    Nursing Homes: Complaint Investigation Processes Often Inadequate to
    Protect Residents (Letter Report, 03/22/99, GAO/HEHS-99-80).

    Federal and state practices for investigating complaints about nursing
    home care are often not as effective as they should be. GAO found many
    problems in the 14 states it reviewed, including procedures or practices
    that may limit the filing of complaints, understatement of the
    seriousness of complaints, and failure to investigate serious complaints
    promptly. Complaints alleging that nursing home residents were being
    harmed have gone uninvestigated for weeks or months. During that time,
    residents may have remained vulnerable to abuse, neglect (which can lead
    to serious problems like malnutrition and dehydration), preventable
    accidents, and medication errors. Although the federal government
    finances more than 70 percent of complaint investigations nationwide,
    the Health Care Financing Administration (HCFA) plays a minimal role in
    providing states with direction and oversight regarding these
    investigations. HCFA has left it largely to the states to decide which
    complaints put residents in immediate jeopardy and should be
    investigated immediately. More generally, HCFA's oversight of state
    agencies that certify federally qualified nursing homes has not focused
    on complaint investigations. GAO recommends (1) stronger federal
    requirements for states to promptly investigate serious complaints
    alleging situations that may harm residents but are not classified as
    posing an immediate threat, (2) more federal monitoring of states'
    efforts to respond to complaints, and (3) better tracking of the
    substantial findings of complaint investigations. GAO summarized this
    report and the preceding one in testimony before Congress; see: Nursing
    Homes: Stronger Complaint and Enforcement Practices Needed to Better
    Ensure Adequate Care, by William J. Scanlon, Director of Health
    Financing and Public Health Issues, before the Senate Special Committee
    on Aging. GAO/T-HEHS-99-89, Mar. 22 (10 pages).

    --------------------------- Indexing Terms -----------------------------

     REPORTNUM:  HEHS-99-80
         TITLE:  Nursing Homes: Complaint Investigation Processes Often
                 Inadequate to Protect Residents
          DATE:  03/22/99
       SUBJECT:  Elder care
                 Elderly persons
                 Nursing homes
                 State programs
                 Safety standards
                 Sanctions
                 Patient care services
                 Noncompliance
                 Federal/state relations
                 Negligence
    IDENTIFIER:  Medicaid Program
                 Medicare Program
                 HCFA State Agency Quality Improvement Program
                 Maryland
                 Michigan
                 Washington

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    HE99080.book GAO

    United States General Accounting Office

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

    March 1999 NURSING HOMES Complaint Investigation Processes Often
    Inadequate to Protect Residents

    GAO/HEHS-99-80

    United States General Accounting Office Washington, D.C. 20548 Let
    te r

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

    GAO

    Health, Education, and Human Services Division

    B-281767 Letter

    March 22, 1999 The Honorable Charles E. Grassley Chairman The
    Honorable John B. Breaux Ranking Minority Member Special Committee
    on Aging United States Senate

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

    In our July 1998 report to you, we found that unacceptable care
    was a problem in many California nursing homes, including one in
    three where state surveyors identified serious or potentially
    life-threatening care problems. We also reported that federal and
    state oversight is not sufficient to guarantee the safety and
    welfare of nursing home residents. 1

    In a companion report issued last week, we further found that
    current federal enforcement efforts cannot ensure sustained
    compliance with federal standards for nursing home care. 2

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

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

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

    B-281767 Page 2 GAO/HEHS-99-80 Nursing Home Complaints

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

    Results in Brief Federal and states' practices for investigating
    complaints about care provided in nursing homes are often not as
    effective as they should be.

    Among many of the 14 states we examined, we found numerous
    problems, including

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

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

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

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

    B-281767 Page 3 GAO/HEHS-99-80 Nursing Home Complaints

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

     a HCFA initiative to strengthen federal requirements for
    complaint investigations was discontinued in 1995, and resulting
    guidance developed for states' optional use has not been widely
    adopted;  federal reviews of state nursing home inspections are
    primarily intended

    to focus on the annual surveys of nursing homes, and very few
    reviews are conducted of complaint investigations;  since 1998,
    HCFA has required state agencies to develop their own

    performance measures and quality improvement plans for their
    complaint investigations, but for several of the 14 states we
    reviewed, such assessments addressed complaint processes
    superficially or not at all; and  HCFA reporting systems for
    nursing homes' compliance history and

    complaint investigations do not collect timely, consistent, and
    complete information.

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

    Background Nearly all nursing homes accept residents with either
    Medicare or Medicaid and are projected to receive nearly $39
    billion in federal payments from

    these programs in 1999. The federal government, through HCFA, has
    responsibility for establishing requirements that nursing homes
    must meet to participate in the Medicare and Medicaid programs and
    ensuring that these standards are met. HCFA carries out this
    responsibility by contracting with states to monitor nursing
    homes. As part of these

    B-281767 Page 4 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

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

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

    B-281767 Page 5 GAO/HEHS-99-80 Nursing Home Complaints

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

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

    Table 1: Federal and State Expenditures for Complaint
    Investigations, 1998 Total expenditures for complaint
    investigations

    Percentage of total survey and certification expenditures

    Percentage of total expenditures

    federally funded

    Average expenditures

    per on- site investigation

    Average expenditures

    per home

    Maryland $ 232, 666 8 60 $1,199 $885 Michigan 1, 204, 179 16 71
    1,361 2,694 Washington 2, 156, 161 30 59 664 7,592 U. S. total
    $58, 833, 689 20 71 $1,430 $3,397

    B-281767 Page 6 GAO/HEHS-99-80 Nursing Home Complaints

    Some States' Complaint Practices Are Limited in Protecting Nursing
    Home Residents

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

    Procedures and Practices May Limit the Public's Filing of
    Complaints

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

     Michigan requires that either complainants write a complaint or
    the state will provide assistance in writing the complaint. About
    95 percent of publicly reported 6 complaints were submitted in
    writing between July 1997 and June 1998.  Maryland's policy is to
    accept and act on a complaint by phone even

    though callers are encouraged to submit a written complaint.
    However, state officials provided us conflicting information as to
    whether calls would be consistently documented and investigated
    when callers agreed to submit a written complaint but did not do
    so. Over 70 percent of

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

    B-281767 Page 7 GAO/HEHS-99-80 Nursing Home Complaints

    Maryland's publicly reported complaints that the state
    investigated were identified as written complaints between July
    1997 and June 1998. 7

     In contrast, Washington readily accepts complaints by phone and
    nearly all complaints are received by phone. This contributes to
    Washington receiving a considerably higher number of complaints
    than Michigan or Maryland.

