[Senate Hearing 107-401]
[From the U.S. Government Publishing Office]
S. Hrg. 107-401
SAFEGUARDING OUR SENIORS: PROTECTING
THE ELDERLY FROM PHYSICAL AND SEXUAL
ABUSE IN NURSING HOMES
=======================================================================
HEARING
before the
SPECIAL COMMITTEE ON AGING
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
SECOND SESSION
__________
WASHINGTON, DC
__________
MARCH 4, 2002
__________
Serial No. 107-20
Printed for the use of the Special Committee on Aging
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SPECIAL COMMITTEE ON AGING
JOHN B. BREAUX, Louisiana, Chairman
HARRY REID, Nevada LARRY CRAIG, Idaho, Ranking Member
HERB KOHL, Wisconsin CONRAD BURNS, Montana
JAMES M. JEFFORDS, Vermont RICHARD SHELBY, Alabama
RUSSELL D. FEINGOLD, Wisconsin RICK SANTORUM, Pennsylvania
RON WYDEN, Oregon SUSAN COLLINS, Maine
BLANCHE L. LINCOLN, Arkansas MIKE ENZI, Wyoming
EVAN BAYH, Indiana TIM HUTCHINSON, Arkansas
THOMAS R. CARPER, Delaware PETER G. FITZGERALD, Illinois
DEBBIE STABENOW, Michigan JOHN ENSIGN, Nevada
JEAN CARNAHAN, Missouri CHUCK HAGEL, Nebraska
Michelle Easton, Staff Director
Lupe Wissel, Ranking Member Staff Director
(ii)
C O N T E N T S
----------
Page
Opening Statement of Senator John Breaux......................... 1
Prepared statement of Senator Larry E. Craig..................... 4
Perpared statement of Senator Harry Reid......................... 4
Prepared statement of Senator Debbie Stabenow.................... 5
Prepared statement of Senator Tim Hutchinson..................... 5
Statement of Senator Ron Wyden................................... 6
Statement of Senator Herb Kohl................................... 7
Statement of Senator Blanche Lincoln............................. 8
Panel I
Bruce Love, Son of physical abuse victim Helen Love, Mill Creek,
CA............................................................. 9
Barbara Becker, Daughter-in-law of physical abuse victim Helen
Straum-kamp, Evansville, IN.................................... 17
Michael Peters, Esq., Counsel for rape victim Jane Doe, Orlando,
FL............................................................. 23
Panel II
Leslie Aronovitz, Director, Health Financing and Public Health
Issues, Health, Education and Human Services Division,
General Accounting Office, Washington, DC...................... 34
Mark Malcolm, Coroner, Little Rock, AR........................... 52
Charles Fuselier, Sheriff, St. Martinville, Louisiana on behalf
of the National Sheriffs' Association.......................... 65
Henry Blanco, Board Member, National Association of Adult
Protective Services Administrators, Phoenix, AZ................ 116
Delta Holloway, RN, Boise, ID, on behalf of American Health Care
Association.................................................... 124
APPENDIX
Statement submitted by Deborah Bradford.......................... 143
Letter from Carol Brown.......................................... 154
Statement of W. Garrett Boyd..................................... 156
Statement from Cathy Newman...................................... 158
Statement of Bette Vidrine....................................... 160
Statement of Cassie Tracy........................................ 164
Letter and additional material submitted by Robert Marshall,
Delaware State Senate.......................................... 167
Statement of the National Association of Orthopaedic Nurses...... 173
Testimony from Toby Edelman, Center for Medicare Advocacy........ 178
(iii)
SAFEGUARDING OUR SENIORS: PROTECTING THE ELDERLY FROM PHYSICAL AND
SEXUAL ABUSE IN NURSING HOMES
----------
MONDAY, MARCH 4, 2002
U.S. Senate,
Special Committee on Aging,
Washington, DC.
The committee met, pursuant to notice, at 1:32 p.m., in
room SD-628, Dirksen Senate Office Building, Hon. John Breaux
(chairman of the committee) presiding.
Present: Senators Breaux, Kohl, Wyden and Lincoln.
OPENING STATEMENT OF SENATOR JOHN BREAUX, CHAIRMAN
The Chairman. The committee will please come to order. Good
afternoon to everyone. We thank all of our guests for being
with us. I also want to acknowledge our colleagues who are here
for what I consider to be a very important hearing this
afternoon. I thank all of our guests in the audience and
particularly thank the witnesses, who we will introduce in just
a moment, for their testimony.
Today, we will examine a subject that is difficult for most
of us to fathom, and that is physical and sexual abuse of
individuals who reside in nursing homes. It is a subject that
really should not exist. I genuinely wish that there was no
issue of physical and sexual abuse in nursing homes to
investigate at all.
Sadly, this investigation is another chapter in a long
history for too long of abuses and problems in nursing homes.
We as a nation must not tolerate abuse of our senior citizens
in any form nor in any place. The Special Committee on Aging
spent 14 years from way back in 1963 to 1977 investigating
nursing home care. Other chairmen of this Special Committee on
Aging and other committees in the Congress focused their
attention on this particular problem after 1977.
We continue the work that began in 1998. Now, in the year
2002, 40 years have passed without a clear determination on the
conditions of nursing homes as far as safety for our senior
citizens.
Let me say up front and at the beginning that this hearing
is not an indictment in any way of the entire nursing home
industry. I recognize, this committee recognizes, the Congress
recognizes, that there are many very fine nursing home
facilities in this country that provide critical quality health
care that is needed and necessary, and that also provides those
quality care provisions in a very safe manner.
However, the prevalence of abuse highlighted by this
investigation has forced me to come to grips with the fact that
our nation's public policy has been unable to adequately ensure
the safety of our seniors in nursing homes.
This prompts me once again to look toward promoting and
supporting other long-term care alternatives to nursing home
care. This becomes all the more critical as the baby boom
generation draws closer to senior citizen status. Today, the
focus is on the response of law enforcement and other agencies
to physical and sexual abuse in nursing homes.
Our committee asked the General Accounting Office, the
investigative arm of the Congress, to investigate and determine
how law enforcement responds to these crimes after we received
complaints of confusion about where to make these complaints of
abuse and complaints about which agency was responsible for
investigating these allegations of abuse.
The General Accounting Office will share its findings in
the report that I am releasing today. GAO's report not only
addresses law enforcement's response to reports of physical and
sexual abuse, but also finds the problem is even greater, that
there is a pervasive lack of coordination among all the
agencies that are charged with the responsibilities of
protecting our seniors. By this, I mean law enforcement, social
services, and also government.
To illustrate this point, I had a chart prepared that
reflects the myriad of agencies involved in responding to the
claims of physical and sexual abuse in nursing homes.
Immediately it becomes very clear, in my opinion, that
while many agencies have jurisdiction, all too often no agency
has the ultimate responsibility to investigate the allegations
of physical and sexual abuse in nursing homes.
When everyone is in charge, it is clear that no one is in
charge. We need to know that seniors in nursing homes are
treated like everyone else when a crime does occur. We need to
know that trained criminal investigators are notified
immediately and can provide the evidence required for any
necessary prosecutions.
We cannot continue to provide a system that discriminates
against seniors with a bureaucratic reporting system that
leaves abusive crime scenes stale and incapable of forensic
investigation. A crime is a crime no matter where it is
committed. Whether it is on a street corner in an urban city,
or whether it is in a nursing home, it matters not. There is a
crime and somewhere there is a criminal.
One last point I would like to make relates to the
International Association of Chiefs of Police. This committee
made repeated attempts to invite this association to represent
the interests of police officers and detectives throughout the
Nation with regard to how nursing home crimes are addressed.
I recognize that there are strong elder abuse units in
police departments throughout the Nation that are doing
outstanding work in this area. My own State of Louisiana is
represented by Sheriff Charlie Fuselier, who is doing a great
job in this particular area and will tell the committee about
it.
However, I would like to read into the record a portion of
the letter that I received from the International Association
of Chiefs of Police declining this committee's invitation to
participate in the hearing today, and it states the following:
``The IACP membership has not yet taken a formal policy
position on the issue. Let me assure you that this is not an
indication of the level of importance it believes this issue
merits.''
That is simply, to me, unacceptable for the national
association representing the police chiefs in their law
enforcement responsibilities. I believe the letter concisely
makes the point of this hearing: too many police departments do
not have abuse of seniors in nursing homes anywhere on their
radar screen. Out of sight, out of mind is not acceptable. I
think it is clear that we have much work to do to ensure that
they are better trained and sensitized to the crimes against
seniors that occur in institutions.
Moreover, it is essential that they not be treated
differently from anyone else outside institutions or treated
differently because of their age.
Before we introduce our first panel of witnesses, I'd like
to recognize our colleagues on the Aging Committee. First,
Senator Ron Wyden.
[The prepared statements of Senator Breaux, Senator Craig,
Senator Reid, Senator Stabenow, and Senator Hutchinson
follows:]
Prepared Statement of Senator John Breaux
Good morning. I would like to thank all of you, especially
my fellow members, for attending today's investigative hearing.
I would also like to thank the Committee's Ranking Member,
Senator Larry Craig, for his support throughout this
investigation. Finally, and most importantly, I would like to
thank the witnesses for being here today. Your testimony will
assist the Committee greatly in determining how best to address
the vital issues raised today.
Today, we will examine a subject that is difficult for any
of us to fathom - physical and sexual abuse in nursing homes.
It's a subject that should not exist, and I genuinely wish that
there was no issue of physical and sexual abuse in nursing
homes to investigate at all today. Sadly, this investigation is
but another chapter in a long history - far too long - of
abuses and problems in nursing homes. We as a country must not
tolerate abuse of our senior citizens in any form.
The Special Committee on Aging spent 14 years from 1963 to
1977 investigating nursing home care. Other Chairmen of the
Special Committee on Aging and other committees focused
attention on the problems after 1977. Senator Grassley and I
continued that work beginning in 1998. Now, in 2002, 40 years
have passed without a determination that nursing homes are safe
for seniors.
Let me say upfront that this hearing is not an indictment
of the entire nursing home industry. I recognize there are many
fine nursing homes in this country that provide quality care
that is safe from abuse. However, the prevalence of abuse
highlighted by this investigation has forced me to come to
grips with the fact that our nation's public policy has been
unable to insure the safety of our seniors in nursing homes.
This prompts me once again to look toward promoting and
supporting other long-term care alternatives to nursing home
care. This becomes all the more critical as the Baby Boomers
draw closer to senior citizen status.
Today, the focus is on the response of law enforcement and
other agencies to physical and sexual abuse in nursing homes.
The Committee asked the Government Accounting Office to
investigate and determine how law enforcement responds to these
crimes after we received complaints of confusion about where to
make complaints of abuse and complaints about which agency was
responsible for investigating abuse. GAO will share its
findings in the report I am releasing today.
GAO's report not only addresses law enforcement's response
to reports of physical and sexual abuse in nursing homes but
also finds the problem is even greater - there is a pervasive
lack of coordination among all the agencies charged with
responsibilities of protecting our seniors - by this I mean,
law enforcement, social services and government. To illustrate
this point, I had a chart prepared that reflects the myriad of
agencies involved in responding to claims of physical and
sexual abuse in nursing homes. Immediately, it becomes clear
that while many agencies have jurisdiction, all too often, no
agency has ultimate responsibility to investigate allegations
of physical and sexual abuse in nursing homes.
We need to know that seniors in nursing homes are treated
like anyone else when a crime does occur. We need to know that
trained criminal investigators are notified immediately and can
provide the evidence required for any necessary prosecutions.
We cannot continue to provide a system that discriminates
against seniors with a bureaucratic reporting system that
leaves abuse scenes stale and incapable of forensic
investigation.
One last point that I'd like to make relates to the
International Association of Chiefs of Police. This Committee
made repeated attempts to invite this association to represent
the interests of police officers and detectives throughout the
nation with regard to how nursing home crimes are addressed. I
recognize that there are strong elder abuse units in police
departments throughout the nation that are doing exemplary work
in this area. However, I would like to read into the record a
portion of the letter I received from the national association,
declining the Committee's invitation to participate in the
hearing today. It states the following:
...the IACP membership has not yet taken a formal policy
position on the issue. Let me assure you that this is not an
indication of the level of importance the IACP believes this
issue merits....
I believe this letter concisely makes the point of this
hearing. Too many police departments do not have abuse of
seniors in nursing homes anywhere on their radar screen. I
think it is clear that we have much work to do to ensure that
they are better trained and sensitized to the crimes against
seniors in institutions. Moreover, it is essential that they
not be treated differently from anyone else outside
institutions or treated differently because of their age.
Before introducing the witnesses, I would like to recognize
other Senators for any opening remarks.
------
Prepared Statement of Senator Larry Craig
We are here this morning to examine the serious and growing
problem of physical abuses of our nation's most vulnerable
citizens. I want to begin by thanking Senator Breaux for
convening this very important investigative hearing. We began
this committee's investigation on Elder Abuse last year,
including a discussion of abuses that happen in the elder's own
home. I am pleased to see that this committee is continuing to
explore different aspects of the problem, including instances
of abuse that occur in nursing homes.
The challenges we face in remedying nursing home abuse are
formidable. Employees of nursing homes with the legal duty to
report suspected occurrences of abuse often fail to report to
appropriate state and local agencies, including law
enforcement. When cases are reported, there is often a long
delay. Evidence is allowed to perish. When prosecutors finally
get these cases, they have trouble acquiring reliable testimony
from victims and other witnesses.
I'm hoping to hear today how existing state and local
efforts to combat abuse in nursing homes might be enhanced by
more collaborative approaches. In the state of Idaho, we have
interagency protocols related to elder abuse responses both at
the state and local level that have been quite effective. These
formal protocols have the signatures of top officials in Adult
Protection, the Ombudsman program, survey agencies, law
enforcement, and prosecutors, demonstrating their commitment to
work together on these cases. The protocols require specific
reporting, facilitate collaborative investigations, and allow
the exchange of client information between professionals acting
on behalf of victims.
Additionally, existing federal resources should be better
targeted to provide technical training in the identification,
investigation, and prosecution of crimes perpetrated against
the elderly in nursing homes and in the community. A high level
of competence and expertise is necessary to effectively take on
these very difficult cases.
I look forward to hearing the testimony today.
------
Prepared Statement of Senator Harry Reid
Good afternoon Chairman Breaux and Ranking Member Craig.
The physical and sexual abuse of seniors is an unpleasant
issue--but we cannot afford to look the other way and pretend
that this problem does not exist. However unthinkable such
crimes against vulnerable seniors are, they really do occur.
They are not isolated incidents--and the number of victims will
only continue to increase as our population ages--unless we
take effective steps to prevent abuse.
