to three days; falls and
                               aspirations (introducing food or liquids into the lungs) are common but are often not documented
                               or reported; supplies are low; the home learned that state officials were coming for an inspection
                               and directed the employee to falsify residents’ charts.
45 days      94 days           The home failed to change the resident’s incontinence products, resulting in a rash and blisters;
                               he was hospitalized for fluid in the lungs because the home failed to provide adequate care; he
                               lost at least 40 pounds because his dentures were lost and the home failed to provide the
                               necessary dental care to ensure that his new dentures fit properly.

                                       Page 51                                         GAO/HEHS-99-80 Nursing Home Complaints
                                     Appendix III
                                     Summary of Unassigned or Uninvestigated
                                     Complaints for the Baltimore, Detroit, and
                                     Seattle Metropolitan Areas

           Calendar days
           since complaint
Priority   was receiveda     Summary of allegation(s)
45 days    63 days           At 10:00 a.m., family members arrived at the home to take the resident to a medical appointment
                             and found her lying in bed, totally soaked in urine, including her hair and pillow. She was lying on
                             top of the made bed, dressed in a hospital gown with her bare feet and legs totally exposed.
                             Complainant believes she was left this way all night because no other beds on the ward were
                             made. A week later, another family member found the resident in a similar condition. This time,
                             she was wearing a sweatshirt, but no underwear or diaper. There were no clothes in her closet for
                             her to be changed into. A week later, the resident was rushed to the hospital with an extremely
                             low sugar level. She has never had diabetes and never had a problem with her blood sugar.
                             Complainant believes it is possible that the resident was accidentally or intentionally injected with
                             insulin (possibly that of her roommate, who is a diabetic).
                                     aThis  column represents the number of days from the date the complaint was received to the day GAO
                                     visited the agency. Because Michigan measures its time frame in calender days, not in workdays, as
                                     do Maryland and Washington, we show only calendar days for Michigan.

                                     Page 52                                            GAO/HEHS-99-80 Nursing Home Complaints
                                          Appendix III
                                          Summary of Unassigned or Uninvestigated
                                          Complaints for the Baltimore, Detroit, and
                                          Seattle Metropolitan Areas

Seattle                                   As of January 6, 1999, there were 40 complaints, received between
                                          September 1998 and December 1998, filed against 11 nursing homes in the
                                          Seattle metropolitan area that had not been investigated and that exceeded
                                          the state’s investigation time frame. The following table summarizes the
                                          complaints filed against nine of these homes that received three or more
                                          such complaints.

Table III.3: Uninvestigated Complaints for Nursing Homes in Seattle With Three or More Such Complaints

                   Calendar days
Priority in        since complaint
workdays           was receiveda       Summary of allegation(s)
Washington Home 1
45 workdays        69 days (45         Floor of resident’s room was dirty; urine on floor at noon was still there at 4:30 p.m. Staff
                   workdays)           never asked preference on meals. Staff told resident he could not have bed rails because it
                                       was against the law.
10 workdays        68 days (44         Resident fell from wheelchair and was cut above eye. Complainant asked staff to call
                   workdays)           medical aid, but staff said not needed because laceration was not deep. Complainant
                                       insisted, and resident was taken to hospital where he received 6 sutures and was observed
                                       for pain in right arm. Complainant was removing the resident from this home, but was
                                       concerned about the residents who remain.
10 workdays        68 days (44         (Same resident and incident as previous complaint; new allegations.) Fell from wheelchair,
                   workdays)           apparently because staff did not strap in properly. Staff of new nursing home visited home
                                       where incident occurred and was allowed to read resident’s chart without a release from the
                                       resident. Complainant concerned about confidentiality.
Washington Home 2
10 workdays        89 days (58         Staff did not feed resident and told the complainant to feed resident. Staff ignored resident
                   workdays)           after they learned family complained to state. Did not maintain cleanliness of urinary
                                       catheter. Resident now hospitalized, and home will not take resident back.
10 workdays        77 days (51         Insufficient staffing resulted in inadequate hygiene, resident falls. Resident was charged for
                   workdays)           wheelchair management training, but home never provided training.
10 workdays        76 days (50         Resident (same as in above complaint) billed for wheelchair management training, but never
                   workdays)           received training.
Washington Home 3
10 workdays        71 days (47         Resident sustained two fractures of her leg, which home believed occurred while moving
                   workdays)           resident. Sent resident to hospital for X-ray, and suspended person who made the transfer.
10 workdays        54 days (35         Nurse allowed relative and others to give resident his medication. Nurse did not always
                   workdays)           administer recommended dosage of morphine, but gave more. Room and facility not always
                                       clean and staff did not bathe resident until complaint was made. Nurses changed diet from
                                       regular to liquid to keep him from throwing up, and would not restore regular diet because
                                       didn’t want to clean up the mess if he threw up again. Doctor never came to see resident.
10 workdays        48 days (31         Resident did not receive pain medications ordered by the doctor. Resident’s family was not
                   workdays)           given proper admission paperwork to sign.