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

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

    States Establish Widely Varying Categories for Prioritizing
    Complaints

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

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

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

    Number of complaints received Number of complaints per 1, 000

    nursing home beds

    Maryland 642 21 Michigan 2,243 45 Washington 8,748 336

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

    B-281767 Page 8 GAO/HEHS-99-80 Nursing Home Complaints

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

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

    Complaints May Receive an Inappropriately Low Investigation
    Priority

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

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

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

    B-281767 Page 9 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

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

    Note: Percentages may not add to 100 because of rounding. a
    Maryland and Washington define their time frames as workdays,
    whereas Michigan defines its time frames as calendar days.

    b About 5 percent of Michigan's complaints were placed in other
    miscellaneous categories or their priority was unknown. c
    Michigan's highest priority category requires an investigation
    within 24 hours.

    State Number of

    complaints classified as immediate jeopardy

    Number of immediate jeopardy complaints

    per 1,000 beds Immediate jeopardy

    complaints as a percentage of total complaints investigated

    Maryland 0 0 0 Michigan 24 0. 5 2 Washington 223 8. 6 8

    Priority time frame a Maryland Michigan b Washington

    Within 2 days c 0 2 8 Within 10 days 22 N/ A 81 Within 45 days 34
    92 9 Next survey d 44 N/ A 3

    B-281767 Page 10 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

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

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

    B-281767 Page 11 GAO/HEHS-99-80 Nursing Home Complaints

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

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

     The complaint alleged that a resident was found dead with her
    head trapped between the mattress and the side rail of the bed,
    with her body lying on the floor. The state categorized this
    complaint as one needing to be investigated within 45 days. The
    state investigated this complaint within 13 days and determined
    that 11 of 24 sampled beds had similar side rail violations. Our
    concern about whether this complaint was appropriately classified
    is supported by another HCFA region's interpretation of HCFA's
    guidance to states. The Denver region would have considered this
    situation to be an immediate jeopardy complaint to be investigated
    within 2 workdays, noting that an unexplained resident death
    related to a medical device, side rails, or other restraints
    exemplifies a possible immediate jeopardy situation requiring an
    on-site investigation within two workdays.  Another complaint
    alleged that an alert resident who was placed in a

    nursing home for a 20-day rehabilitation stay to recover from hip
    surgery was transferred in less than 3 weeks to a hospital because
    of what the complainant termed an unprecedented rapid decline [in
    the resident's condition]. One of the members of the ambulance
    crew transporting the resident to the hospital filed a written
    report stating that the resident had dried . . . blood in his
    fingernails and on his hands . . . sores all over his body . . .
    smelled like feces and [was] unable to walk or take care of
    himself. Patient is in very poor condition as far as his hygiene.
    I personally feel he was not being properly cared for. The state
    categorized this complaint as needing an investigation at the next
    on-site inspection, took more than 4 months to begin its
    investigation, and determined that the nursing home had harmed the
    resident.  Another complaint alleged that the home's staff would
    not send a

    resident with maggots in the sores on his feet to the hospital
    because the home's director of nursing did not want the state
    agency to be notified by the hospital and investigate the home.
    The state categorized this complaint, received 105 days before our
    visit, as needing to be investigated within 45 days, but it had
    not yet been investigated.

    B-281767 Page 12 GAO/HEHS-99-80 Nursing Home Complaints

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

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

     Kansas' auditors said that about 10 percent of 213 complaints
    reviewed were classified too low, given their potential
    seriousness. Among the complaints categorized as not requiring an
    investigation until the earlier of the home's next annual survey
    or within 6 months of receipt was one alleging that a resident had
    skin tears, purple lesions, feces and food on his clothing, broken
    eyeglasses, and was not being fed regularly. Another complaint
    charged that a nurse's aide abused several residents.
    Pennsylvania's auditors identified several complaints as
    categorized too

    low, including one filed by a licensed practical nurse recently
    employed by the home. The nurse alleged that there had been at
    least 12 deaths at the home over a 2-week period, including a
    resident who choked to death because she had mistakenly been given
    solid food; a resident who was sent to the emergency room because
    her feeding tube had become dislodged and was entirely within her
    stomach; and a resident who had received 10 times the prescribed
    dosage of a medication. This nurse's complaint was placed in the
    lowest category, delaying its investigation until the home's next
    annual survey.

    States Frequently Do Not Investigate Complaints Within Required
    Time Frames

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

    B-281767 Page 13 GAO/HEHS-99-80 Nursing Home Complaints

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

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

    Note: N/ A = not applicable. a Maryland's data provide information
    on the last date of the investigation, but not when the
    investigation was initiated. Based on our review of complaints
    received in early 1998, only 1 of 18 complaints was initiated
    within the assigned time frame of 10 workdays, and only 4 of 11
    complaints were initiated within the assigned time frame of 45
    workdays.

    b When using the federal requirement of 2 workdays to investigate
    immediate jeopardy complaints, Michigan investigated 42 percent of
    these complaints on time. c About 5 percent of Michigan's
    complaints were identified as those to be investigated within
    miscellaneous time frames. Although state law requires serious
    complaints other than immediate

    jeopardy to be investigated within 30 days, Michigan's Department
    of Consumer and Industry Services changed the 30- day requirement
    to a 45- day requirement in 1998. As shown, Michigan did not meet
    even the 45- day time frame in most cases. We asked each state
    visited to provide copies of all complaints in the Baltimore,
    Detroit, and Seattle areas that had not yet been investigated and
    that exceeded the assigned time frame. Baltimore and Detroit each
    had

    Time frame Number of complaints Percentage investigated within
    time frame

    Maryland

    2 workdays 0 N/ A 10 workdays 47 21 a 45 workdays 72 69 a

    Michigan

    24 hours 24 21 b 45 days c 1,273 26

    Washington

    2 workdays 223 78 10 workdays 2, 331 47 45 workdays 252 89 90
    workdays 78 100

    B-281767 Page 14 GAO/HEHS-99-80 Nursing Home Complaints

    over 100 such complaints, while Seattle had 40. 12 From the
    complaints provided, we identified those for homes having at least
    three outstanding complaints not investigated within the states'
    prioritized time frames, and we summarized the allegations of each
    complaint. Many of these complaints alleged potential resident
    abuse by staff; resident neglect, including malnutrition and
    dehydration; preventable accidents; medication errors; and
    understaffing. See appendix III for this summary.