Certainly we must make sure that crimes against the elderly
are reported and those responsible are prosecuted. Even more
importantly, we need to do everything we can to prevent abuse
before it happens.
For the past several years, Senator Kohl and I have focused
our efforts on protecting our most frail and vulnerable seniors
from workers with criminal backgrounds and known histories of
abuse. We are the sponsors of the Patient Abuse Prevention Act,
legislation that would require all long-term care facilities to
conduct criminal background checks on potential employees. The
Patient Abuse Prevention Act would also create a national
registry of abusive workers. This registry would give long-term
care facilities the ability to weed out workers who are known
abusers. We need a national registry so offenders cannot
continue to cross state lines and find employment in new
facilities where they may continue to prey on the elderly.
Our bill is a culmination of several years of work on this
issue, including numerous hearings in this committee. It is an
inexpensive, common-sense proposal that we are confident will
prevent many cases of abuse. In fact, a report by the
Department of Justice revealed that 7 percent of FBI background
checks on potential long-term care workers uncovered serious
criminal convictions--including assault, rape and kidnapping.
Our bill would help nursing homes identify these dangerous
workers applying for jobs.
I understand that abuse of seniors is a complex problem and
our legislation is only part of the solution. But as you listen
to the stories today, I am sure you will agree that if our bill
could prevent only one incident of abuse, it would be worth it.
I urge my colleagues to join Senator Kohl and me in supporting
the Patient Abuse Prevention Act, and I look forward to
learning about other ways to protect our nation's seniors.
------
Prepared Statement of Senator Debbie Stabenow
Chairman Breaux, thank you for convening a hearing today on
the topic of abuse in nursing homes. While it is difficult for
us to imagine that anyone would abuse a patient in a nursing
home, the sad reality is that this abuse does occur. Today's
hearing will help shed light on this critical issue and perhaps
help find solutions.
The General Accounting Office (GAO) study conducted for
this committee on abuse in nursing homes discovered that it is
difficult for families to even discuss this issue. GAO
estimates that much abuse is under-reported. Combine that with
GAO's findings that there are many barriers to reporting abuse,
and that many cases are not adequately investigated nor
prosecuted, and we clearly have a problem. GAO's final
recommendation is that the Center for Medicare and Medicaid
Services should work to facilitate the reporting,
investigation, and prevention of abuse to ensure protection of
nursing home residents.
While this is a difficult issue for families to discuss, I
think it is very important that this committee be an open forum
so that we can consider the recommendations made by GAO. I also
look forward to hearing from the other witnesses who will
provide valuable information. I am strongly committed to ending
abuse and neglect in nursing homes and I am pleased that our
committee is taking on this issue that is so important for
seniors and families.
------
Prepared Statement of Senator Tim Hutchinson
Mr. Chairman, thank you for holding this critically
important hearing today. Physical and sexual abuse of any kind
is abhorrent and intolerable, but it is especially so in
nursing homes, where vulnerable, unknowing, elderly patients
are the victims.
I know that some of the testimony we will hear today tells
of abuse that is incomprehensible. While these are difficult
truths to fathom, we must be aware of what is happening and
work together to convict bad actors and prevent further abuse.
In my home State of Arkansas, long-term care facilities
have operated for many years under several state laws aimed at
reducing the incidence of abuse and improving the quality of
care. The Adult Abuse Act of 1983, for example, requires
incident reporting of suspected abuse or neglect of residents.
The Staffing Requirements for Nursing Facilities and Nursing
Homes Act of 1999 has enabled Arkansas nursing homes to achieve
minimum staffing levels of direct care workers that exceed the
requirements of Arkansas' bordering state neighbors.
Furthermore, and directly related to today's hearing topic,
Arkansas nursing homes conduct criminal background checks of
their direct care staff in compliance with the Mandatory
Criminal Records Checks for Applicants, Elder Choices Providers
and Employees Act of 1997.
As Mark Malcolm, the Pulaski County Coroner, will mention
in his testimony today, Arkansas also enacted legislation in
1999 to require all resident deaths to be reported to their
county coroners. This legislation was strongly supported by the
nursing home industry and patient groups throughout Arkansas.
Arkansas nursing homes and legislators have taken steps to
address this deplorable crime against the elderly. We must
continue to be vigilant, however, both in Arkansas and
nationwide, to prevent such abuse.
I look forward to hearing our witnesses today and thank all
of them in advance for their testimony.
STATEMENT OF SENATOR RON WYDEN
Senator Wyden. Thank you very much, Mr. Chairman, and let
me commend you for holding this hearing. This gives us a chance
to come back to an issue that must not be shunted aside and
thank you for all of your leadership.
Mr. Chairman and colleagues, having been involved in this
issue now for over 20 years, dating back to my days as co-
director of the Oregon Gray Panthers, I can say without a doubt
that there is a real pattern to how these issues unfold.
First, there is a government report like the one that is
being released today that outlines a serious pattern of abuses.
Second, there are promises made by government and industry
to clean house and all sides pledge that it is going to be
different.
Finally, there is backsliding 6 months or so later and
going back to something resembling business as usual. Mr.
Chairman, I think it is so important that this time it be
different. With your leadership we have that opportunity
because I believe that a country that does not get this right,
a county that does not protect the most vulnerable people in
our nursing homes, is a country that has lost its moral compass
and that cannot be tolerated.
Now, for just a moment, I want to talk about what I think
are the central challenges in front of us as we go forward and
put in place a reform package, and I want to note, Mr.
Chairman, that I think the legislation that you are looking
at--increasing reporting of senior abuse, enforcement of the
laws--is absolutely critical and it seems to me any reform
effort has to start with those and other patient protections.
I would add to it that I would like to see us strengthen
the so-called watch lists. There is already an effort underway
that I think is totally inadequate to watchdog the most
deficient facilities, and I think that watch list ought to be
strengthened.
Second, the idea that the Federal Government does not
require the reporting of instances when there is suspicion of a
crime, a brutal crime against a senior, is unacceptable. I know
that there are discussions underway to speed notification of
that, but I think those at a minimum ought to be part of a
package of patient protection.
Third, it seems to me we have to continue to ensure that
there are the funds necessary to carry out these changes.
Perhaps the best measure of the short shrift that seniors in
nursing homes get in our society are the inadequate
reimbursements in Medicaid facilities, particularly in states
like mine, that have held costs down, and that has to change as
well.
Finally, I would hope that we would also put a focus on
building up the advocacy networks of friends and relatives and
ombudsmen, because you can pass laws, Mr. Chairman, by the
crate full. We can pass one law after another, and if we do not
have the friends and the relatives and the ombudsmen mobilized
at the grassroots level, if we do not have that army of citizen
advocates, all the laws in the world do not ensure that the
older people in these facilities get the protections they
deserve.
Mr. Chairman, it seems to me this time there is a chance to
break that pattern, the pattern that you and I have seen on
this committee for years and years. It is a pattern of
indifference. It goes back to what I have seen since my days as
Director of the Gray Panthers, and I am determined to work with
you and our colleagues on a bipartisan basis so this time it
really is different. Thank you.
The Chairman. Thank you very much, Senator Wyden. Next, we
will hear from Senator Herb Kohl. Senator Kohl.
STATEMENT OF SENATOR HERB KOHL
Senator Kohl. Thank you, Mr. Chairman. We appreciate your
leadership on this committee, and while we also appreciate your
holding this hearing, it is really sad that it is still
necessary. Everyone knows, Mr. Chairman, that you have done
everything in this committee's power to bring this sad
situation to light and to try to change it.
This committee has held many, many hearings on problems in
nursing homes. We have heard stories of people suffering from
severe malnutrition and dehydration and life-threatening bed
sores. As we will hear today, in addition to neglect and
substandard care, our elderly and disabled also have to worry
about being beaten and even sexually abused.
Unfortunately, this is not new. Over the past several
years, we have continued to hear accounts of abuse and neglect
in nursing homes. When we talk about nursing home residents,
we're not just talking about nameless faceless people. These
are our parents and our grandparents, our aunts and our uncles.
They are sick and disabled, and they depend on nursing home
staff to protect them and care for them.
It is important to emphasize that the vast majority of
nursing home employees work hard and do their best to provide
the highest quality care. But, as we know, it only takes a few
abusive staff to terrorize patients and to unfairly portray the
entire nursing home industry in a negative light.
As some of you know, I have introduced legislation, co-
sponsored by Senators Breaux and Reid, that would take a major
step toward addressing this problem. The Patient Abuse
Prevention Act would create a national registry of abusive
long-term care workers which will prevent abusers from moving
from state to state and continuing to find work with vulnerable
patients. This legislation would also require an FBI criminal
background check to prevent people with serious criminal
convictions from working with patients.
I am pleased that the American Health Care Association and
the American Association of Homes and Services for the Aging,
which represent nursing homes and other long-term care
providers all across the country, are now strong supporters of
this bill. They recognize that background checks will benefit
their industry and have worked with my office over the past few
years to refine the bill. Their suggestions improved the bill
and demonstrate their commitment to protecting their nursing
home residents.
During the past 5 years, this committee has heard from the
HHS Inspector General's Office, the GAO, local prosecutors,
state inspectors, and auditors and now the nursing home
industry. They all recommend establishing a national background
check system.
I hope this hearing provides the final boost to pass this
legislation. It is past time to act to protect our nation's
seniors and disabled patients, and so again I thank you, Mr.
Chairman, for co-sponsoring the bill and for once again
bringing this important issue to light.
The Chairman. Thank you, Senator Kohl. Next we will hear
from an outstanding member of our committee, Senator Lincoln,
from Arkansas.
STATEMENT OF SENATOR BLANCHE LINCOLN
Senator Lincoln. Thank you, Mr. Chairman, and thank you for
calling this very important hearing today, and to all of our
witnesses and panelists that will be here today, we appreciate
your concern and your willingness to come before us today and
tell some very trying stories.
Most of us assume that our elderly and disabled citizens
living in nursing homes are safe and cared for properly. While
this is very often true, we will be hearing some very shocking
stories today of how cruelly some of our most vulnerable
citizens have been abused in nursing homes, and as Senator Kohl
mentioned, it is disturbing enough just to think that we still
require a hearing on this issue.
I was surprised to find out about the gaps in security and
the lack of coordination between various sectors charged with
protecting elderly and disabled people in nursing homes, and I
was also concerned to learn that law enforcement agencies often
treat crimes in nursing homes differently than crimes committed
outside of nursing homes.
Some of you all may remember one of our former senators
from Arkansas, Senator David Pryor, who also served on this
committee. Years ago, Senator Pryor went undercover to work in
a nursing home and to reveal some of the difficulties and some
of the challenges that we were facing in our nation's nursing
homes, and today I am going to be proud to introduce Mark
Malcolm, who is our Pulaski County, Arkansas coroner, who has
done tremendous amount of work in trying to improve the quality
of care in nursing homes as well as point out what some of
those difficulties and challenges are.
I will talk more about Mr. Malcolm later when I introduce
him, but one thing that is very important is that in 1999, Mr.
Malcolm helped to introduce legislation in the Arkansas
legislature to require that all deaths of nursing home patients
be reported to the county coroner for investigation regardless
of the cause of death, and it has uncovered a great deal for us
in Arkansas to better understand how we can provide greater
care for our aging constituents in our communities.
With the growing elderly population and a growing
likelihood that our parents and even we ourselves will spend
some portion of our aging years in a nursing home, ensuring the
safety and the quality of care of nursing residents becomes
even more important to all of us. I am confident that we can
develop solutions to close these gaps and to better protect
these vulnerable citizens.
So I look forward to the testimony today and I thank you
again, Mr. Chairman, for as always bringing about some
incredibly important issues to the constituents that we serve.
The Chairman. Thank you very much, Senator Lincoln, and
thank all the members for their commitment to this committee
and the work that we are trying to do and for your involvement.
We would like to welcome now our first panel. This is a
special panel. It is not easy when you are talking about a
mother-in-law or a mother and some very bad things that happen.
But I only thank you by also saying the obvious, that your
testimony can help future generations from never having to
experience some of the problems that your families have
experienced, and in that sense, your testimony here is
incredibly important for future generations.
We would like to introduce Mr. Michael Peters. He is from
the State of Florida. He is an attorney for a person who will
be known as Ms. Jane Doe, who suffered a rape in a nursing
home.
We will have Ms. Barbara Becker, who is the daughter-in-law
of a person who was attacked by a resident in a nursing home.
Our first witness will be Mr. Bruce Love. Mr. Love is the
son of Ms. Helen Love, who died after her neck was broken in an
incident in a nursing home by an employee of that nursing home.
Fortunately, before she passed away, a short time before she
passed away, two days, there was a taped deposition of what
happened in her own words, which I think is very graphic and
very, very helpful, and we would like, Mr. Love, if it would be
all right to show that before you give us your statement, and
if we could have that interview. It is about 3 minutes.
Mr. Love, I know that this could not be very easy for you,
but again, as I said earlier, your appearance here today helps
to make sure that it never happens again.
Mr. Love. That is correct, sir.
The Chairman. We would be pleased to hear from you.
STATEMENT OF BRUCE LOVE, SON OF PHYSICAL ABUSE VICTIM HELEN
LOVE, MILL CREEK, CA
Mr. Love. Thank you for having me here, Mr. Chairman, and
members of the committee. Obviously, I am Bruce Love, and that
was my mother, and you just saw the film clip. I will just tell
the story, and this is basically in her own words in the
beginning of this deposition.
On Thursday evening, July 30, that was when I saw her for
the first time lying on a gurney, waiting for treatment after
she had been assaulted Tuesday evening at Valley Skilled
Nursing Home.
My mother's own words are: ``I was in good spirits Tuesday
evening, watching TV. I had a bout of diarrhea and had the urge
to go. I asked the attendant on duty for Imodium AD pills but
got no response. When I leaked some diarrhea into my diaper, I
called to be changed. It was sometime later when the attendant
showed up and was quite upset that my diaper was dirty, because
he had changed me earlier in his shift.''
``He called me names and was very rough and abusive in
changing me. I told him to stop or I would yell for help. He
said, `Here is something for you to yell about,' and used an
alcohol water swab through my vagina and my raw rectum.''
I would like to add one more thing to the list. I did not
know what Class II open sores were. I do now.
``I was on fire and yelled for help. I tried to sit up and
grab the right side of the bed rail. He punched me with the
flat of his hand, covered my mouth to stop my scream, and
chopped me in the back of the neck with his other hand. With
his left hand, he dug his fingernails into my wrist to break my
grip on the side rail. With his right hand over my mouth, and
his left hand squeezing my wrist, he pushed me down into my
bed.''