                                          Page 53                                         GAO/HEHS-99-80 Nursing Home Complaints
                                     Appendix III
                                     Summary of Unassigned or Uninvestigated
                                     Complaints for the Baltimore, Detroit, and
                                     Seattle Metropolitan Areas

                Calendar days
Priority in     since complaint
workdays        was receiveda     Summary of allegation(s)
10 workdays     44 days (29       Resident who was generally confined to bed got up, walked down hall, fell, and fractured hip.
                workdays)         Was in hospital for surgery.
10 workdays     30 days (20       Stolen items. Facility reeks of urine. A resident lies on floor in front of elevator and attacks
                workdays)         visitors.
10 workdays     27 days (17       Resident was found urine-soaked every visit. Left in nightclothes. Not wearing eyeglasses
                workdays)         or hearing aid.
Washington Home 4
10 workdays     96 days (63       Resident fell out of bed in spite of side rails, and suffered head laceration requiring stitches.
10 workdays     71 days (47       Staff member slapped resident on leg, which already had nerve damage.
10 workdays     68 days (44       Verbal abuse and public humiliation of talkative resident by therapist.
10 workdays     37 days (25       Fracture of leg below kneecap of unknown origin. Patient has osteoporosis.
10 workdays     54 days (35       Home is billing 12 percent interest on outstanding charges. Home cannot locate lift chair that
                workdays)         was owned by deceased resident.
10 workdays     26 days (16       Verbal abuse by nursing assistants, including a threat to take away call light because of the
                workdays)         resident’s frequent use of it.
10 workdays     24 days (15       Alleged neglect--untreated leg wound was bed sore; leg may have to be amputated. Patient
                workdays)         showing mental decline, without satisfactory diagnosis.
Washington Home 5
10 workdays     90 days (59       Home trying to force a resident out, into adult home not suitable to needs of wheelchair-
                workdays)         bound resident.
10 workdays     54 days (35       Resident with history of hitting staff and other residents apparently hit fellow resident on
                workdays)         head, causing bruise and abrasion with slight bleeding.
10 workdays     28 days (18       Resident with history of aggression hit another resident in jaw.
10 workdays     21 days (13       Poor care and service; quality of care in home has declined. Catheter leaked and soaked
                workdays)         resident, but aide left resident wet; so resident called 911--taken to hospital.
10 workdays     19 days (11       Resident wanted to leave nursing home, as could function on own. Overmedicated to point
                workdays)         that could not think and speak clearly. Nothing to do in nursing home. Disagreements
                                  among family, resident, and nursing home staff impeded eventual transfer to independent
                                  living. Nursing home social worker and state case manager tried to prevent independent
                                  living by labeling suicidal. A near-failure of system of rights and protections, requiring
                                  ombudsman’s repeated intervention.
10 workdays     16 days (10       Resident has had numerous falls--12 within a few weeks--in spite of mats around bed,
                workdays)         special alarm, lap tray on wheel chair. Latest fall required emergency room visit and stitches,
                                  as did another fall.
Washington Home 6
10 workdays     93 days (62       Resident found covered in blood, feeding tube pulled out, yet resident unable to have pulled
                workdays)         out on own due to physical limitations. Hospitalized.

                                     Page 54                                           GAO/HEHS-99-80 Nursing Home Complaints
                                     Appendix III
                                     Summary of Unassigned or Uninvestigated
                                     Complaints for the Baltimore, Detroit, and
                                     Seattle Metropolitan Areas

                Calendar days
Priority in     since complaint
workdays        was receiveda     Summary of allegation(s)
10 workdays     43 days (28       Resident had burn on leg, which was brought to complainant’s attention by home’s staff.
10 workdays     36 days (24       Resident was served cup of coffee so hot that it caused her to drop it and burn her right leg.
10 workdays     22 days (14       Resident, who is being treated for mental and other difficulties, receives visits from son who
                workdays)         verbally abuses resident. Resident gets upset and stops eating. Complainant fears son
                                  contributing to recurrence of mental difficulties.
Washington Home 7
10 workdays     108 days (72      Ongoing problem with theft of resident’s personal items. Difficult to contact nursing home
                workdays)         staff by phone to resolve issue. Facility has not resolved issue.
10 workdays     71 days (47       Neglect, inadequate staffing, untrained staff: Resident looked like swallowed watermelon due
                workdays)         to impacted bowel—a recurrent problem. No bowel movement charted in 10 days.
                                  Medications not given, but appears records falsified to show given. Home discontinued
                                  ordered medication.
10 workdays     64 days (42       Home unresponsive in addressing care problems brought to its attention. Due to reduced
                workdays)         staff, administration of medications is erratic. Call lights not answered for 2 hours, so not
                                  getting to bathroom timely—now have rash from being urine-soaked. Missed 3 weekly
                                  baths. Turnover of temporary staff creates communication problems.
Washington Home 8
10 workdays     33 days (21       Concern over care needs not being met.
10 workdays     44 days (29       Staff shortages leading toward burnout.
10 workdays     37 days (25       Resident says young man fractured his hand. Staff treated resident roughly and tried to
                workdays)         force him to eat. Doctor unable to answer questions about medications or other care
Washington Home 9
10 workdays     58 days (38       Staffing inadequate to meet needs of residents. Call lights not answered, or answered late.
                workdays)         Reportable incidents not reported and recorded properly.
10 workdays     27 days (17       Medication error—order was changed but missed by staff, so that resident received higher
                workdays)         dosage than ordered for a month.
10 workdays     18 days (10       Medication error—mix-up of residents, so that resident received own medications and
                workdays)         another resident’s on same morning. Doctor and nurses intervened, and close monitoring of
                                  vital signs followed.
                                     aThis  column represents the number of days from the date the complaint was received to the day GAO
                                     visited the state agency.

                                     Page 55                                            GAO/HEHS-99-80 Nursing Home Complaints
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