    Delayed Investigations of Complaints Prolong Harm to Residents

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

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

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

    Description of allegations Days until

    investigation started Scope of harm found a

    Maryland

    Nurse charted that resident's intravenous fluid was flowing well;
    however, fluid was going under the resident's skin and not into a
    vein. Resident had to be hospitalized. 139 Isolated Resident had
    caked feces all over his body, dried blood under his fingernails
    and on his hand, and pressure sores all over his body. A member of
    the ambulance team that transported the resident to the hospital
    questioned whether the home properly cared for the resident. 130
    Isolated

    Inadequate supervision led to falls. One resident suffered a
    dislocated jaw and could not chew. A feeding tube was inserted
    into the resident. The resident later developed pneumonia, was
    hospitalized, and was put on life support. 54 Isolated

    Three residents were hospitalized with several pressure sores. One
    resident had a sore that was exposed to the bone. Another resident
    had four sores; a third resident had three sores. The state noted
    that the home did not ensure proper nutrition for one of these
    residents to prevent the development of the sores. 39 Isolated

    (continued)

    B-281767 Page 15 GAO/HEHS-99-80 Nursing Home Complaints

    Note: Data include a complete chronological sample of complaints
    received in early 1998 that were investigated and resulted in a
    violation indicating that actual harm had occurred. In Maryland,
    we reviewed 102 complaints received between January 1 and February
    28, 1998; in Michigan, we Description of allegations Days until

    investigation started Scope of harm found a

    Michigan

    Resident had multiple pressure sores and multiple fractures caused
    by falls, resulting in hospitalization. 228 Pattern Resident had
    swelling and bruising on chest, shoulder, and forearm. The
    emergency room diagnosed fractured ribs. 216 Isolated Resident was
    verbally abused by an aide, who told resident to go to the
    bathroom in her diaper after resident asked for a bedpan. The home
    failed to draw a conclusion about the incident, but suspended the
    aide. The state noted the home had a history of not being able to
    draw conclusions about abuse incidents.

    152 Isolated Aide was rough in transferring resident from
    wheelchair, resulting in laceration needing 25 stitches. 146
    Isolated

    Resident with history of 13 altercations with other residents hit
    a resident who suffered a laceration. The home had not implemented
    safeguards to prevent such occurrences. 112 Isolated

    Resident's weight and fluids were not monitored. Also, resident's
    foot was swollen, possibly requiring amputation. Resident also
    found sitting in urine, not clean, and missing personal property.
    Resident rushed to emergency room.

    99 Pattern Male aide slapped a female resident and squeezed her
    hand causing a bruise. Another resident struck a home employee,
    who slapped the resident's face in response. 88 Isolated Resident
    sustained a fractured nose and laceration of her forehead as a
    result of improper positioning in her wheelchair. Resident sent to
    hospital for stitches. 45 Isolated Resident, who had blood drawn,
    was noted to have a badly bruised hand and elbow. Complainant
    alleged that a laboratory representative stated that sometimes
    they have to get rough in order to draw blood from residents.

    37 Isolated Home failed to monitor resident's condition; resident
    became unresponsive and was hospitalized for dehydration and a
    urinary tract infection. Home failed to use bed side rails for
    seven residents, resulting in lacerations/ injuries to four
    residents who fell out of bed.

    33 Pattern A resident's leg was fractured three different times,
    possibly due to rough handling of resident during transfer by
    aide. Allegation also stated that aides are not properly trained
    to transfer residents who have fragile bones.

    33 Pattern Resident hit another resident. 17 Isolated Resident
    found dead with head between mattress and bed side rail, with body
    lying on the floor. 13 Isolated

    Washington

    Resident had repeatedly developed pressure sores while in the
    nursing home. 27 Isolated Resident fell while being transferred
    from wheelchair to toilet, and as a result, re- broke hip. 9
    Isolated Quadriplegic left the home in an electric wheelchair and
    died of hypothermia after the battery ran out. 3 Isolated

    Inadequate staffing resulting in deteriorated care of many
    residents. Medications were late, and a diabetic's blood was not
    tested for sugar level. 1 Widespread Resident suffered a hairline
    fracture of the foot while being transferred from wheelchair to
    bed. 0 Isolated

    B-281767 Page 16 GAO/HEHS-99-80 Nursing Home Complaints

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

    repeatedly; widespread violations are pervasive, affecting a large
    number of residents and occurring frequently.

    HCFA's Complaint Investigation Standards Are Minimal, and Its
    Oversight of States' Complaint Practices Is Weak

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

    Previous HCFA Efforts to Strengthen Federal Standards for Nursing
    Home Complaint Investigations Were Abandoned

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

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

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

    B-281767 Page 17 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

    Federal Monitoring of States' Complaint Practices Is Limited

    HCFA's major efforts to monitor states' performance in surveying
    and certifying nursing homes are largely focused on annual
    surveysnot on complaint investigations. HCFA requires its regional
    investigators to replicate or observe a 5-percent sample of state
    investigators' nursing home inspections and requires states to
    develop performance measures and

    B-281767 Page 18 GAO/HEHS-99-80 Nursing Home Complaints

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

    Few Federal Monitoring Surveys Are Performed for Complaint
    Investigations

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

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

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

    B-281767 Page 19 GAO/HEHS-99-80 Nursing Home Complaints

    Initial State Quality Improvement Reports Identify Few Problems
    With Complaint Practices

    HCFA requires each state to evaluate its performance in complaint
    investigations beginning in 1998 as part of the State Agency
    Quality Improvement Program. However, our review of the 1998
    reports submitted to HCFA by states that either we visited or had
    a recent state auditor's report 14 indicated that several states
    had not yet developed performance measures or improvement plans
    related to nursing home complaints, and that the states that had
    evaluated complaint processes ignored concerns that we and the
    state auditors raised. Furthermore, under the new Quality
    Improvement Program, HCFA regional offices appeared to be less
    directly involved in evaluating state agencies' performance in
    complaint handling than with previous oversight approaches.

    Among the states visited,  Maryland had not developed a Quality
    Improvement Program or

    baseline performance measures for nursing home complaints. 15

     Michigan's final 1998 quality improvement report noted that staff
    turnover had delayed its ability to begin evaluating whether all
    complaints were investigated and processed within the time frames
    but stressed that the state agency feels confident that this
    [performance standard] will be (and currently is) met. This
    statement conflicts with our findings that most investigations in
    Michigan were conducted later than the 45-day time frame adopted
    by the state agency.  Although Washington's quality improvement
    program includes

    performance measures related to training staff in conducting
    complaint investigations and properly documenting the results, it
    did not evaluate the timeliness of complaint investigations. As
    noted above, we found that Washington categorizes its complaints
    at a higher priority level than do Maryland and Michigan and is
    more timely in investigating them. Nevertheless, Washington met
    its time frames in only about 55 percent of the complaints
    investigated.