``I heard a second aide come to the door of my room to see
about the commotion. When she saw him choking me, I kicked at
my feet to get her attention, but she just laughed and went
away. Then I knew no one was going to help me. I could not
resist his strength and weight, and I could not breathe with
his forcing my head down on to my chest. My deep inner fear
told me to stop resisting him or he would kill me. I was afraid
of dying this way, so I relaxed and went limp, playing dead.
Finally, he let up his grip and stopped pushing me down. I just
lay there trying not to breathe too loudly.''
``Finally he walked toward the door. My roommate Shirley,
who had remained quiet during the assault and watched through
the curtain, spoke up and said, `I saw what you did to Helen,
so you'll have to kill me, too.' My assailant left the room.
After a time of silence, I called to Shirley, and she was
overjoyed to hear my voice. She thought I was dead. We stayed
quiet all night in fear that he would be back. When daylight
came, I thanked God I was still alive and I knew something was
very wrong with my neck because it hurt terribly.''
``All my life I have feared being neglected in a nursing
home, and now I know what it is like. I was so close to death
and somehow survived the attack. I don't want anyone else to
suffer like this. Please, son, would you tell someone who can
help.''
I am here today to fulfill my mother's request and I mean
that. After my father's death, my mother could no longer live
by herself and came to live with me and my family first in
California and then Nevada. My brother and I both happen to
live out here. When I moved back to a remote area of
California, my mother moved to Sacramento to live with my
brother and his family.
In 1998, she was in U.C. Davis Hospital for some health
evaluations. She suffered a broken finger when in a hospital
bed she was negligently pushed against a steel door frame. The
hospital assumed responsibility and moved my mother to Valley
Skilled Nursing Home for physical rehabilitation, and that was
her only reason to be there was to get this done.
Wednesday, January 29, I called the nursing home to speak
with the RN to arrange for him to bring my mother up to where I
live for a visit. During this call, I was informed that my
mother had been roughed up a little bit. He informed me that
one of the aides of the previous evening shift had an
altercation with my mother and used physical force against her.
He told me her sheets had been changed this morning because
there were blood stains on them. At that point, he was
interrupted. When he came back on the phone, he told me there
was an individual there who wished to speak with me, at which
time he handed the phone to someone else.
I did not know who this person was, and I had to question
him to find out that he was the Administrator of Valley Skilled
Nursing Home. He told me that the problem was taken care of and
that the employee would no longer be tending my mother.
In addition, the administrator told me that the Department
of Health Services had been notified. He also told me that the
nursing home doctor would evaluate my mother for possible
injuries, and if any were found, she would be taken across the
street to U.C. Davis Medical Center. This ended our
conversation.
I was very upset, so I immediately telephoned my brother
and I could not reach him at work. Then I called a friend who
was a local deputy sheriff. He advised me to speak with his
sergeant and also the district attorney's office in the county
that I live in.
Both officers advised me to get my mother away from the
nursing home and to a hospital as soon as possible. They also
suggested that I have a family member transport my mother to
ensure that she would be cared for in a humane and loving
manner.
I was finally able to reach my brother at home about 4 p.m.
He immediately went to the nursing home to see our mother and
called me from there. He was alarmed at my mother's condition.
Her neck was very sore and painful. She had bruises on her chin
and chest and lacerations on her right wrist.
She told Gary that she had been hit very hard on her chin
and on the back of her neck. My brother telephoned our mother's
personal physician and recommended Gary take our mother to the
hospital as soon as possible. Gary had to go home and get my
mother's wheelchair because he was not receiving any
cooperation from the nursing home in moving her to the
hospital.
When he returned, my brother was told by the nursing home's
evening shift supervisor he could not take my mother out of the
nursing home, at which time he called me for help. I spoke with
his supervisor and informed him that we indeed were taking my
mother to the hospital regardless of his protests.
Ironically we were informed by the nursing home official
that it was not medically advisable to move our mother to the
hospital. My brother had to use force to overcome the protest
of the nursing home to get my mother out of the nursing home.
This took an additional hour.
During this time, my brother called the Sacramento Police
Department and explained what happened. They sent an officer to
Valley Skilled Nursing Center, and they also sent a
photographer to the hospital to be there when my mother
arrived.
After extensive evaluation at the hospital, it was
determined that my mother had indeed suffered grave injuries to
her neck, and in fact her neck was broken. Vertebra 3, 4 and 5
were displaced leaving my mother's head hanging to the side.
She was unable to hold up her head. In the hospital's
attempted emergency surgery--I want to clarify one point.
She was given anesthesia to see if she could tolerate this
and she expired. However, due to my mother's health condition
and sensitivity to anesthesia, she expired on the table and had
to be revived. The only remaining treatment for this injury was
the installation of a halo, which had to be screwed into my
mother's skull with metal bolts and rigidly attached to her
upper torso.
In addition, a soft cast had to be applied to her right arm
where the offender had grasped her wrist so hard that it was
cracked. My mother lived in great pain and severe restriction
of movement for the rest of her life, which was less than 60
days. She died on September 24, 1998, 2 days after this
deposition tape that you saw, and she had requested removal of
the halo due to severe pain just prior to expiration.
Prior to my mother's death, the offender had pleaded not
guilty to the charge of assault and elder abuse. After my
mother's death, he immediately changed his plea to guilty of
elder abuse in order to avoid the manslaughter charges.
If I could add another point where I was very frustrated
with this was his people beat us to the district attorney's
office and they had a plea bargain before we could even get the
rest of our information there. So the district attorney's
office did not help us.
He spent one year in the Sacramento County Jail. As for
Valley Skilled Nursing Center, they hired this individual to
care for the elderly; they failed to perform an adequate
background check before hiring this person. After
investigation, my attorney learned that he had been dismissed
from two prior nursing home positions for aggressive behavior
toward residents.
The nursing home also failed to recognize the extent
of my mother's injuries and to take her to the hospital
immediately. If my brother and I had not stepped in and
intervened, my mother might never have received any medical
attention for the broken neck and broken wrist after being
assaulted by this employee. Moreover, this man might still be
caring for the elderly today.
Since the focus of this hearing is to hear about the
response of law enforcement and other agencies to the physical
and sexual abuse in nursing homes, I would like to share my
experiences in this regard. We got no assistance from the
social services agencies that we contacted. The ombudsman who
was very good to us had no authority to do more than conduct a
cursory interview and write up his observations.
A state agency surveyor in the building where my mother's
neck was broken was there to investigate another spot or
another matter. No one from that nursing home reported to her,
and she was in the very next morning while my mother was still
there.
Prosecutors did their best to prosecute the assailant, but
much of the information was provided by our attorney. That is
where the initiative came from to go after this guy was through
my attorney's office.
Finally, the judge seemed unsure about the trial and what
to do with the nursing home aides who abuse the elderly. After
prompting from the attorneys, the assailant's license was
revoked, and he was ordered not to have contact with the
elderly in future work.
However, in spite of his actions that contributed to my
mother's death or the charge of elder abuse, he only spent 6
months of a total of a year in the county jail.
There are no words to describe how devastating his
experience is to me and my family. We entrusted my mother's
care to institutions that failed us in every respect. My only
hope is that somehow telling my mother's story, I can prevent
this from happening to anyone else's mother in the future. I
urge this committee to take action to ensure our senior
citizens are protected at home, and after hearing what you had
to say, I thank you, I thank you very much for your commitment
to do this. Thank you for inviting me here today.
[The prepared statement of Mr. Love follows:]
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The Chairman. Mr. Love, thank you so very much for what I
know has been a very difficult time that you have been through.
We certainly apologize for you having to go through it, but
your statement here today is extremely important, and we thank
you for being with us.
Next, we will hear from Ms. Barbara Becker. Ms. Becker.
STATEMENT OF BARBARA BECKER, DAUGHTER-IN-LAW OF PHYSICAL ABUSE
VICTIM HELEN STRAUKAMP, EVANSVILLE, IN
Ms. Becker. Mr. Chairman, members of the committee, thank
you very much for allowing me to represent my mother-in-law
Helen Straukamp, a homicide victim.
According to the facility, Helen had been injured. The
hospital was informed that she suffered a fall, but an employee
later told us of the actual assault. An eyewitness reported
that Helen was picked up by the arms from a standing position,
lifted off the floor and slammed into a wall and handrail,
falling to the floor unconscious.
Helen was never even able to stand again and died 22 days
later. The coroner ruled her death a homicide. The picture on
the left is the way she was prior to the assault. I discovered
on my own in Louisville that the perpetrator of this assault
was a male mental patient with a decades long violent history,
which included four shootings, SWAT teams, prison time, et
cetera. None of this was ever mentioned in the investigations.
I found documents signed by the nursing home showing that
they knew of his history. After the assault on Helen, this
resident was soon given his usual access to the entire
population of the facility. He threatened to castrate a
wheelchair-bound resident while a surveyor was in the facility.
He attempted to assault yet another elderly female
resident, and the administration of the facility did nothing. I
notified a detective and the prosecutor's office. A judge
issued an order for an involuntary removal to a psychiatric
unit where he had to be placed in total lockdown and charged
with involuntary manslaughter pending a competency hearing.
My experiences with regulatory agencies, law enforcement,
et cetera, are as follows: Due to my dogged determination for
accountability, I contacted elected representatives including
the Governor, the State and U.S. attorneys, HCFA, HHS, and the
GAO. It required four investigations to reveal 42 pages
covering 6 years of previously undiscovered violations from the
date of this man's admission.
No immediate jeopardy level was imposed due to Helen's
death. HCFA overrode the state's flat fine, and imposed a
$1,000 per day fine, but the scope and severity level remained
unchanged. Still out of compliance on a revisit, the civil
money penalty continued and total fines amounted to $60,800.
But by not appealing, they were granted an automatic 35 percent
discount on the Federal fine regardless of a homicide.
To this day, the facility's record on the CMS web site
appears very favorable. The entire experience with the state
regulatory agency was adversarial from the very first meeting.
There was absolutely no doubt to me who was being protected and
it was not the residents.
In my first meeting with the department of health official
I was personally told, ``Well, this was not like a beating.''
You can tell for yourself. The former assistant commissioner of
the Department of Health refused to discuss the case with me.
Law enforcement investigated but only the perpetrator. I
contacted Adult Protective Services three times, only to be
told that they do not handle nursing home cases. They are
actually barred from investigating nursing home cases in my
state without orders from the Department of Health. Department
of Health rarely uses this resource.
I contacted our Peer Review Organization, and received only
a letter and a brochure declining to even investigate. The
Medicaid Fraud Unit completed a very thorough investigation and
validated every piece of evidence that I had provided.
I pushed the completed case through the AG's office, who
took no action, and on to my local prosecutors. They declined
to investigate or prosecute. There has yet to be any justice
for a homicide.
All I hear from the industry are labels of ``isolated
incidents,'' which must by now number in the hundreds of
thousands. Frivolous lawsuits, no matter how horrific the case.
I hear whining for more money, less regulation, and what I
refer to as tort ``de-form.'' The system leaves no alternatives
for victims.
I could have provided reams of evidence today until I
realized that countless victims and family members like me have
stood here before you evidence in hand. Countless congressional
reports, GAO reports and studies have been presented to
Congress for years, as you know. The evidence is already in.
Those with the power to stop these atrocities no exactly what
is happening.
You have seen thousands of certificates of unnatural
deaths, thousands of pictures of the bodies of victims of our
system. At least 15 of the 25 largest chains have been accused,
found guilty, or have admitted to Medicare fraud of multi-
millions. To my knowledge, not one owner or operator has gone
to prison. They are not even required to pay back all the
defrauded funds.
Negligent homicide and elder abuse within my home or the
community is treated as criminal, not so inside a nursing home.
It is just a regulatory offense with no criminal
accountability.
I am from a long line of patriots and veterans from World
War I through Desert Storm, yet veterans referred to as the
``greatest generation'' are enduring these same nursing home
atrocities and treated as those least deserving of our
country's respect. Yet, there is considerable concern for the
Afghan detainees in Cuba, and it is a felony to euthanize a
mockingbird in Washington.
Helen's homicide was included in Congressman Waxman's
report to Congress July 30, 2001 on reported abuse in one-third
of our nursing homes and has received nationwide media
attention.
It is long past time to restore the civil and
constitutional rights of nursing home residents. Thousands are
waiting to hear the results of today's hearings.
They would like to know when we will have justice, and with
all due respect, what will I be able to tell everyone across
the country when I go home? Thank you.
[The prepared statement of Ms. Becker follows:]
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The Chairman. Ms. Becker, thank you very much for your
contribution as well. I know also that it is not easy to talk
about these matters, but it is incredibly important that we
receive the information, and we thank you for doing so.
So, Michael Peters.
STATEMENT OF MICHAEL PETERS, ESQ., COUNSEL FOR RAPE VICTIM JANE
DOE, ORLANDO, FL
Mr. Peters. Thank you, chairman. Thank you for inviting me
here today. I am a trial lawyer in Orlando, FL. I have made
this trip today because this, indeed, is an important issue
that your committee has chosen to address.
I am here today because I believe our national treasure,
our elderly population, is at risk on a daily basis in nursing
homes across the country. I salute Mr. Love and Mrs. Becker. I
am humbled in their presence, because although I have heard
many tales of horror such as theirs in the course of my work, I
have never experienced it firsthand. I can only imagine the
pain that their family has gone through, and I salute them for
being here today to relive that before this committee, hoping
that something will be done.
The past 4 years of my law practice have been devoted
exclusively to the representation of nursing home victims,
victims of abuse and neglect. I have seen things I never
thought imaginable. I have a case where a man in Tennessee was
completely helpless lying in bed, and a certified nursing
assistant crawled up on top of him and beat him repeatedly
about the head, and he ultimately was sent to the hospital and
died from these blows.
A woman in Florida, 90-year-old woman, helpless again,
lying in bed, and was beaten in the head with an aluminum can
because she dribbled some of the formula in the can out of her
mouth. She too died.
I have seen bed sores the size of footballs where you can
see all the way down to a person's bone, but nothing that I
have come across is more shocking than the case, the facts of
the case that I came here today to tell you about, and that is
a case where a 36-year-old woman who had suffered a massive
stroke. As a result of this stroke, she was completely
paralyzed on the left side of her body, she was not only
physically disabled, but significantly mentally disabled as a
result of the brain injury from this stroke. After
hospitalization, she was sent to a nursing home because she
could not care for herself. She needed 24-hour skilled nursing
care, and she would probably for the rest of her life.
All of the things that we take for granted, she had to have
somebody do for her. Get out of bed in the morning, brush your
teeth, comb your hair, dress yourself, she needed assistance
eating. If she needed to go to the bathroom, she needed
assistance. Everything, like I said, that you and I take for
granted, she had to have help with, and she was there for 2\1/
2\ years, and this was being done.
As you can imagine over that period of time, she developed
a level of trust and confidence in those people that saw her in
a very intimate way every single day of her life. That trust
and confidence was shattered sometime in April of 2000. Sadly,
my client did not even know that that trust and confidence had
been shattered. It was not until January 13, late at night,
that she began to have excruciating stomach pains. The fact of
the matter is she was in labor.
On January 14, in the wee hours of the morning, a nursing
assistant came in to change her diaper, her adult diaper, only
to find a baby lying in feces in her diaper with the umbilical
cord still attached. You see my client had been raped. She had
no knowledge of this incident. She had no knowledge that she
was even pregnant. She carried this baby full term, 9 to 10
months, and nobody from the nursing home ever figured it out,
the people that were bathing her everyday, that saw her naked,
they did not figure it out. It was not until they came in and
found the baby lying there.
She delivered that baby in that room by herself in the dark
feeling excruciating pain with no anesthesia, with no medical
help, with nobody. The nursing home did not call the
authorities. They did send her out to the hospital or she was
sent out to the hospital, and miraculously that baby lived. The
baby is alive today and is being raised by her cousin in
Orlando, FL.
I can only say that I spent an hour sitting in my office
when this case came into my office, trying to figure out how
something like this could have happened. I have yet to figure
that out. There are many questions that have been raised by
this situation, and none of those questions in my mind have
been answered yet. But I promise you that I am going to find
out the answers if I can.
The good news is that in this particular case, local law
enforcement was able through DNA match to identify a suspect,
make an arrest. That person has been arraigned and will stand
trial in Orlando, FL for this heinous crime.
I certainly would like to answer any questions that this
Senate committee has regarding this issue. I think that in
other cases, the case in Tennessee where the man was beaten to
death, there was not a good response by law enforcement. They
never did make an arrest. From what I can tell from the
paperwork, they never made any reasonable investigation of the
matter. The state agencies and local agencies likewise chose to
slide this under the rug, and they still have not identified
the man that beat him to death. I think there is a very
important issue here, and I appreciate your devotion, the
commitment that you have made to address the issue. Thank you.
The Chairman. Thank you, Mr. Peters, and thank you, Mr.
Love, and Ms. Becker, for your presentations. You know that in
the almost 30 years I have been in Congress, this is probably
the most disturbing testimony that I have ever experienced on
any committee either in the House or in the Senate.
You know we have special laws that protect crimes against
juveniles and children in this country, as we should, because
they are a vulnerable population, but certainly seniors,
particularly in institutions of care, nursing homes and what
have you, are also particularly vulnerable and maybe even more
so than a child, because they are outside of a family setting,
many times without seeing any relatives or loved ones over a
relatively long period of time.
So, while it is important that we give that attention to
juveniles, it is equally important, if not more so, to make
sure that we give that same degree of attention to problems
when crimes are committed against seniors. I mean it just goes
without saying that for every crime, there is a criminal
somewhere.
What you are telling this committee, I think, is that law
enforcement is not really involved sufficiently to take care of
that. While it is tragic that these things happen, it is
equally as tragic if nothing is ever done about it, because
that would only allow it to occur again in the future.
Mr. Love, your testimony about your mother is just very
important and very difficult to give. How did you find out
about what happened? How did you first learn that your mother
had had her neck broken?
Mr. Love. I saw my mother----
The Chairman. Get close to that mike, please.
Mr. Love. Excuse me. On Thursday when I went down to see my
mother, I found out this through the evaluation of the hospital
emergency room. The very next morning, I went over to Valley
Skilled, and what was ironic was her charts were still being
filled out that Helen was awake, spontaneous, and she had left
the facility Wednesday night.
The Chairman. How many days was it from the time it
happened?
Mr. Love. This was 2 days later. Her charts were still
being filled out on a Friday that she was, you know, alive, you
know, was responsive, that kind of stuff, and my mother had
been removed Wednesday night.
The Chairman. Did anybody from the facility call the family
to tell them that something bad had happened?
Mr. Love. Until I had called, she was, like I said, beaten
on a Tuesday night, this was Wednesday morning--I was only
advised from the shift supervisor--not the shift supervisor--
the RN that was taking charge of what had happened to my
mother. Otherwise, there was no call the night before, and----
The Chairman. Who was the first to call the law enforcement
officials? Was it the nursing home?
Mr. Love. No, they did nothing. My brother took the
initiative to call the nursing home--not--excuse me--the
nursing home--called Sacramento Police Department to make sure
there was an officer that would help him respond to, you know,
ease and facilitate getting my mother, you know, over to the
emergency room, and the law enforcement responded with also a
photographer, who came in the middle of the night and took the
police photographs to substantiate what her injuries were.
The Chairman. Did the nursing home ever call law
enforcement?
Mr. Love. No.
The Chairman. What you also say, in effect, is that the
nursing home really hired a criminal?
Mr. Love. That is what I understood. Our attorney did some
investigative work into this gentleman's background, and it was
not a very good background.
The Chairman. The person who did this to your mother had
actually been dismissed from two prior nursing homes for
aggressive behavior toward residents.
Mr. Love. Yes, and my attorney has more detail, but that
kept it brief so we could portray this.
The Chairman. You mentioned that there was a survey, a
state agency surveyor, in the building when your mother's neck
was broken. Can you elaborate on what, not who it was by name,
but what was that person's position? Was he a state official in
the nursing home of some sort?
Mr. Love. She was from Health and Human Services and this
is for the Aging, and they also take care of the same--the
ombudsmen turn their reports into these people, and this lady
was in Wednesday morning on another incident, but was never
notified while she walked right down the hallway past my
mother's bed, but was never notified that there was an incident
at all as of Wednesday morning, and the lady was there, and I
had talked with that woman.
The Chairman. So you have a situation here where the
nursing home personnel, which knew about what happened, neither
notified law enforcement nor did they notify the state agency
that regulates nursing homes?
Mr. Love. That is correct. Also no other evaluation was
done on her by anyone outside of the nursing home, so that led
us to believe we were very fortunate to discover my mother's
injuries at that particular time, because I do not know if she
would have ever received anything, since the only people that
had looked at her at all were internal.
With my mother's neck broken, one of her complaints was
they tried to have her doing range of motion movement to see if
she could function and what was going on, and everyone I have
ever talked to said with a severe neck injury, you would never
do something like that, and the person that did this was the
director of nursing.
The Chairman. You certainly do not do that with a broken
neck.
Mr. Love. I would not think so, sir.
The Chairman. Ms. Becker, again, thank you for what I know
is difficult, but I also want to assure you that these hearings
will not be forgotten after you leave. You said that the
facility had said that your mother-in-law had been injured in a
fall. Is that how they characterize what had happened to her?
Ms. Becker. What they left on our answering machine was
just simply that she had been injured. The documents that they
sent with her to the hospital indicated that she fell.
The Chairman. So the family was notified how? By a call
left on an answering machine from the nursing home?
Ms. Becker. Yes.
The Chairman. They indicated that your mother-in-law had
been injured.
Ms. Becker. Injured.
The Chairman. But did not elaborate how?
Ms. Becker. No.
The Chairman. What did you do after that? Did you call the
nursing home and say what do you mean, how is she, or did you
call and find out more about it, and what did they say?
Ms. Becker. Initially I called. She had fallen before, so I
assumed injured, she had fallen. We called to find out whether
she was still at the nursing home or at the hospital, and she
was already back at the nursing home because the hospital was
not told. So we went directly there as soon as we made contact
with them, but there was no mention of the assault until an
employee came forward in secrecy and----
The Chairman. How long after the incident happened did you
find out what really happened, the fact that your mother-in-law
had been picked up from a standing position, slammed into a
wall and a handrail, and fallen unconscious. How long after it
happened did you actually find out what really happened?
Ms. Becker. We had been gone for the day. I would say we
had been at the nursing home for maybe 45 minutes when this
person came forward.
The Chairman. Do you know if the nursing home ever called
law enforcement after it happened?
Ms. Becker. No, sir, they did not.
The Chairman. Do you have any knowledge as to whether they
reported what actually happened to the state authorities that
regulate the nursing home?
Ms. Becker. I do not think so. I reported it.
The Chairman. You yourself had called the state and all
these other agencies that you called as well?
Ms. Becker. Law enforcement, yes.
The Chairman. You said that you did not get much help from
the regulatory agencies at all?
Ms. Becker. Right.
The Chairman. How about from law enforcement?
Ms. Becker. They did a very good job up to the point of
investigating this male mental patient, but once he passed
away, there was nothing further done.
The Chairman. Do you think that from your knowledge, had
the nursing home done a background check on employee--this was
a mental patient in there?
Ms. Becker. Resident, yes.
The Chairman. I am sorry. That is for Michael. The person
that did this to your mother-in-law was actually a patient in
the facility?
Ms. Becker. Correct.
The Chairman. Right. But that patient had a long history of
rather violent mental problems?
Ms. Becker. Yes.
The Chairman. Mr. Peters, another absolutely horrifying
story. I mean it is just almost unimaginable. On your
situation, did the nursing home call law enforcement?
Mr. Peters. Not to my knowledge, chairman. Like I said, she
was sent to the hospital pretty soon after that, but I have not
been able to see anywhere in the records so far that the
nursing home called the family. The family ended up finding out
when the hospital called.
The Chairman. So the family found out not from the nursing
home where it happened, but actually from the hospital where
she was admitted after the baby was discovered, I take it?
Mr. Peters. That is what I understand so far.
The Chairman. When was the family first involved with law
enforcement officials about what happened?
Mr. Peters. It was within a couple of weeks.
The Chairman. A couple of weeks?
Mr. Peters. A couple of weeks within her being admitted to
the hospital.
The Chairman. But obviously the situation here is even more
separated from the time of the actual crime, which was the
rape, and not being discovered until the lady had the actual
baby in the nursing home 9 months later.
Mr. Peters. That is correct.
The Chairman. Tell me about the employee who perpetrated
the crime. I mean this was a criminal. Was there any reason to
suspect that this person had any kind of tendencies in his past
record to be involved in this type of activity?
Mr. Peters. None that I can find so far, but the case in
terms of the civil case is still ongoing, and for that reason I
cannot speak a whole lot, but I can say that I will be doing
discovery on that very issue. I do know that he was a 9-year
employee of the nursing home. What I do not know is what his
actions were during that 9 year period. I have not gotten his
records.
The Chairman. Can you tell us how and who found out who was
responsible?
Mr. Peters. Yes. There was an anonymous call from a woman
who evidently worked at the nursing home, but she never
identified herself. She called the police officers.
The Chairman. I take it that the evidence indicated either
through DNA or some other manner of gathering evidence that
this person was, in fact, responsible?
Mr. Peters. Yeah. What was bothersome to me is getting into
this the nursing home originally tried to say that my client
had been taken out of the facility during the time that she
would have become pregnant. Well, the records show that is
clearly not the case and a couple of witnesses came forward to
try to trump up a story to that effect, and it has all been
disproved. Believe it or not, this man originally claimed that
this was a consensual sexual relationship, and that is why--and
he voluntarily gave his DNA, and then they matched up, and, of
course, anybody that spends 2 minutes with my client knows that
the notion that this was consensual is absurd.
The Chairman. Can you tell--my last question--can you tell
us how the law enforcement officials got involved in this case?
I know there is civil litigation going on, but from a law
enforcement standpoint, how did they become involved in this
case?
Mr. Peters. They were called likewise by the hospital,
because what I have found in these----
The Chairman. Not by the nursing home?
Mr. Peters. Not by the nursing home. What I was going to
say what I found in these cases is that when a hospital gets a
patient that has obviously been the victim of some kind of
incident in the nursing home, they are pretty quick to get on
the phone and call the police because they do not want any of
that responsibility falling into their lap.
The Chairman. Thank you, Mr. Peters, and thank all of you
for very powerful testimony. Senator Wyden.
Senator Wyden. Thank you, Mr. Chairman. Your excellent
questioning highlights, it seems to me, how the safety net that
is supposed to protect vulnerable seniors is just full of
holes. Mr. Love, I was particularly struck by the last page of
your testimony--basically the entire system broke down--the
social service agencies, the ombudsman did not have the
necessary authority, the state surveyors, the prosecutors, the
judge. I mean at every step of the way the system that is
supposed to be there for seniors as a safety net, there was not
any there.
What I would like to do for just a couple of moments is
have you trade places with all of us who are sitting on this
side of the dias. We want to make sure that we do not have
witnesses here in another 18 months saying exactly the same
thing. I think, Ms. Becker, you put it very well. The question
is what do we say when we go home? What do we say about it
being different?
The question will be what is it like in 2 years when the
press has gone away and some of the attention is not there?
Will we have exactly the same system that exploits and rips
these people off? So what I would like to do for a few minutes
is just have each of you put yourself in our shoes. We want to
make it different this time. Give us a couple of priorities.
Each one of you, start with you, Mr. Love, then you Ms. Becker,
and then you, Mr. Peters. You have got the election certificate
today and tell the U.S. Senate what you think ought to be done.
Mr. Love.
Mr. Love. It is ironic. I tried to do something like this
to help you along with just some ideas. A few of the
recommendations are--when you were leading into when we started
this, someone said this, like put a face on the problem. You
are not going to forget it, and I am just going to use Polly
Klaus' father keeps things alive, keeps things stirred, and
when you do this, the interest is there. I do not know of too
many people that do not know the Polly Klaus story.
From my situation, the other part was I feel some of the
laws are there, and all they have to do is enforce them. But
they have to take that initiative. I have no complaint with the
Sacramento PD, so if I was listening to this--they did what
they could, but the detective told me once it is turned over to
the DA, I cannot do anymore.
There is one thing I am going to try and say with this in
some way or another, we have to with some aid promote Health
and Human Services enforcement, but get them free of
limitations by supervisory pressure not to go after offenders.
I cannot say too much specifically on sources, but we had an
individual come to us and say that she was too efficient and
she needed to tone it down, and if she did not do that, it was
going to cost her her job.
Senator Wyden. What level of involvement did this come
from? Was this a governmental person?
Mr. Love. This was a governmental person, and like I said--
--
Senator Wyden. Somebody in government said you are doing
too much to protect seniors?
Mr. Love. This was a supervisory level, you know, and this
woman did not like it, she would not have a position, and she
had to say that off the record for keeping her job.
The other thing is I know a little bit about, you know, the
IRS and a few other things, but in the IRS, if you are in a
corporation, and you are one of the officers, and shall we say
money is lost, and you are an executive in that position, they
can go after you personally to make sure that the government is
reimbursed for what should have been paid in the first place.