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

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

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

    B-281767 Page 20 GAO/HEHS-99-80 Nursing Home Complaints

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

     New York had not yet established performance standards for
    nursing home complaints.  Tennessee reported that it planned to
    begin implementing new

    complaint performance standards in October 1998.  Wisconsin cited
    the implementation of a new data system as the cause

    of its delay in tracking complaints as part of quality improvement
    efforts but stressed that our belief is that we are fine, but we
    have no data to support or refute this belief.

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

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

    Inadequate Reporting Systems Hamper Effective Federal and State
    Management of Complaint Investigations

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

    B-281767 Page 21 GAO/HEHS-99-80 Nursing Home Complaints

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

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

    In our report on California nursing homes, we determined that the
    results of complaint inspections are often cited as state, not
    federal, deficiencies. 19

    Thus, the results of complaint investigations may not appear in
    federal databases. Furthermore, state officials reported that
    complaints might appear to be unsubstantiated in federal databases
    when the state has actually substantiated the complaint. In
    contrast, Washington and Michigan report that they record most
    violations they identify in both

    16 HCFA recently has begun posting results of nursing homes' most
    recent annual survey on the Internet, available at
    http://www.medicare.gov/nursing/home.asp. Results of complaint
    investigations are not publicly available from the Internet.

    17 For an assessment of the weaknesses of HCFA's management
    information systems and the impact those weaknesses have on HCFA's
    enforcement activities, see GAO/HEHS-99-46, Mar. 18, 1999.

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

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

    B-281767 Page 22 GAO/HEHS-99-80 Nursing Home Complaints

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

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

    Conclusions Our work in selected states reveals that serious
    complaints alleging harm to residents often remain uninvestigated
    for extended periods. Such delays

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

    Recommendations To make complaint investigations a more effective
    tool for protecting nursing home residents' health and safety, we
    recommend that the HCFA

    Administrator revise federal guidance and ensure state agency
    compliance through the following actions:

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

    B-281767 Page 23 GAO/HEHS-99-80 Nursing Home Complaints

     Strengthen federal oversight of state complaint investigations,
    including monitoring states' practices regarding priority-setting,
    on-site investigation, and timely reporting of serious health and
    safety complaints.  Require that the substantiated results of
    complaint investigations be

    included in federal data systems or be accessible by federal
    officials.

    Agency, State, and Industry Comments and Our Response

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

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

     a new interim requirement that states should investigate
    complaints alleging actual harm to residents within 10 workdays,
    and a complaint improvement project with the intention of
    developing additional minimum standards for complaint
    investigations;  increased federal oversight of complaints,
    including allowing HCFA

    regional offices to conduct additional monitoring surveys based
    upon complaints and new state agency performance measures relating
    to complaints; and  improved reporting on complaint information,
    including a review of the

    form states use to report complaint information to HCFA, further
    direction to states requiring that complaint findings be included
    in the federal as well as state database in a timely manner, and a
    review of potential long-term improvements in the federal data
    system.

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

    B-281767 Page 24 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

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

    B-281767 Page 25 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

    William J. Scanlon Director, Health Financing

    and Public Health Issues

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

    Contents

    Letter 1

    Appendix I Scope and Methodology

    30

    Appendix II Nursing Home Complaint Investigation Expenditures

    34

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

    40

    Appendix IV Comments From the Health Care Financing Administration

    56

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

    Appendix V Comments From Maryland's Department of Health and
    Mental Hygiene

    65

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

    67

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

    75

    Tables Table 1: Federal and State Expenditures for Complaint
    Investigations, 1998 5

    Table 2: Complaints Received Between July 1, 1997, and June 30,
    1998 7 Table 3: State-Investigated Complaints That Were Considered
    Potential

    Immediate Jeopardy, July 1997 Through June 1998 9 Table 4:
    Percentages of State-Investigated Complaints in Maryland,

    Michigan, and Washington, by Priority Category, July 1997 Through
    June 1998 9 Table 5: Percentage of State-Investigated Complaints
    Meeting Time

    Frame for Investigation, July 1997 to June 1998 13 Table 6:
    Complaints in Which Investigation Substantiated Federal

    Deficiency and Resulted in Home Being Cited for Actual Harm to One
    or More Residents 14 Table II.1: Estimated Expenditures for
    Nursing Home Complaint

    Investigations, by State, Fiscal Year 1998 36

    Contents Page 28 GAO/HEHS-99-80 Nursing Home Complaints

    Table II.2: Expenditure Rates by Home, Visit, and Bed, Fiscal Year
    1998 38 Table III.1: Unassigned Complaints for Nursing Homes in
    Baltimore

    With Three or More Such Complaints 40 Table III.2: Uninvestigated
    Complaints for Nursing Homes in Detroit

    With Three or More Such Complaints 45 Table III.3: Uninvestigated
    Complaints for Nursing Homes in Seattle

    With Three or More Such Complaints 53

    Abbreviations

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

    Page 29 GAO/HEHS-99-80 Nursing Home Complaints

    Page 30 GAO/HEHS-99-80 Nursing Home Complaints

    Appendix I

    Scope and Methodology Ap pe ndi x I

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

    In each of the three states visited, we  interviewed state
    officials and complaint investigators and obtained

    documentation of each state's complaint investigation procedures
    and practices,  analyzed computerized data on all complaints the
    states had received

    from July 1997 through June 1998,  obtained and reviewed the files
    of complaints that each state received

    and investigated in early 1998, and  obtained and reviewed the
    files of complaints that the states had not yet

    investigated at the time of our visits in late 1998 and early
    1999. For each of the 14 states included in our work, we reviewed
    the state agency quality improvement program report that was
    submitted to HCFA at the end of 1998. In addition, we interviewed
    HCFA officials, including representatives of each of HCFA's 10
    regions, regarding federal guidance to and oversight of state
    agencies. We also obtained from HCFA data on federal and state
    expenditures on nursing home complaint investigations for all
    states.

    State Auditors' Reports We also reviewed reports from 11 states
    whose state auditor (or similar organization such as the Office of
    Inspector General) had performed

    reviews of the state's long-term-care activities and whose
    investigation reports were issued between December 1995 and April
    1998. Each of these reports addressed some aspect of the state's
    nursing home complaint process. The 11 states were Iowa, Kansas,
    Kentucky, Louisiana, New York, North Carolina, Ohio, Pennsylvania,
    Tennessee, Texas, and Wisconsin.