So one of the things I would consider is can you hold
owners or managers of a corporation criminally responsible? All
I am saying is my experience has been there has been a number
of cases that I have had a chance to see or know about where
the people are fined, the insurance companies pay the fine, and
business goes on as usual.
Senator Wyden. Is business going on as usual at the
facility where your mom was?
Mr. Love. I cannot speak recently on that. But what I am
saying is there were other litigations that came in after our
case and that was going to be substantially damaging to them,
and the insurance company no longer wanted to insure them. They
had lost their insurance after our case is what my
understanding was.
The biggest thing what I am saying was is if someone would
be held criminally responsible, and I will use the terms that I
have written right here, for continued abuse in the conduct of
the operations of a nursing home, and there is no corrective
measures, are we to believe that there is no consequences for,
shall we say, continuing bad business when--all I am saying if
I was a member of a corporation, and my corporation did not pay
it, if I am the one that has got the assets, they could go
after me and take them back. I just wonder whether something
along that line.
I will make one last statement, and I will be brief. After
contacting my attorney to make sure I was correct with this,
collect the fines and penalties assessed by the state agencies
for nursing home violations. In California, this would help you
get the needed funds for enforcement, and the money just is not
gone after or it is appealed and appealed and appealed and
reduced quite substantially.
But with her passing on to me the knowledge that there is
millions of dollars that have not been gone after to be
collected that have been assessed for Class A, which is the
most serious violations, I do not know what to say. They had
been fined. Nothing is being done.
Senator Wyden. Good recommendations. Ms. Becker.
Ms. Becker. I believe I said something like that in my
testimony. We have regulations, probably more than we need.
They are not worth the paper they are written on if they are
not enforced. To me the biggest insult of the whole experience
has been that had this happened in my home, there is no
question I would have been investigated, I would have been
prosecuted, and I probably would have been put in prison. That
is why I cannot let it go. I think that would change a
tremendous amount of things down the ladder.
Senator Wyden. Sends a powerful message. Mr. Peters.
Mr. Peters. Yes. The first thing I would do, and I am
certainly no expert on what can be done on the Federal level
versus the state level, but I would suggest having Federal
imposed regulations in law across the board for nursing homes
in the United States that require mandatory criminal background
checks, mandatory investigation into their background for
whatever facilities they worked at previous, because the nature
of the nursing home business is people move around a lot, and
they get lost in the shuffle.
They need to have their background investigated going back
probably, you know, 5 to 10 years. Then I would impose Federal,
stiff Federal penalties, when nursing homes have cases of
unreported abuse or it is discovered after the fact that there
was abuse and they knew about it and they did not do anything
about it.
Then if you can discover that they violated these Federal
regulations on hiring, the penalties need to be stiff and maybe
include license revocation.
The third thing I want to talk about real briefly, if I
can, has nothing to do with we are talking about the response.
I think one of the big things in looking at nursing home care
going forward in this country is prevention, and again I do not
know if this can be done on a Federal level, but security
cameras in rooms, affectionately known as ``granny cams,'' if
the residents and their families want them, they can agree to
it, you can put them in there, and I am telling you people do
not do things when they know the camera is watching. It may not
eliminate all the bad apples that get in, but it will certainly
limit the bad behavior.
Senator Wyden. Mr. Chairman, my time is up, but I think
because you and I are on the committee involved in
communications issues, that is an area we ought to follow up
with Mr. Peters on, because he has, in effect, said let us look
at a tool that would empower the patients and families. In
other words, you are not forcing it on them. You are saying let
us look at something that empowers them to have this added tier
of protection.
Senator Breaux and I are both on the committee that deals
with these issues, and we will have the chance to follow that
up as well. Thank you, Mr. Chairman.
The Chairman. Well, we got cameras catching people running
red lights, for God's sakes. I mean you think if you can use
cameras with something as insignificant as that, something like
this is something that should be considered.
Senator Kohl.
Senator Kohl. Thank you very much, Mr. Chairman, and I
would like to say I can guarantee that your coming here and
testifying is not going to be in vain, and if I guaranteed
that, I am sure you would look at it with some degree of
question, but I do believe that this hearing is going to result
in improvement in the kind of care and the kind of oversight
that we give to our elderly who are in nursing homes.
Just to talk about this bill that we have been trying to
get passed now for 5 years, this national registry of abusive
long-term caregivers, the bill also would require that the FBI
conduct criminal background checks to see if there are any
serious violations in the history of a potential employee, of a
health care facility, which I think you indicated, Mr. Love,
was on the record of the abuser of your family member. There
was a record of a criminal violation.
Mr. Love. That is correct, Senator. My attorney was dogged
enough to go back and find, you know, what had happened with
this previous individual. We were not given that information.
My attorney found out.
Senator Kohl. Would the three of you be at least minimally
satisfied if we could pass that bill? That is to say establish
a national registry of those people who have abusive
backgrounds, and also require that the FBI conduct a criminal
background check on any people who apply for employment? Ms.
Becker.
Ms. Becker. May I ask a question?
Senator Kohl. Yes.
Ms. Becker. Would it be mandatory that if a facility just
does not report, say they have an employee who abuses one of
their residents, and if they do not report that and let that
person move from place to place, which happens a lot, would
there be stiff penalties for doing so?
Senator Kohl. So you are suggesting we add that provision
to the bill?
Ms. Becker. Yes, sir.
Senator Kohl. OK.
Mr. Love. They found out in California that you are
supposed to turn in any violations, so the nursing home is
supposed to do that. What they found is instead of turning in
the paperwork, there is a habit of, shall we say, you go down
the road and we will keep our mouth shut, get lost. That is why
homework had to do be done in reverse to find out what this
individual was about.
Senator Kohl. Just to get at this question about reporting
it, presumably the reason that a facility would not report it
is because it would reflect badly on them?
Mr. Love. That is correct.
Senator Kohl. But if, in fact, there was no public
declaration other than this person is listed as an abuser, then
the facility would have no compunction about reporting that
person as an abuser to be listed on a registry; right?
Mr. Love. I would agree with that. That was the reason in
California, again, the background checks are supposed to be
performed to put the responsibility on the new hiring agency,
and shall we say some are not diligent in that aspect?
Mr. Peters. Senator Kohl, I think the national registry
idea would be a great starting place, which would allow nursing
homes to, in fact, investigate their employees on a nationwide
level. Therefore, if you have a CNA, a certified nursing
assistant, that has worked in Arizona, and had problems and
moved to Florida to work, it would be required by the new
nursing home to check the national registry. If that person is
on it, they would be precluded from hiring that person. You are
going to eliminate some of the bad apples. I think it is a real
good place to start.
Senator Kohl. OK. Well, as I said, we cannot guarantee that
we can get this bill passed, but we have been trying for 5
years to get it passed, but I believe our chances are better
than they have ever been before, and I believe your presence
here today, your testimony, the record that you are
establishing, will have a lot to do with providing the impetus
to get the bill passed, and I think it is going to be done. So
we all appreciate your coming.
The Chairman. Thank you, Senator Kohl. I would just make an
observation. Back in 1998, Congress passed an appropriations
bill that allowed the states in that legislation to request FBI
criminal background checks for nursing home employees. It is
cheap, relatively simple. FBI does the work, gives you a
report. I think there are probably only two states that availed
themselves of that opportunity now. They can do it right now.
The FBI will do the work for them, but they are not doing it.
Senator Lincoln.
Senator Lincoln. Thank you, Mr. Chairman, and once again
thanks for your leadership in this issue on behalf of our
seniors, but also on behalf of aging Americans. When I was a
staffer here in Washington before I was elected, I can remember
calling home to my mother, and she did not have time to talk to
me on the phone because she was going over to the elementary
school. She was a room mother, and I made the comment to her, I
said I am the youngest of your four children, you have not had
a child in the public schools in almost 25 years now, and I
said why are you going over? She said because those kids need a
room mother, they need a valentine cookie, they need a bean bag
toss at Halloween, and in jest she said, she said I want those
children to grow up as well adjusted as possible. She said you
never know. They may be the ones running the nursing home you
put me in one day.
So it is not just these atrocities and these tragic stories
that you have shared with us today, but it is the fear in our
aging population of what they may be subjected to, because of
the stories you have shared with us. I do not have any
questions for you. I just want to tell you how grateful I am
that you were willing to bring these stories to light, to bring
these stories to us, in hopes that we can work with those in
states who have gone a little bit further, who have pushed the
envelope.
There are some things in our State in Arkansas where we
have seen some terrible things happen, and we have worked with
our coroner, who will be testifying in the next panel, but
certainly so many things that we could be doing, and hopefully
in conjunction with Senator Kohl and Senator Breaux and Senator
Wyden and myself, we can continue to bring to light to our
colleagues and move forward in some areas, particularly in
legislation. It will be of great assistance, not only to ensure
that the tragic stories you have told us today do not occur
again, but that we can help to eliminate any fear of those
aging constituents out there who are fearful of where they
might be themselves one day.
So thank you very much for coming. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Lincoln. I want to thank
the panel again. This is obviously very powerful testimony, and
shame on us if we do not follow up and get something done as a
result of it. I assure you that we intend to and intend to do
it aggressively, and this panel would be excused, and hope to
continue to work with you.
I would also note for the record, I mean I think the
testimony we have heard is not typical of nursing homes in this
country. I mean the fact that it ever happens is one incident
too many.
The Chairman. Let us welcome up the second panel. Ms.
Leslie Aronovitz with the General Accounting Office who did the
report for us; Mr. Mark Malcolm who is the coroner from Little
Rock, who maybe Senator Lincoln will say something about; Ms.
Delta Holloway, who is with the American Health Care
Association, representing the nursing home industry; Mr. Henry
Blanco, the National Association of Adult Protective Service
Administrators; and from my home State of Louisiana, Sheriff
Charlie Fuselier, on behalf of the National Sheriffs'
Association.
I told everyone that for Sheriff Fuselier, as he testifies,
I will engage in simultaneous translation so that everybody can
understand us. [Laughter.]
But Charlie, we are very happy that you are here with us.
Let us take Ms. Aronovitz, again with the General Accounting
Office, to give us her testimony from GAO. Thank her very much
for what has been a very long effort on the part of GAO in
looking at this issue, and on abuse in nursing homes, and I
think they did a terrific job.
Ms. Aronovitz.
STATEMENT OF LESLIE ARONOVITZ, DIRECTOR, HEALTH FINANCING
AND PUBLIC HEALTH ISSUES, HEALTH EDUCATION AND HUMAN SERVICES
DIVISION, GENERAL ACCOUNTING OFFICE, WASHINGTON, DC
Ms. Aronovitz. Thank you, Chairman Breaux, and committee
members. I am deeply saddened but unfortunately not shocked by
the testimony we have heard on the first panel. The fact is we
cannot overstate the vulnerability of nursing home residents
who are physically and mentally abused and impaired.
The Federal and state oversight agencies and the nursing
homes themselves are fully aware of the heightened risk these
fragile residents face. In fact, these entities have policies
and procedures in place intended to protect residents from
abuse. Nevertheless, our work in three states confirms that
significant gaps in these protections leave residents at
considerable risk. I say this fully acknowledging that even the
best of safeguards cannot prevent every incident of abuse.
The ambiguous and hidden nature of abuse in nursing homes
makes the prevalence of this offense difficult to determine.
For reasons such as fear of recrimination of adverse publicity,
as was mentioned, we found that family members, nursing home
staff and even management do not always report allegations of
abuse timely enough for it to be fully investigated or at all.
We were also concerned that some states do not interpret
and apply the definition of abuse in the way that the Centers
for Medicare and Medicaid Service's officials believe that the
definition should be applied. In Federal nursing home
regulations, CMS defines abuse as the willful infliction of
injury, unreasonable confinement, intimidation or punishment
with resulting physical harm, pain or mental anguish.
The states we visited maintain their own definitions that
are consistent with this one, but their application of the
definition varies. For example, Georgia survey agency officials
were less likely to determine that an aide had been abusive if
the aide's behavior appeared to be spontaneous or the result of
a reflex response.
Pennsylvania officials were not likely to cite an aide for
abuse unless the aide caused the resident serious injury or
obvious pain. So, for example, of someone took a hairbrush and
struck the back of a resident's head and no injury appeared,
they might be less likely to decide that that was, in fact,
abuse.
The Illinois survey agency considered any nonaccidental
injury to be abuse and cited aides even when residents were
combative or had not suffered serious injury. In discussing the
states' different approaches, CMS officials contended that an
aide who slaps a resident, regardless of whether it was a
reflexive response, should be considered abusive.
In light of these different perspectives, we have
recommended that CMS clarify the definition of abuse to ensure
that states cite abuse consistently and appropriately.
Another problem we identified consistent with the testimony
you just heard is that existing protections are not adequate to
keep a person with a history of abuse from getting a job in a
nursing home. For instance, when hiring nurse aides who are the
primary caregivers in nursing homes, facilities are required to
check a state registry for information on these perspective
employees.
However, the registry is limited to information about an
aide's employment in nursing homes within the state. Even when
an aide has been cited for abuse within the state, there may be
a considerable time lag between before that information gets
entered into the state registry.
We believe that such a serious citation warrants due
process, but currently there is no time limit on the beginning
of the process and on the end, not in the middle where due
process occurs that needs to be fixed.
For instance, there is no time limit on states completing
the investigation that could lead a nurse aide to be cited nor
in a decision being rendered after a hearing has taken place.
That just extends the time period that a name would
actually go on the registry if, in fact, a nurse aide was
determined to be abusive. At the states we visited, it took 5
to 7 months on average between the initial finding of abuse and
its entry in the registry, and several cases took over 2 years.
During this time, a nursing home employer consulting the
registry would have found clean records for these aides. There
can be other cracks in employment screening. For instance, in
the case of certain employees such as laundry aides or
maintenance workers, there is no registry or licensing entity
for a nursing home employer to consult.
These individuals would have to have a criminal conviction
which would be found in law enforcement records before an abuse
history would show up on a background check. Furthermore, some
states allow individuals to begin working before facilities
complete their background checks. In Illinois, a new employee
can work for 3 months before the criminal background check is
complete, while in Pennsylvania, an aide can work for 1 month
under these circumstances.
In Georgia, on the other hand, criminal background checks
must be completed within 3 days of the request and nurse aides
cannot start work before then.
Overall, we believe that existing safeguards need to be
strengthened and we are making five recommendations for CMS to
address the systemic problems discussed in our report.
However, state officials and nursing homes must also
practice unflagging vigilance. The extreme vulnerability of the
nursing home population calls for nothing less. Mr. Chairman,
this concludes my prepared remarks, and I will be glad to
answer any questions any of you may have.
[The prepared statement of Ms. Aronovitz follows:]
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The Chairman. Thank you very much, Ms. Aronovitz, for the
good work that GAO has done for this committee.
Senator Lincoln, do you want to introduce Mark Malcolm?
Senator Lincoln. I would be honored to. Thank you, Mr.
Chairman. We are extremely honored in Arkansas to have Mark
Malcolm who was appointed as coroner of Pulaski County on
January 1, 1995 by the Pulaski County judge and serves as the
only full-time county coroner in our State of Arkansas.
He served as the Chief Deputy Coroner for 8 years prior to
being appointed as coroner. He also serves, however, as
instructor for the University of Arkansas Criminal Justice
Institute, the University of Arkansas at Little Rock, and the
University of Arkansas for Medical Sciences. He also founded
the Pulaski County Coroner's Office of Professional Education
Program which provides death investigation training to law
enforcement officers, prosecutors and coroners throughout our
State.
He also holds the fellow status with the American Board of
Medi-Legal Death Investigation and is one of 26 board certified
death investigators in the United States.
So, Mr. Chairman, I think you will agree along with that
criteria and background, and also the fact that he helped to
introduce legislation in our legislature, our state
legislature, to require that all deaths of nursing home
patients be reported to the county coroner for investigation
regardless of the cause of death, and certainly without this
law, many cases of abuse resulting in the death of nursing home
residents would have gone and would continue to go unreported.
So we are extremely honored and privileged to have such an
individual in our state who cares so much about making sure
that in point in fact these laws are adhered to and what is on
the books is actually practiced. We appreciate very much the
service you give to the people of Arkansas, Mr. Malcolm, and we
welcome you to the committee.
Mr. Malcolm. Thank you.
The Chairman. Mr. Malcolm, with that powerful introduction,
you are on.
STATEMENT OF MARK MALCOLM, CORONER, LITTLE ROCK, AR
Mr. Malcolm. Thank you, Mr. Chairman, and members of the
committee. Thank you for the opportunity to be here, and
certainly I am grateful for Senator Lincoln's introduction.
In January 1994, my office began fielding the first
inquiries regarding deaths of nursing home patients. The
questions came primarily to us from family members and were
generally centered on the level of care or lack thereof
provided by the facility. More specifically, did the level of
care contribute to or cause the death?
The initial investigations consisted primarily of nursing
home medical and hospital record reviews, study of physician
orders, physician interviews, interviews of both current and
former nursing home staff members, and in most cases we found
that the level of care was adequate and did, in fact, not
contribute to the cause of death.
Some cases, however, warranted further scrutiny. From 1994
until 1998, my office conducted six exhumations of nursing home
patients. After a full post-mortem examination, all six were
determined to have been unnatural deaths. Two cases were ruled
as medication errors and four were asphyxial deaths.
The case that drew the most attention was that of a 78-
year-old man who died on the evening of July 28, 1998. He had
been improperly placed in a vest restraint and was discovered
wedged between his mattress and bed rail. He was so tightly
compressed in the position that four staff members had to work
to free him. He was dead by the time he was extricated.
Despite the circumstances of the death and a large injury
to his upper chest that was evident at the time of his removal,
the administrator of the home notified the family that the
decedent had died naturally and in his sleep. An audit by the
Arkansas Department of Human Services Office of Long-Term Care
brought that death to my attention and an investigation began.
Following exhumation and autopsy, the death was ruled as
positional asphyxia.
Under existing Arkansas law, this death and other cases of
unnatural death in nursing homes should have been reported to
the coroner and to law enforcement, and despite the existing
statutory requirement to report the deaths, nursing home
administrators chose to release the decedents to funeral homes
preventing that legally required investigation.
Whatever the motive, it was clear that a law directed
specifically to long-term care patients was necessary. In
January 1999, I began working with the counsel for the Office
of long Term Care. We authored a bill, submitted it to the
state legislature. That bill was passed and signed into law as
included in your packet of information today.
Essentially what the law requires is that all deaths of
nursing home patients in Arkansas be reported to the county
coroner regardless of the cause of death. The law further
requires that if a person is transferred to a hospital from the
nursing home, and they die within their first 5 days of
admission, that case also must be reported to the coroner.
Every nursing home patient who dies in Pulaski County,
Arkansas is examined by me or a member of my staff. In addition
to the physical examination, there are complete reviews of
medical records, interviews with physicians, facility staff and
family. We compare the pharmacy records to the doctors'
prescriptions. We match that against the nurses' notes to
ensure that medications are properly administered.
Since July 1, 1999, my office has conducted approximately
2,400 nursing home investigations. The majority of these cases
we have found the level of care to be adequate. In 56 of these
death investigations, we have uncovered a much different story.
We have dinner-plate sized bed sores with infected, necrotic,
dying tissue, infected feeding tubes, rapid and unexplained
weight loss, dehydration, improperly administered medications,
and medication errors that have resulted in death.
We have found basic needs such as general hygiene and
dental care neglected, urine and fecal matter dried on bed
linens and in diapers that have been left unchanged for what is
most assuredly hours. We have seen a patient whose care had
been so poor that a mucous growth formed on the roof of her
mouth. It was left untreated. It eventually sloughed off and
she asphyxiated and died.
When my staff and I arrived to examine this woman and
conduct our investigation, there were ants on her body and in
her bed.
Without this law in place, in my State, these cases would
go unreported and unnoticed and the decedents would simply be
released to funeral homes and the families would be left none
the wiser.
In 16 years at the coroner's office in Pulaski County, I
have been active at my state legislature on a variety of
different issues, but I can tell you, members of this
committee, none more important than Act 499 of 1999. The
intention of the legislation was solely for the protection of
the long-term care patient. However, independent oversight such
as that provided by my office can also provide a modicum of
protection to respectable, responsible facilities against
frivolous accusations and unwarranted claims.
Facilities that are staffed by competent, conscientious
health care professionals welcome an independent confirmation
of their good care in the currently litigious atmosphere of
their industry.
Mr. Chairman, that concludes my prepared remarks. Be happy
to answer any questions.
[The prepared statement of Mr. Malcolm and related
information follow:]
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The Chairman. Thank you very much, Mr. Malcolm, for your
testimony. Next from Louisiana Sheriff Charlie Fuselier.
Charlie, thank you for coming up. We really appreciate it.
STATEMENT OF CHARLES FUSELIER, SHERIFF, ST. MARTIN VILLE, LA,
ON BEHALF OF THE NATIONAL SHERIFFS' ASSOCIATION
Mr. Fuselier. I would like to thank you, Senator Breaux,
and the members of the Special Committee on Aging.
The Chairman. Pull that mike a little closer, if you can, a
little bit closer.
Mr. Fuselier. Thanks for inviting me to testify as to law
enforcement efforts to address nursing home abuse at this
hearing on crimes against the elderly in nursing homes. It is
my hope that this testimony will help to improve the quality of
life for older adults residing not only in nursing homes but in
any type of residential care facility which includes group
homes, assisted living facilities, and mental retardation
facilities.
By initiating the first Triad Program in the Nation on
August 30, 1989, the St. Martin Parish Sheriff's Office has an
established and long-standing record of commitment to older
adults that is recognized as extending beyond my jurisdiction
in St. Martin Parish, LA.
The Triad Program has proved to be a successful crime
prevention program aimed at older adults. Currently, there are
some 834 Triad Programs in 47 states. Additionally, England,
Canada, and Australia have expressed interest in utilizing the
concept in their countries. In 1990, the St. Martin Parish
Sheriff's Office instituted the statewide Elderly Crime Victim
Assistance Program through grant funding from the Louisiana
Commission on Law Enforcement and the Administration of
Criminal Justice.
In 1992, the Elderly Protective Services Program was
initiated in the State of Louisiana. These two programs served
to heighten our understanding of the severe vulnerability of
infirm older adults especially when they are in the care of
those persons they know and trust.
During the 1994 legislative session in Louisiana,
legislation was enacted creating the Committee for Law
Enforcement Services to the Elderly. This committee was formed
in response to the growing concern of crimes against the
elderly to include abuse, neglect and exploitation of the
elderly residing independently in their homes as well as those
in residential care facilities.
Representation on this committee includes members from the
Louisiana Commission on Law Enforcement, the Louisiana
Sheriffs' Association, the Louisiana Municipal Chiefs of
Police, the State of Louisiana Justice Department, the
Governor's Office of Elderly Affairs, the Councils on Aging and
the American Association of Retired Persons and the Louisiana
District Attorneys Association.
Early on members of this committee recognized and expressed
a concern about law enforcement's response to crimes in
residential care facilities. The concern grew that there was an
apparent lack of continuity in the response by law enforcement
from jurisdiction to jurisdiction to crimes committed in
residential care facilities.
As a result of the committee's concern, a Crime in
Residential Care Facilities Conference was held in Baton Rouge,
LA on November 12, 1997. The agenda included a legal session,
investigating crimes in residential care facilities, physical
and behavioral indicators of abuse, neglect, and the role and
responsibilities of the various investigating agencies.
The roles and responsibility section of that conference
included a panel of representatives from the Department of
Health and Hospitals, the State of Louisiana Justice
Department, Elderly Protective Services, the Louisiana Nursing
Home Association, state long-term care ombudsman, the police
supervisor of Baton Rouge Crimes Against the Elderly and a
sheriff. In Louisiana, this conference was the impetus for the
underlying questions about local law enforcement's response to
crimes in residential care facilities.
In 1999, the legislation was enacted forming the Aged Law
Enforcement Response Team, the ALERT officer. The ALERT program
established a 40-hour elderly service officer certification
through the Peace Officers Standard and Training Council. Law
enforcement officers successfully completing the course
lectures and written tests were certified as elderly service
officers.
The objectives of the ALERT program are: to create a
statewide network of law enforcement officers with specialized
training in working with the elderly to ensure uniformity in
the delivery of high quality law enforcement services to
elderly citizens; to have the ALERT ESO officer serve as the
primary point of contact when elderly victims are involved; and
to provide training within their agency and others in the
parish on effectively assisting older adults.
These objectives pertain to all elderly in Louisiana
whether residing independently or residing in residential care
facilities. The 40 hour curriculum includes 19 hours of
instructions on identification of abuse, neglect and
exploitation; the role of the long-term care ombudsman in
nursing homes; investigating crimes in residential care
facilities; criminal statutes dealing with the cruelty,
exploitation and sexual battery of the infirm; and the United
States Attorney's Office role in nursing home abuse.
Plans are currently being drafted for 2003 to include
having at least one ALERT trained assistant district attorney
in each judicial district.
In conclusion, there is a general assumption that because
the infirm elderly are residing in residential care facilities,
that government will assure that they are in a safe
environment. The reality is that because of their confinement,
in some instances, the infirmed elderly can be trapped in a
situation of abuse and have no one to turn to for protection.
Certainly, physical and sexual abuse in residential care
facilities are a strong priority that needs to be addressed by
law enforcement with the same type of responses given to crimes
committed to other citizens living independently outside a
facility.
Law enforcement's general perception is that they are
treated the same as everyone. The reality is that without
specialized training such as offered by the ESO ALERT program,
law enforcement generally does not have the skills to properly
evaluate such a complex situation.
Twenty-five years ago, there were very few juvenile
officers. Now, they are a significant part of the law
enforcement community. As we the baby boomer arrive and
outnumber our nation's youth in the next 10 to 15 years, the
ESO ALERT officer will be an essential part of the law
enforcement community, much like the juvenile officers are
today.
Chairman Breaux, and members of the Special Committee on
Aging, I submit that providing for expanded training for law
enforcement officers to address the growing needs of a rapidly
aging population is clearly necessary to address the growing
problem of physical and sexual abuse in residential care
facilities.
I look forward to working with you and I stand ready to
take your questions.
[The prepared statement of Mr. Fuselier and related
material follow:]
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The Chairman. Sheriff Fuselier, thank you for a really
terrific statement and a very good story.
Mr. Blanco, Henry Blanco, we are pleased to receive your
testimony.
STATEMENT OF HENRY BLANCO, BOARD MEMBER, NATIONAL ASSOCIATION
OF ADULT PROTECTIVE SERVICES ADMINISTRATORS, PHOENIX, AZ
Mr. Blanco. Mr. Chairman, members of the committee, I would
like to extend congratulations to you and the committee for
providing a forum to discuss this serious issue. I am the
Program Administrator for the Aging and Adult Administration
within the Arizona Department of Economic Security. We are also
the designated unit on aging under the Older Americans Act.
The Chairman. Mr. Blanco, speak up a little bit and get
that mike a little bit closer. It does not pick it up too well.
Maybe push it down a little bit. I think it is a little too
high. There you go.
Mr. Blanco. However, today I am testifying before you as
representative of the National Association of Adult Protective
Service Administrators, or NAAPSA.
The association represents Adult Protective Services, APS,
programs nationwide by providing advocacy, training, research
and innovation in the field of APS. All states in our union
have identified APS programs. However, there is no Federal law
that provides direction for APS. As a result, program
parameters are entirely up to each state.
Some APS programs are not involved in investigating
allegations of abuse in long-term care facilities. Adult
Protect Services are those services provided to elderly and
disabled adults who are in danger of abuse, neglect or
exploitation, and who are unable to protect themselves and have
no one to assist them.
It is estimated in the United States, two million older
persons and persons with disability are abused, neglected or
financially exploited each year. Most experts believe this
number may be only the tip of the iceberg since many victims
are unable to report their abuse and have no one to do so for
them.
According to the most recent figures from the National
Center for Health Statistics, there are currently 16,700
nursing homes in the United States with 1.8 million beds
serving 1.6 million residents. Of these homes, 95.6 percent of
them are certified for Medicaid and/or Medicare participation.
Without question, the physical and sexual abuse of our
elders in long-term care facilities must be highlighted and
addressed with all possible resources. I would like to provide
you an example of three cases that APS is involved in, and I
have further examples in my written testimony.
The first case was an 64-year-old woman who was placed in a
long-term care facility. The client was to have a diagnostic
test, a barium enema; the doctor had ordered one tap water
enema to be given the night before. The client, however, was
not an easy person to get along with, often demanding and
belligerent. Two LPNs decided to get even with the client
because of her behavior and gave her 15 enemas with
approximately three feet of tubing completely inserted into her
rectum.
None of this would have come to light if the client had not
complained that the nurses had verbally abused her. The case
took 3 years to get to court.
In a second case, an 85-year-old woman was raped at a local
nursing home. She was alert, oriented and competent. The client
said the male caregiver had raped her. A long-term care
facility chose not to believe her. Instead gave her two
Tylenols, told her to go bed, get a good night sleep and they
would discuss it in the morning. Another source in the facility
reported the incident to APS and to law enforcement.