    Data Analysis Each of the three states we visited provided us with
    electronic databases on complaints received in 1997 and 1998.
    These data include information

    such as the number of complaints received and investigated, the
    priority category assigned, and when the complaint was received
    and investigated.

    Appendix I Scope and Methodology

    Page 31 GAO/HEHS-99-80 Nursing Home Complaints

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

    Complaints Received in Early 1998

    We asked each state to give us access to its file of complaints
    received in early 1998.

     In Maryland, we reviewed 102 complaints that the state received
    between January 1, 1998, and February 27, 1998.  In Michigan, we
    reviewed the 59 complaints the state received between

    January 1, 1998, and January 15, 1998.  In Washington, we reviewed
    the 133 complaints received between

    January 1, 1998 and January 7, 1998. We reviewed the nature of
    complaints received, the priority levels assigned, whether the
    complaint resulted in an investigation and the timeliness of the
    investigation, and whether an investigation substantiated the
    allegations and resulted in any federal or state deficiencies.
    Table 6 summarizes all complaints received in the three states
    during these periods in early 1998 that resulted in the state
    identifying a violation of federal standards and that were of a
    severity level that actual harm to residents was found.

    Uninvestigated Complaints in Baltimore, Detroit, and Seattle

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

    Appendix I Scope and Methodology

    Page 32 GAO/HEHS-99-80 Nursing Home Complaints

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

    HCFA Oversight Efforts

    We contacted each of HCFA's 10 regional offices and requested  the
    number of federal monitoring surveys the region conducted during

    1996, 1997, and 1998, and how many of these represented reviews of
    complaint investigations;  State Agency Quality Improvement
    Program reports for the 14 states we

    or state auditors had reviewed and that the states had submitted
    to HCFA at the end of 1998; and  any additional guidance or
    oversight methods for complaint

    investigations that the regional office had developed.

    Complaint Investigation Expenditure Data

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

    1 In Baltimore, complaints that were assigned a priority
    classification of next on-site investigation were included if they
    were not investigated within 45 working days.

    2 For these states, expenditure data from the fourth quarter of
    1997 and the first three quarters of 1998 were used.

    Appendix I Scope and Methodology

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

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

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

    Page 34 GAO/HEHS-99-80 Nursing Home Complaints

    Appendix II

    Nursing Home Complaint Investigation Expenditures Appe n di x I I

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

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

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

    Appendix II Nursing Home Complaint Investigation Expenditures

    Page 35 GAO/HEHS-99-80 Nursing Home Complaints

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

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

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

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

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

    (continued)

    Appendix II Nursing Home Complaint Investigation Expenditures

    Page 36 GAO/HEHS-99-80 Nursing Home Complaints

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

    expenditures State

    Nursing home federal certification and state

    licensing expenditures

    Nursing home complaint expenditures as a percentage of total

    expenditures Dollars Percentage Dollars Percentage National
    $300,923,161 19.6 $41,851,120 71.1 $16, 982,569 28.9

    Alabama 4, 513,957 25.8 915,584 78.7 247,381 21.3 Alaska 718,294
    10.6 44,929 59.1 31,132 40.9 Arizona 2, 974,070 16.4 326,283 67.0
    161,001 33.0 Arkansas 4,572,890 23.5 864,920 80.5 209,945 19.5
    California 32, 295,110 22.3 5, 371,302 74.5 1, 834,312 25.5
    Colorado 4,411,078 16.4 604,763 83.7 117,878 16.3 Connecticut 6,
    513,868 13.1 501,715 58.8 351,886 41.2 Delaware 1,571,149 14.0
    123,536 56.3 96,028 43.7 District of Columbia 884,804 10.0 54,461
    61.3 34,340 38.7 Florida 10,074,324 11.4 886,421 77.1 263,636 22.9
    Georgia 5, 129,227 20.2 698,176 67.3 339,661 32.7 Hawaii 904,436
    11.4 72,672 70.2 30,814 29.8 Idaho 1,717,627 11.9 128,585 62.7
    76,334 37.3 Illinois 20, 141,264 20.3 2, 361,634 57.6 1, 735,050
    42.4 Indiana 7, 221,142 24.6 1, 252,656 70.6 522,195 29.4 Iowa
    3,680,882 20.9 483,649 62.9 284,659 37.1 Kansas 5,795,741 19.5
    760,129 67.1 371,992 32.9 Kentucky 2,990,823 27.9 615,417 73.8
    218,894 26.2 Louisiana 2,620,308 6. 3 137,827 83.6 27,128 16.4
    Maine 1, 786,290 24.9 335,846 75.6 108,512 24.4

    Maryland 2,980,394 7. 8 140,614 60.4 92,053 39.6

    Massachusetts 8,009,692 11.6 723,255 77.9 205,546 22.1

    Michigan 7,627,160 15.8 858,315 71.3 345,864 28.7

    Minnesota 7, 011,762 10.7 538,930 71.6 213,828 28.4 Mississippi
    2,396,923 17.5 298,351 71.2 120,824 28.8 Missouri 9, 585,434 30.2
    2, 112,904 73.1 778,952 26.9 Montana 2, 615,725 15.6 328,038 80.5
    79,519 19.5 Nebraska 2,783,633 18.6 342,063 66.0 176,260 34.0
    Nevada 1,628,137 15.7 143,965 56.2 112,089 43.8

    (continued)

    Appendix II Nursing Home Complaint Investigation Expenditures

    Page 37 GAO/HEHS-99-80 Nursing Home Complaints

    Federal complaint expenditures State complaint expenditures

    State Nursing home federal

    certification and state licensing expenditures

    Nursing home complaint expenditures as a percentage of total

    expenditures Dollars Percentage Dollars Percentage

    New Hampshire 891,682 4. 7 32,665 78.1 9, 134 21.9 New Jersey
    8,701,678 11.5 569,847 57.1 428,978 42.9 New Mexico 1,315,590 15.9
    177,305 85.0 31,284 15.0 New York 17, 089,866 17.1 1, 613,194 55.3
    1, 303,696 44.7 North Carolina 5,751,723 24.4 1, 029,176 73.3
    374,173 26.7 North Dakota 1,393,939 7. 2 73,931 73.4 26,745 26.6
    Ohio 15, 592,087 17.7 2, 129,053 77.1 632,731 22.9 Oklahoma 2,
    809,476 12.1 262,191 77.4 76,718 22.6 Oregon 3, 467,206 2. 9
    76,050 76.9 22,874 23.1 Pennsylvania 15,295,820 13.8 1, 097,780
    52.2 1, 005,789 47.8 Rhode Island 2,113,621 12.4 195,587 74.4
    67,243 25.6 South Carolina 1, 548,950 24.1 328,645 87.9 45,184
    12.1 South Dakota 1,260,880 7. 2 73,517 80.9 17,347 19.1 Tennessee
    3, 863,975 14.0 363,191 67.1 178,414 32.9 Texas 29,270,138 35.5 8,
    638,940 83.1 1, 761,302 16.9 Utah 1,551,866 17.3 236,563 88.2
    31,702 11.8 Vermont 603,018 5. 5 26,204 78.8 7, 068 21.2 Virginia
    3,454,394 15.5 299,591 56.0 235,466 44.0

    Washington 7,245,469 29.8 1, 278,506 59.3 877,655 40.7

    West Virginia 1,762,342 16.3 163,071 56.8 123,803 43.2 Wisconsin
    9,895,572 15.7 1, 048,376 67.4 507,816 32.6 Wyoming 879,581 16.0
    110,802 78.8 29,732 21.2

    (continued)

    Appendix II Nursing Home Complaint Investigation Expenditures

    Page 38 GAO/HEHS-99-80 Nursing Home Complaints

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

    Nursing home complaint expenditures

    Complaint expenditures

    per home Number of

    complaint visits per home

    Complaint expenditures

    per visit Number of

    complaint visits per 1,000 beds

    Complaint expenditures

    per bed National $58, 833, 689 $3, 397 2.4 $1,430 23.7 $34

    Alabama 1, 162,965 5,215 1. 4 3,716 12.7 47 Alaska 76, 061 5,071
    0. 8 6,338 16.7 106 Arizona 487,284 2,901 2. 0 1,463 19.4 28
    Arkansas 1, 074,865 3,894 2. 1 1,844 22.2 41 California 7, 205,614
    5,074 3. 7 1,353 41.7 56 Colorado 722,641 3,156 1. 9 1,684 22.3 38
    Connecticut 853,601 3,296 0. 9 3,632 7.4 27 Delaware 219,564 4,990
    0. 9 5,778 8.4 48 District of Columbia 88, 801 4,036 1. 5 2,691
    10.6 28 Florida 1, 150,057 1,542 1. 2 1,333 11.1 15 Georgia 1,
    037,837 2,859 2. 7 1,061 25.0 27 Hawaii 103,486 2,407 0. 8 2,957
    9.4 28 Idaho 204,919 2,440 1. 2 2,029 17.8 36 Illinois 4, 096,684
    4,655 3. 7 1,256 32.4 41 Indiana 1, 774,851 3,097 2. 6 1,203 27.0
    32 Iowa 768,308 1,645 1. 8 936 23.7 22 Kansas 1, 132,120 2,795 3.
    8 739 57.8 43 Kentucky 834,312 2,649 2. 5 1,057 32.5 34 Louisiana
    164,955 501 0. 6 805 5.7 5 Maine 444,357 3,392 2. 5 1,351 36.2 49

    Maryland 232,666 885 0. 7 1,199 6.5 8

    Massachusetts 928,801 1,647 1. 1 1,553 10.5 16

    Michigan 1, 204,179 2,694 2. 0 1,361 17.8 24

    Minnesota 752,759 1,680 0. 8 2,057 8.2 17 Mississippi 419,175
    2,065 1. 8 1,145 21.7 25 Missouri 2, 891,856 5,100 4. 4 1,159 49.3
    57 Montana 407,557 3,881 0. 8 4,739 11.4 54 Nebraska 518,323 2,160
    2. 3 953 31.2 30 Nevada 256,054 5,226 2. 1 2,510 23.4 59 New
    Hampshire 41, 799 504 1. 1 475 11.5 5 New Jersey 998,825 2,782 2.
    7 1,032 19.4 20

    (continued)

    Appendix II Nursing Home Complaint Investigation Expenditures

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

    State Nursing home

    complaint expenditures

    Complaint expenditures

    per home Number of

    complaint visits per home

    Complaint expenditures

    per visit Number of

    complaint visits per 1,000 beds

    Complaint expenditures

    per bed

    New Mexico 208,589 2,513 2. 5 993 29.4 29 New York 2, 916,890
    4,406 2. 2 1,978 12.5 25 North Carolina 1, 403,349 3,482 1. 7
    2,013 17.7 36 North Dakota 100,677 1,144 0. 4 3,248 4.4 14 Ohio 2,
    761,784 2,732 1. 5 1,802 16.2 29 Oklahoma 338,909 823 1. 1 762
    13.2 10 Oregon 98, 924 607 0. 2 3,805 1.9 7 Pennsylvania 2,
    103,569 2,626 0. 9 2,827 7.8 22 Rhode Island 262,830 2,602 2. 3
    1,143 22.5 26 South Carolina 373,829 2,124 1. 8 1,194 18.9 23
    South Dakota 90, 864 797 0. 4 1,893 6.0 11 Tennessee 541,605 1,517
    1. 5 1,028 13.5 14 Texas 10, 400, 242 8,006 4. 5 1,772 50.7 90
    Utah 268,265 2,885 1. 8 1,597 22.7 36 Vermont 33, 272 739 0. 5
    1,512 5.9 9 Virginia 535,057 1,891 0. 7 2,585 6.8 18

    Washington 2, 156,161 7,592 11.4 664 124.6 83

    West Virginia 286,874 1,938 0. 4 4,347 5.4 24 Wisconsin 1, 556,191
    3,662 2. 0 1,839 17.8 33 Wyoming 140,534 3,513 1. 3 2,703 16.5 45

    Page 40 GAO/HEHS-99-80 Nursing Home Complaints

    Appendix III

    Summary of Unassigned or Uninvestigated Complaints for the
    Baltimore, Detroit, and Seattle Metropolitan Areas Ap pe ndi x I I
    I

    Baltimore As of December 14, 1998, there were 101 complaints,
    received between January and November 1998, filed against 56
    nursing homes in the

    Baltimore metropolitan area that had not yet been assigned to an
    investigator and that also exceeded Maryland's investigation
    timeframes. 1

    The following table summarizes the complaints filed against 12 of
    these homes that received three or more such complaints.