The local law enforcement Sex Abuse Unit was able to
retrieve the sheets. Semen was found on the sheets. She had
been raped. The certified nurse's assistant was arrested, tried
and sent to jail.
In a third case, a 74-year-old woman was raped by a CNA.
Another staff person saw the CNA with his pants down around his
ankles and asked what was going on? The CNA said he was
``adjusting himself.'' The victim unfortunately was demented,
unable to communicate. Rape could not be substantiated and
charges were not filed.
These cases are complex and involve the necessary
coordination of many different jurisdictions and agencies.
Coordination between APS, law enforcement, regulatory agencies,
professional licensing boards, long-term care ombudsman
programs, Medicaid fraud units, to name a few, are critical in
successfully addressing these issues.
There are several initiatives that we would recommend. My
full statement includes additional recommendations. I would
like to highlight a few of them. The first one as the
congressional report indicates, salary and training for
caregivers is a major issue. The issue of salaries, other
benefits and working conditions and their relationship to
quality must be addressed.
Second, many states have mandatory reporting laws. Some
states provide protection from civil or criminal liability for
the reporting source. Other states protect the reporting source
and retribution by their employer for reporting to APS or law
enforcement. These protections and requirements should be
available nationwide.
Third, the Social Services Block Grant is the only fund
source of Federal funding that provides special funds for the
delivery of adult protective services. SSBG has been reduced
over the past few years from 2.8 billion to 1.7 billion.
Thirty-one states depend on these funds to provide protective
services to victims like those I have described.
Although the president's budget for fiscal year 2003 holds
SSBG at 1.7 billion, we are heartened by the recent news that
the White House is supportive of Senator Lieberman's and
Santorum's care legislation that would restore SSBG funding on
a temporary basis. Their bill is Senate bill 1924.
Fourth recommendation, we recommend that we provide a
dedicated funding source for the expansion, enhancement and
development of services for a nationally funded APS program.
Fifth recommendation would be to strengthen the
requirements for fingerprinting and background checks for all
employees of long-term care facilities. A major obstacle in
this area is the expense and the amount of time required for
fingerprint clearances.
A sixth recommendation is to recognize that physical and
sexual abuse occurs at all levels of care, and most be
aggressively addressed regardless of where it occurs.
A seventh recommendation would be to review Federal
regulations, both programmatic and funding, to ensure that
obstacles to coordinating and cooperation are not created for
the many state and Federal agencies involved in long-term care
facilities.
One of the areas to review is the ability to share
information, which may be essential but considered
confidential. Adults served by Adult Protective Services are
among this country's most vulnerable citizens. Those in our
nation's long-term care facilities are often most isolated.
They need our help. They deserve your attention, and they
have earned the right to be safe in their older years
regardless of where they reside. Mr. Chairman, I would like to
submit my full testimony for the record. Thank you.
The Chairman. Without objection, the whole statement, of
course, will be made part of the record.
[The prepared remarks of Mr. Blanco follow:]
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The Chairman. Mr. Blanco, if you would kind of pass that
mike over to Ms. Holloway so she will be able to give us her
testimony, we would appreciate it.
Ms. Holloway, thank you for being with us.
STATEMENT OF DELTA HOLLOWAY, RN, BOISE, ID, ON BEHALF OF THE
AMERICAN HEALTH CARE ASSOCIATION
Ms. Holloway. Thank you. Good afternoon.
The Chairman. Same thing, these mikes. You got to really
kind of get close to them to make them really work well.
Ms. Holloway. OK. We will try to do this. OK. Good
afternoon, Senator Breaux and committee members. Thank you for
inviting me this afternoon to testify before you. My name is
Delta Holloway and I have worked with the elderly and the frail
for the last 25 years. I am a registered nurse. I am a nursing
home administrator. I have served my profession as the Director
of Nursing and I currently am the President and Quality
Assurance Officer for Western Health Care in Boise, ID.
I am testifying today on behalf of the American Health Care
Association. AHCA represents over 12,000 long-term care
facilities, but most importantly these facilities care for over
one million patients.
First, I must say that the examples of abuse, the many
cases of abuse that we have heard today, are utterly
deplorable. Incidences like these just must be prevented. I
want to say for the record on behalf of myself, AHCA and all of
the caregivers, criminal acts while rare in nursing homes must
be prosecuted to the fullest extent of the law.
It is important that we ensure the public is aware that
these terrible situations are by far the exception and not the
rule. The report released today by the General Accounting
Office raises several serious issues and makes very many sound
recommendations. We concur with each and every one of GAO's
recommendations.
To be most effective, providers need two things. We need a
clear definition and process for abuse, and we need partnership
with law enforcement. Yes, it is important to recognize our
residents have medical conditions that make some of the
activities of daily living very difficult. Some medically
necessary clinical procedures involve therapeutic contact and
oftentimes that contact might cause pain.
But therapeutic contact is not abuse! A definition that
distinguishes between appropriate, although uncomfortable, care
and contact and abuse must be established.
For an example, I provided care to an elderly woman with
significant dementia and difficult behavioral issues. My
patient acted out and was abusive to her caregivers. She often
refused meals and her care when she did not take her routine
medications. When she was on the medications, she was much
happier and she truly did enjoy a better quality of life.
On one occasion, one of my registered nurses attempted to
force her mouth open to administer the medication. A certified
nursing assistant witnessed this act and reported it to me
immediately. I called the survey agency immediately and started
my own investigation.
I suspended the nurse with pay until I could complete a
further investigation. After our investigations, the
facilities, the survey and certification agency, and in this
case the state board of nursing, the state board did not revoke
her license. However, I did terminate her.
Second, providers need to be acknowledged as full partners
with state agencies and law enforcement in the abuse
prevention, reporting and investigation process. A system that
is not adversarial and views providers as a part of the
solution would be far more effective and much more beneficial
to what matters, and that is our patients.
Nursing homes are required to report all incidents of
abuse, or suspected abuse, within 24 hours, to conduct an
investigation and to give a written report to survey and
certification agency within 5 days and other state agencies in
some states.
Among the 50 states, there are many different reporting
requirements that are probably in need of standardization.
Streamlining and standardizing the process so that providers
report an allegation of abuse to the state survey agency would
eliminate confusion among consumers, patients, and providers.
As I said, we wholeheartedly agree with the recommendations
from the GAO report.
We do have several suggestions that might even strengthen
those. First, there should be one single point of contact to
make a report, preferably to the state survey agency. There
would be one number listed.
Second, we believe that education and training of local law
enforcement and Medicaid Fraud Control Units on the nursing
home environment, on the patients that we serve, and on the
staffing is highly needed.
Finally, we need a precise definition of what is abuse that
will lead to a better understanding of the problem and more
successful targeting and eventually the prosecution of those
that are truly guilty.
AHCA has been working with Senator Kohl to develop a
national criminal background system check. Any such system
should act quickly, and it should include all health care
settings. This should also be funded 100 percent so as to not
take away the resources for our primary mission which is
patient care. We support Senator Kohl's legislation and we will
work toward passage of this bill.
Last, but certainly not least, government must be a partner
in facilitating staffing of our homes. CMS just finished a
report that documents the need of over 400,000 additional
nursing staff right now. Unfortunately, government has not met
its responsibility for funding this level of staff, nor has it
helped to develop the needed workforce.
In summary, thank you for the invitation to testify and for
treating providers as a part of the solution to protect
residents, to prevent abuse, and to report the incidents. Mr.
Chairman, we care for our patients all day everyday, both
professionally and personally.
No one wants to prevent abuse or punish or remove
perpetrators more than we do. We stand ready to work with
Congress, the administration, local law enforcement, ombudsmen,
adult protection, and any other entity that will allow us to be
a part to protect the vulnerable seniors in our country.
Thank you for the opportunity to testify on this very
critical topic.
[The prepared statement of Ms. Holloway follows:]
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The Chairman. Thank you, Ms. Holloway, and thank all of our
panel for a very enlightening, very informative, and I think
very helpful testimony. Let me begin with Ms. Aronovitz on
behalf of GAO.
As I take it, the study that GAO did for the committee
involved surveys in Georgia, Pennsylvania and Illinois. Were
those the three states?
Ms. Aronovitz. We looked at 158 cases of reported abuse in
those three states. That is correct.
The Chairman. I take it those states were selected to try
and give us an indication of how things would be on a national
level?
Ms. Aronovitz. Absolutely. We had no intention of doing an
evaluation of those particular three states. As a matter of
fact, what we tried to do is use those states to learn about
some of the systemic problems that occur nationwide.
The Chairman. You have helped us a great deal. In the three
states that you all surveyed at GAO, were there found to be
requirements in the law or by practice of a requirement that
the nursing homes report abuse that occurred in the home that
could be potentially criminal to law enforcement or was it a
requirement to report to the health officials of the state or
were there no requirements at all?
Ms. Aronovitz. There is actually no Federal requirement
that nursing homes report abuse to local law enforcement or
their Medicaid Fraud Control Units, who are the state
prosecutory unit or agency.
The Chairman. That was in those three states or is that
nationwide?
Ms. Aronovitz. No. Nationwide there is no Federal
requirement. Now what we found in the three states that state
law often requires this type of reporting, but we also found
that it does not always happen in a timely way.
The Chairman. You mentioned the average time would be some
5 to 6 months in some cases to report an abuse case?
Ms. Aronovitz. That was the situation where a nursing home
reported abuse to the state and the state decided to cite a
nurse aid and put their name in the registry. We found cases
where there was delayed reporting by the nursing home in about
half the cases that we looked at where nursing homes were
supposed to report to the state.
Nursing homes are supposed to report within 24 hours and
that is defined as the day of or the day after the incident
took place. But we found in about half of the cases that we
looked at that reporting took place a week or 2 weeks later and
actually we found eight cases where the nursing home reported
the incident over 2 weeks late.
The Chairman. Obviously the longer the time between the
incident and the reporting, it makes it much more difficult if
not impossible to investigate.
Ms. Aronovitz. Also, it keeps residents who are subject to
abuse vulnerable because no one is protecting them during that
time.
The Chairman. One of the things I mentioned is the thing
that we did--I mean the rule that we passed back in--when was
this--1998, with regard to the attorney general, FBI being able
to do background checks on employees in these type of
facilities. It actually says that the attorney general may
charge a reasonable fee not to exceed $50 per request to any
nursing facility or home health care agency requesting a search
and exchange of records pursuant to this section, and do you
find that this is being done by any of the facilities that you
worked with?
Ms. Aronovitz. Actually, there is no Federal requirement
that a nursing home do a background check. There are state
requirements that that happen. The Federal requirement is that
nursing homes do not hire employees with a criminal background
that has a history of abusing nursing home residents.
The Chairman. But the information we have is that the
states are not really availing--I mean the various institutions
are not really taking advantage of this provision that would
allow them to do these background checks?
Ms. Aronovitz. That is exactly right. We found in the three
states that even though there are state laws requiring criminal
background checks, they are usually done only at the state
level, and when we talked to the FBI, 29 states do not really
avail themselves of Federal FBI checks, nor do other states
routinely.
The Chairman. So obviously, if a person was a criminal in
one state and went to work in a second state, that state check
would not disclose that they were, in fact, hiring a criminal?
Ms. Aronovitz. In most cases that is true. Once in awhile,
the state would require the nursing home to go to another state
if they know that in the last 2 years an applicant worked in a
different state. But typically that would not be the case and
the information about background, criminal background, in
another state would not be reported.
The Chairman. OK. This investigation is very helpful, but
an investigation without follow-up and recommendations and
actions by Congress is not worth very much. Can you summarize
for the committee the recommendations that GAO has presented to
this committee?
Ms. Aronovitz. Absolutely. The first one is that there be a
Federal requirement that the state survey agencies immediately
contact local law enforcement or the MFCUs when there is a
confirmed allegation of abuse.
The Chairman. That is--I do not want to interrupt you--but
that is law enforcement as opposed to a social worker or the
state health agency?
Ms. Aronovitz. That is correct. The nursing homes already
have to report to the state survey agency. We think that there
should be a requirement that this also be reported immediately
to the local law enforcement of MFCU.
The second is that the Centers for Medicare and Medicaid
Services need to convince states to make it much easier to know
how to report abuse, and one suggestion, having one phone
number would be very useful. We found in looking at phone books
in nine cities in the three states that it was very common to
get phone numbers that look like you could report abuse. For
instance, numbers in the book that said ``senior help line'' or
``fraud and abuse line,'' and in fact, those numbers had no
jurisdiction or ability to take the calls at all or complaints.
The third one would be to clarify the definition of abuse
so that all states would be applying that standard consistently
and appropriately.
The fourth one would be to assure that nursing homes do not
hire people with criminal backgrounds, and, in fact, CMS needs
to study the prevalence of this and to try to figure out other
options for convincing states to assure that nursing homes are
not, in fact, hiring people with criminal backgrounds, and also
we feel very strongly that we need to shorten the time period
between the time a state survey agency decides to cite a nurse
aide with abuse and the time it actually gets reported to the
registry.
The opportunity there to not disturb due process would be
at the beginning of the process. Right now there is no
requirement that a state survey agency investigate the case and
make a decision about whether to cite a nurse aid within any
reasonable timeframe. In addition, at the end of the process,
once the hearing takes place, there is no requirement that the
hearing officer make a decision and report those findings
immediately.
The Chairman. Thank you very much for that very good
summary.
Ms. Aronovitz. You are welcome.
The Chairman. Sheriff Fuselier, I am really proud of your
testimony. I think this is an indication of one example when
our state has done a very credible job. You can be very proud
of the leadership role that you have played in putting this
process together, and I am just looking at the map you have
here of where we have the ALERT officers. It covers almost the
entire State of Louisiana, and where you have the elderly
services officers in addition in some parts.
I mean can you tell me the Triad Program, I mean it is an
association that was really put together through AARP and law
enforcement officials and how does that structure work?
Mr. Fuselier. Well, the Triad Program is a program with the
sheriffs, the chiefs and the older American groups, generally
AARP or the Council on Aging, where we come together and form a
SALT council and get interested people who are interested in
the prevention of the victimization of the elderly to actually
sit down at a table and discuss the problems that we are
having.
This may include people from the nursing homes, clergy,
anybody who provides this service to the seniors, and this is
one way to pass information across. I think it was probably the
forerunner of community oriented policing, because this
happened before that.
The Chairman. Ms. Aronovitz was talking in terms of there
is a requirement that the nursing homes report abuse to the
state health officials. You know there are several categories
here and I think logic indicates, a common sense approach to
this. You can have a nursing home that gives poor treatment.
You can have a nursing home that the poor treatment becomes
abuse. Then you can have a situation where the abuse is so
clearly defined as a criminal act in the case of a person with
a broken neck because they have been thrown against the wall,
or a rape victim who suffered that indignity in a nursing home.