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

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

    Priority Calendar days

    (workdays) since complaint was received a Summary of allegation(
    s) Maryland Home 1

    Next on- site 189 days (130 workdays) A nurse allowed a respite
    resident with Alzheimer's disease to leave the nursing home;
    family disputes nurse's belief that resident was aware of where
    she was going. Family requested that a physician examine resident;
    however, a nurse examined her instead. Family was also

    unaware that home ordered a psychiatric consultation resulting in
    medication being ordered, and disputes home's claim that family
    was notified. Family alleges that the resident's medical records
    were falsified. Next on- site 152 days (104

    workdays) Blind resident does not get needed assistance such as
    identifying food provided her, or help leaving room. Next on- site
    123 days (83

    workdays) Understaffing, with 64 residents and only 3 to 4 aides.
    Next on- site 120 days (81

    workdays) Understaffing, with 64 residents and only 3 to 4 aides.

    Maryland Home 2

    10 workdays 249 days (171 workdays) Nurse aide struck resident in
    the chest.

    Next on- site 230 days (158 workdays) Nursing home and complainant
    agreed on a time to discharge a 91- year- old resident with
    dementia. Home discharged the resident earlier, and the new
    nursing home was unprepared

    for resident's arrival. The family was not notified that resident
    was transferred early and arrived to help the resident move to
    find that resident had already been transferred.

    10 workdays 229 days (157 workdays) Visitor overheard a nurse aide
    verbally abusing a resident.

    10 workdays 125 days (85 workdays) Resident alleged that a nurse
    aide verbally abused her. Aide was suspended pending
    investigation.

    (continued)

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

    Page 41 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days

    (workdays) since complaint was received a Summary of allegation(
    s)

    Next on- site 96 days (65 workdays) No hot water for several weeks
    or months at a time, so resident was not bathed or cleaned
    properly. Inadequate supply of diapers, towels, washcloths,
    resulting in resident sitting in urine

    for extended periods of time. Lack of staff, resulting in resident
    not being adequately hydrated, fed, turned, or kept clean.
    Unskilled nursing assistants attended resident. Charting of intake
    and bowel movements was false. It was charted that resident had a
    bowel movement, but resident was severely impacted and needed
    immediate medical intervention. Scales and thermometers did not
    always function properly. Fluids were not routinely offered and
    time was not taken to make sure that the resident drank enough. If
    feeding took too long, the staff would not wait to ensure that the
    resident ate enough. Resident was admitted to the hospital 4 times
    in 10 years with dehydration and a urinary tract infection.

    Maryland Home 3

    Next on- site 147 days (101 workdays) Complainant visited resident
    on a Saturday and Sunday and found resident dirty with dried

    feces and no sheet on the bed. On Sunday, resident was wet. When
    complainant asked aide for a towel, wash cloth, and soap, she was
    given paper towels and told the home did not have any soap. The
    complainant asked the home's staff for a water pitcher and was
    told that the

    home does not use water pitchers, only cups in the utility closet.
    Complainant could not find a cup in the closet and the aide told
    her that none was available. Call lights unanswered on both days.

    Next on- site 137 days (93 workdays) Staff does not stay to ensure
    that resident takes medications. Resident in same clothes for 3

    days. Resident received no medications for 10 days; family not
    notified. 45 workdays 70 days (47

    workdays) Resident sent to emergency room with diagnosis of
    possible infection. Hospital staff found resident's intravenous
    line dirty and clogged because nursing home staff did not flush
    the line.

    Maryland Home 4

    Next on- site 236 days (162 workdays) Physical, verbal, and
    emotional abuse of a resident by nursing home staff and resident's
    physician who is part of the home's staff. 10 workdays 223 days
    (153

    workdays) Resident feeds self with a special spoon but is
    dependent in all other activities of daily living. On two shifts,
    aides refused to help the resident out of bed. Resident's supper
    tray was delivered but the resident was not provided any
    assistance to eat. Aide grabbed the resident's shoulder after the
    resident told the aide that her shoulder hurt. Pressure sores have
    worsened since admission to the home. 45 workdays 116 days (78

    workdays) Resident developed contractures because the home did not
    provide range- of- motion exercises as ordered.

    Next on- site 101 days (67 workdays) Management's treatment of
    employees is affecting care. Promised pay raise never came.

    Next on- site 97 days (66 workdays) Nursing home staff did not
    answer call lights. A resident with infection was not given an

    antibiotic as ordered. 10 workdays 67 days (44 workdays) Nursing
    home offered no explanation to family for resident's leg fracture,
    so the family moved

    resident to another home. Home told state survey agency that it
    would investigate; however, no indication as of December 1998 that
    agency had received the home's report.

    Maryland Home 5

    Next on- site 115 days (77 workdays) Understaffing: unit has 1
    nurse and 7 aides for 52 residents, including 2 with stage III and
    IV pressure sores, 13 with stomach feeding tubes, and 13 requiring
    injections. The nurse is unable to complete what she needs to do.

    (continued)

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

    Page 42 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days

    (workdays) since complaint was received a Summary of allegation(
    s)

    Next on- site 113 days (76 workdays) Understaffing: only 1 nurse
    on the 7 a. m. to 3 p. m. shift with 8 aides for 52 residents,
    including

    2 residents requiring treatment, others requiring injections, and
    13 stomach tube feedings. 10 workdays 47 days (31

    workdays) Resident alleged caregiver at the home bruised her right
    forearm and later threw the resident onto the bed. The hospital
    emergency room report indicated that the arm had soft tissue
    injury. Pictures of the resident show a badly bruised arm. 10
    workdays 35 days (23 workdays) Complainant not satisfied with the
    home's investigation of an incident report that a resident had
    fallen about 13 times in 4 months. The last fall resulted in
    laceration of the resident's forehead. Maryland Home 6

    Next on- site 245 days (169 workdays) Understaffing call lights
    not answered in a timely manner; residents not bathed as
    scheduled; and residents not turned and changed as needed. One
    aide for 15 residents requiring total care on 7 a. m. to 3 p. m.,
    and 3 p. m. to 11 p. m. shift.

    Next on- site 179 days (122 workdays) Discharge planning at home
    is not done appropriately, for example, a hospital- style bed was

    not ordered until resident's Friday discharge, so was not
    delivered until Monday. Residents not given choices of home health
    agencies or equipment companies. Residents' medical records do not
    indicate discharge planning. Discharge planning form usually is
    not completed and given to families to inform them of
    arrangements. Next on- site 167 days (114

    workdays) Family requested restraints for resident because of
    falls, but home refused. Next on- site 145 days (99 workdays)
    Understaffing. Resident lost 22 lbs. in 5 months. Resident's feet
    have sores and are bandaged, but not always changed as ordered.
    Sores are beginning to smell. Complainant found resident's face
    swollen, but staff was unable to explain what happened.