Do we get that in Louisiana in the sense of are we having
people from nursing homes reporting to law enforcement when
there is a suspected case, not just of mistreatment, but I mean
a criminal act that occurred? I mean there is a natural
tendency for nursing homes to say, look, we are going to handle
it internally. There is a natural tendency for police officers
to say we have got enough problems controlling street crime. We
do not have time to go into the nursing home. They will take
care of it. How does it work in the real world?
Mr. Fuselier. I do not think in Louisiana we have taken
that position. I think our position is that we want to protect
our elderly, and I think you can see from the testimony and the
legislation that was enacted that we have taken steps to bring
these people together to address the problem, exactly the
problem that you have said, is that, you know, we want to make
sure that the nursing homes are reporting, and I would say
there are a number of cases probably that are not reported that
should be.
What we have, I think, is there was testimony we need that
one number, and they would get back to local law enforcement,
because I think sometimes we do have some of these things fall
through the cracks, and not necessarily anyone's fault.
The Chairman. Well, I am very proud of what you have done.
I think the message that could come out from Louisiana, ``Don't
mess with the elderly.'' Mr. Fuselier. That is exactly right.
The Chairman. Ms. Holloway, in your testimony on behalf of
the nursing home industry as well as your personal experiences,
this is a difficult situation that needs to be addressed. I am
very pleased that you have indicated the support of the
industry for the recommendations from GAO, and I would say
again that the vast majority of nursing home facilities provide
very much needed service to people who sometimes are very
seriously ill and need 24 hour a day, 7 day a week care.
There will always be bad actors in any business, in any
profession anywhere in the country. Our responsibility,
industry's responsibility, is to come as close as we possibly
can to eliminating it. All of these suggestions or some of them
are costly, and I know that many of the nursing homes are
operating on very narrow margins, many of which have gone under
financially.
You put cameras in nursing homes. That is going to be a
huge expense. I would think that the background checks can be
done at a minimum amount of cost, particularly with the FBI
doing it. Nursing homes or anyone else in these type of
situations dealing with vulnerable people should not hire
people with criminal records in that area, and I am all for an
individual's rights and responsibilities and everything else,
but I do not want to see people who abuse people working in
nursing homes. I mean that is just my common sense approach. I
think the members of the committee would agree with.
What I guess I would ask among other things would the
industry support a requirement that these cases when they are
found out not only be reported to a social worker or the state
health institution, but also be reported to law enforcement?
Because I take it that that is not now a Federal requirement.
What is your comment on that?
Ms. Holloway. I would support that, and I would think that
if we had the one number and it did get reported to the
licensure agency, it would be good if that agency would call
the local police department.
I will say that in my state in 1998, a law was passed that
if there is a death or serious injury to an adult, a vulnerable
adult, an elderly person, the nursing home, the physician, the
family, whomever might be aware of that, needs to report to law
enforcement within 4 hours.
The Chairman. Let me ask. This is the real question here.
We can have all the reporting requirements we want. How do we
assure that when a criminal act occurs in a nursing home
facility, that, in fact, someone in that facility reports it to
criminal law enforcement authorities? I know we can have the
rule.
Ms. Holloway. Sure.
The Chairman. The CMS, Center for Medicare and Medicaid
Services, can adopt a resolution that is saying, look, the
Federal Government tax dollars are paying most of the cost of
operating the facilities, and we have now a national
requirement that these things be reported if they occur within
4 hours or within an hour, immediately, but if a nursing home
decides we are going to handle this internally, it would be
horribly embarrassing if we reported this.
I think the opposite. I mean these things are going to be
found out. We have seen it today. I mean all of these
incidents, they tried to cover them up and people find out
about it. Eventually it comes to light, and I would dare say
that a nursing home that has tried to cover it up is going to
look much worse in the eyes of the public and their
constituents if they did not report it and take prompt action
than one who admits it happened and reported it promptly to law
enforcement.
That is a better nursing home than one who does not report,
but how do we do that? Do we have to have a policeman in every
nursing home in this country?
Ms. Holloway. I hope not.
The Chairman. How do we do it?
Ms. Holloway. I am happy to say, I do not like this because
it is labor intense, but I am liking it more and more. In our
state, we are asked by survey and certification to complete an
incident report. That is a whole different form that we have to
fill out than the record.
First of all, if there is any resident to patient
situation, abuse, or there is suspected abuse, we must call the
survey and certification within 24 hours. I am proud to say
that in our state we call them right away because we want them
to be aware that there is a potential problem.
We also call ombudsmen. We do not call adult protection
unless a family member is involved. We are to complete this
form and it gives the specifics about how we found the
resident, our investigation, and we must talk to all levels of
staff, nursing assistants, nurses, social workers, activity
people, anyone that may have been involved with that resident,
we must develop a plan of action so that this will not to the
best of our ability happen again.
The Chairman. I take it that in your state there is no
legal requirement to report to law enforcement officials if the
type of things happen in that nursing home that we heard about
here today? Is there a legal requirement to do that?
Ms. Holloway. If there is death or serious injury, we do.
The Chairman. If there is death or serious injury, there is
a legal requirement to report not just to the health department
but to law enforcement?
Ms. Holloway. In 4 hours.
The Chairman. Within 4 hours.
Ms. Holloway. Yes.
The Chairman. OK. Thank you. I want to assure you certainly
this senator's intent is to try and work with the industry.
This is an important industry. It provides important services
to millions of senior citizens. We have to assure that it is
being done to the high quality standards that you spoke about
here today and we are going to work with you all to ensure that
that happens.
It is like those first three people that came up indicated
that we hear about this all the time and nothing gets done.
Something will get done.
Ms. Holloway. Senator, I believe something should get done.
The Chairman. Thank you for that attitude.
Ms. Holloway. I need to say that when the survey agency
visits our facility, they read charts, they look for incident
reports, and if from our call, they feel that something does
not sound right, they come to the facility, even before the 5
days when they have the full report. They call and see what
kind of an effect has this situation had on the resident, and I
will tell you that they will be out immediately if there has
been an adverse reaction by the patient.
The Chairman. Thank you very much for your testimony again.
Ms. Holloway. OK.
The Chairman. Senator Wyden.
Senator Wyden. Thank you, Mr. Chairman, and first let me
tell you how much I appreciate your determination. As you know,
this is not the first time this has come up. This is part of a
pattern. We have talked about it now for several hours. Just as
sure as the night follows the day, you have a report like this
GAO report outlining the abuses, the industry and government
pledge that there are going to be changes, and then a year or
so later, there is going to be backsliding.
I mean that is the pattern on this issue. Ms. Aronovitz,
would you disagree with that?
Ms. Aronovitz. No, I think it is very important that there
be the types of fixes that will stick, and right now it is
clear that there are a lot of administrative gaps and criminal
protection gaps in the system, absolutely.
Senator Wyden. I think we are going to have a bill and an
ongoing effort led by our chairman that others of us are going
to sponsor so that we can follow up. I want to ask some
questions to sort of amplify on some of the points that you
made, and I think your report is superb.
So here the country sits literally 20 years into this, the
Federal Government having spent billions of dollars in Medicare
and Medicaid, and the Federal Government does not require
nursing homes to call police where there is a suspicion of a
crime. Any sense how that could possibly have happened? Did the
Federal Government just miss it or did people sit around and
say we cannot afford this rule? What did you find on this point
with respect to how something like that which seems like such a
glaring flaw, how did it happen?
Ms. Aronovitz. The Federal Government does require some
administrative type procedures that ultimately might get at a
problem in which a law enforcement entity ultimately gets
involved, but there are too many steps and, in fact, it is too
circuitous in terms of how that works. For example, a state
agency could, in fact, immediately call law enforcement agency
if it considers abuse that is reported to it by the nursing
home to be severe enough, but it is not absolutely required.
The MFCU, the Medicaid Fraud Control Unit, in many states
is responsible for prosecuting in a criminal sense abuse, but,
in fact, the state survey agencies sometimes screen the
allegations and only refer the ones that they think are the
most severe or the most prosecutable.
There is an example in Illinois where every case of abuse
that we are talking about at the severity we are talking about
automatically goes to the Medicaid Fraud Control Unit and that
unit with its professional prosecutors and criminal
investigators review and screen those cases to decide which
ones to pursue.
We found that there was a much higher conviction rate per
capita in that state when that process was used. The one thing
I should say is that different states have different laws that
sometimes are pretty tough in terms of their requirements.
But they vary extensively across states in terms of what is
required and what types of employees are included. For
instance, in one state we found that nursing homes must report
to the local law enforcement entities if it has to do with a
criminal abuse from a caregiver. In other places, the law
refers to all nursing home employees.
There is enough gaps in state law and enough that we do not
know about those state laws where there should be some Federal
consistent oversight.
Senator Wyden. I think what I was after, is how in the
world could the Federal Government have allowed this to happen?
I mean I find it hard to believe somebody was sitting up there
at CMS or its predecessor and said, you know, let us just be
rotten to seniors today and ignore their needs, but maybe you
can enlighten us as to how this could have happened?
Ms. Aronovitz. I think that CMS depends very much on the
survey and certification agencies. As Ms. Holloway was
describing, the surveys when they are conducted, either
periodically or when a survey agency finds that there is
serious abuse, goes out and does an investigation. When these
surveyors go out, they look at the way nursing homes conduct
their hiring practices and conduct their own investigations
into these instances, and supposedly they will be checking to
assure that nursing homes are following the administrative
processes, and in cases where there were several allegations of
criminal behavior, that those got reported. So I think the
Federal Government's relying on these surveys to identify these
cases does not always happen.
Senator Wyden. Thank you. I think that addresses my
concern. Let me ask you about some of your other findings, and
again what I hope here is to just amplify a little bit so that
we get a sense of why some of these problems are occurring. You
cite the fact that patients and relatives are reluctant to
report abuse and obviously there is fear of retribution, fear
that patients who have nowhere else to go will be pushed out of
the facilities.
What did you hear from the patients and the families on
this point? Particularly did the patients and families tell
your investigators we just do not think they are going to
prosecute and we do not think they are going to enforce the
laws, so that is why we are not speaking out?
Ms. Aronovitz. Actually, our investigation focused mostly
at the overseers and the experts in the field, and we did talk
to quite a few experts who look at this problem and also the
Department of Justice which also believes that this is
underreported, and one of the things that we find are that the
bond or the relationship that builds between a family and the
caregivers of a loved one is very, very strong.
Sometimes we heard that the family will not even believe or
accept the fact that a caregiver could be abusive and sometimes
when a loved one comes to the nursing home and sees that there
is a bruise, there is a lot of mystery around how that bruise
happened, and sometimes the nurse aides and other employees are
given the benefit of the doubt.
As you mentioned, in other cases, the family is afraid that
the loved one might be asked to leave the nursing home and
another place will have to be found, and in some cases there
are just very worried about accusing the nurse aide if, in
fact, they do not have all the facts.
These type of instances usually occur in the privacy of a
resident and a caregiver or another nursing home employee.
There is not usually a lot of witnesses to this, so there is a
lot of mystery around some of these abusive situations have
taken place.
Senator Wyden. Just a couple of other questions. What about
the findings of GAO with respect to the role of the nursing
home administrator? What I have found, because I was the public
member, as a Gray Panther co-director before I was elected to
the House, I was the public member on the Nursing Home Board of
Examiners at home in Oregon, and I think that so much of what
happens in a nursing home is set by the tone of the
administrator.
I gather that you all made some findings that the nursing
home managers are not exactly proactive on a lot of these
matters as well. Can you amplify on that?
Ms. Aronovitz. Yeah, we cannot project or talk about the
universe of all nursing homes, and it is very important that we
understand that, because there are tremendous nursing homes and
nursing home administrators----
Senator Wyden. Absolutely.
Ms. Aronovitz [continuing.] Who have devoted their life to
protecting residents. But in our sample, we looked at 158
cases, 111 of them were instances where a nursing home found
out about an abuse situation, and we could determine the dates
that that abuse situation occurred. In about half the cases, in
54 of those cases, the nursing home administrator did not
notify the state survey agency within the 24 hour required
timeframe.
In 37 of those cases, the state survey agency was notified
2 to 7 days late. In nine instances, they were notified a week
to 2 weeks late, and as I said earlier, in eight of those 54
cases, the nursing home administrator notified the state survey
agency over 2 weeks late.
Senator Wyden. It is an important point and one we will
want to ask you more about as we move to trying to put together
a reform effort, because clearly the tone starts at the top,
and you have addressed some shortcomings there.
One question for you, Ms. Holloway, if I could. What would
you say today are the most important self-policing efforts that
the association has taken on to date? That is important because
obviously you want to have as much self-policing as you can so
that any Federal legislation is targeted to the areas where it
is most needed. What would you say are the most important self-
policing initiatives that the association has taken on to date?
Ms. Holloway. I just have to say one more time, we just
cannot tolerate this abuse. I believe it an honest statement
from us that we wish to work with the recommendations of the
GAO report and do something about a national registry that
would indicate that a staff member should or should not be
hired. Right now that is only certified nursing assistants, and
should be broadened to others.
The other very, very important issue is the criminal
background check. I think that we have been policing ourselves
in some states better than others perhaps. Some do do the
Federal criminal background check. It costs about $50 an
employee and you get the results in two to 3 weeks, where the
state check costs $10 and you get it in five to 7 days.
Senator Wyden. I want to ask one question for the sheriff
if I could, and thank you for your excellent testimony and the
service that you provide. I have always felt with law
enforcement that at some level it comes down to a question of
priorities.
Law enforcement people are incredibly busy, and everybody
is sitting there every single day having to juggle all of these
issues that are so important in terms of protecting the public
health and safety.
What are your thoughts on how we make this issue, the elder
abuse question, a higher priority in terms of law enforcement?
Certainly, the dollars for training can help, but the end of
the day, this is going to be about priorities and making this a
major one.
Mr. Fuselier. Well, Senator, this is one of the goals of
the ESO officer, that we would have this person that would
specialize in doing that. However, in all cases that is not
necessarily his only responsibility, but it would be his, I
guess, top priority, the same as we mentioned with juvenile
officers. You have to take the time to do it. With our growing
population, we are going to have no choice. We have to
recognize the fact that servicing our elderly is a top
priority.
Senator Wyden. Mr. Chairman, thank you.
The Chairman. Well, thank you, Senator Wyden, for your
involvement, your continued involvement. I want to thank this
panel. You all have been extremely helpful. We have got some
good ideas, good suggestions, and thank the first panel once
again. With those two panels, that will conclude this hearing.
The committee will be adjourned.
[Whereupon, at 3:55 p.m., the committee was adjourned.]
A P P E N D I X
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