    Maryland Home 7

    Next on- site 287 days (199 workdays) Resident told therapist that
    an aide verbally abused her. Home was to investigate and report to
    the state survey agency. However, as of December 1998, the state
    did not have the home's investigative report. 10 workdays 270 days
    (186

    workdays) Aide smokes in the home and around residents. Same aide
    mishandled residents threw them into bed and used nasty language.
    Home was to investigate and report to the state; however, as of
    December 1998, there was no indication home had done an
    investigation.

    10 workdays 88 days (59 workdays) After contacting home about its
    investigation of physical abuse of a resident, ombudsman was

    uncomfortable with the home's inconsistent responses. Maryland
    Home 8

    10 workdays 182 days (125 workdays) Resident had discoloration of
    chest that family believed was bruise caused by physical abuse.
    Home to investigate and report to the state; but, as of December
    1998, there was no indication

    home had investigated. 45 workdays 103 days (69

    workdays) Understaffing, resulting in the dining room being closed
    for 2 days. During this time, there were only 3 aides for 70 to 80
    residents. 10 workdays 69 days (46 workdays) Complainant saw a
    nursing home employee shaking resident. Employee terminated by
    home.

    Maryland Home 9

    10 workdays 160 days (110 workdays) Hygiene inadequate-- resident
    was not bathed, teeth not cleaned, and hair not combed. Weight
    loss from April to June, was 134 lbs. to 120 lbs. Home said
    resident spit food out and

    that home had recommended a stomach tube. (continued)

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

    Page 43 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days

    (workdays) since complaint was received a Summary of allegation(
    s)

    Next on- site 157 days (107 workdays) Resident was not provided
    food from Monday night until Wednesday at 3: 00 p. m. Resident was
    sent to hospital after complainant insisted. At hospital, the
    resident was found to have infected

    sacral decubitus ulcer, was dehydrated, and had urinary tract
    infection. Nursing home staff said they had not sent resident to
    the hospital because resident was dying. 45 workdays 147 days (101
    workdays) New aide tried to transfer resident without another aide
    to assist, although the care plan called for two people for
    transfers. Aide said she could not get timely help, so attempted
    to do it by herself. Five days later, resident was found to have
    two fractured legs. Home wrote incident report, but did not
    interview new aide as required until ombudsman opened a case as a
    result of family's concern about home misrepresenting
    circumstances of resident's fall. Family called

    doctor, who ordered X- rays. It is unclear whether home also
    called doctor simultaneously, or earlier as home reported.
    Maryland Home 10

    45 workdays 181 days (124 workdays) Resident was blind,
    intelligent, and sociable. Complainant has found resident alone,
    begging

    for help, screaming  . . .help, where am I?, or please, someone
    get me a drink of water, or please take me to the bathroom." No
    one responded or reassured resident that she was not alone. On one
    occasion, resident was found still in bed at 3: 00 p. m. urine-
    soaked, hungry, and thirsty. She had no breakfast or lunch. Nurse
    said home was short of staff that day. 10 workdays 145 days (99

    workdays) Aide spoke to resident in a very poor manner-- told
    resident to shut up and if she kept ringing her call bell, she
    would be the last one to be answered. Administrator spoke with
    other staff who noted that the aide's attitude was poor toward
    residents and some staff had seen him in altercations with
    residents. They indicated that the aide appeared to be fired/
    wired up.

    10 workdays 119 days (81 workdays) Aide was verbally abusive to
    resident in presence of the family.

    45 workdays 68 days (45 workdays) When admitted to home from
    hospital in July, resident could bathe, walk, and feed self. After
    1

    month in home, these activities stopped. Family met with home's
    staff about three times on quality- of- care issues, but problems
    persisted. Resident readmitted to hospital three times in her 2-
    month stay-- a result of poor care at the home. Resident had
    series of falls. Home said no injuries resulted, but the resident
    suffers pain to the touch of bruised areas. As organ

    transplant recipient, needs sufficient fluids, but had not been
    getting, as evidenced by hospital diagnosis of dehydration.
    Hospital staff questioned whether resident had been receiving
    medications as prescribed. Staffing ratio at home was sometimes 1
    aide to 20 residents on evening shift, so family had to bathe
    resident and put to bed. Resident placed on a toileting program by
    the home, but family has found her with a saturated diaper on,
    indicating resident was not being toileted on a regular basis.
    Maryland Home 11

    10 workdays 243 days (167 workdays) Caregiver handled resident
    roughly causing her to suffer all night. The resident was in a

    rehabilitation unit receiving treatment for a fractured hip.
    Resident's roommate witnessed the incident.

    10 workdays 243 days (167 workdays) Aide was verbally abusive:
    called resident a witch and threatened to throw water on the floor
    and make her walk in it, hoping she would slip; said he would put
    her out of the unit because he was the boss on the floor; put a
    pillowcase over his head to try to disguise himself as resident's
    doctor; threatened to unplug another resident's call bell. Police
    were notified.

    Next on- site 231 days (159 workdays) Resident had two bruises on
    her arms. Ombudsman found no documentation of the bruises in
    records.

    (continued)

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

    Page 44 GAO/HEHS-99-80 Nursing Home Complaints

    a This column represents the number of days from the date the
    complaint was received to the day GAO visited the state agency.

    Priority Calendar days

    (workdays) since complaint was received a Summary of allegation(
    s)

    Maryland Home 12

    10 workdays 112 days (76 workdays) A resident diagnosed with
    schizophrenia alleged someone in the home was sexually abusing

    her. Complaint investigated by nursing home, but no formal report
    generated. 10 workdays 81 days (54

    workdays) Resident alleged an aide placed a pillow over the
    resident's face; resident removed pillow, and aide did it again.
    10 workdays 81 days (54 workdays) Resident said a nurse aide
    yanked the bed covers off and grabbed resident's hand real hard.
    Ombudsman noted resident's hand had a discolored area.

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

    Page 45 GAO/HEHS-99-80 Nursing Home Complaints

    Detroit As of January 11, 1999, there were 129 complaints,
    received between February and November 1998, filed against 62
    nursing homes in the Detroit

    metropolitan area that had not been investigated and that exceeded
    the state's 45-day investigation time frame. The following table
    summarizes the complaints filed against 17 of these homes that
    received three or more such complaints.

    Table III. 2: Uninvestigated Complaints for Nursing Homes in
    Detroit With Three or More Such Complaints Priority Calendar days
    since complaint was received a Summary of allegation( s) Michigan
    Home 1

    45 days 262 days The nursing home changed its billing formula
    resulting in a large increase in fees. 45 days 160 days The air
    conditioning does not work properly in one of the wings of the
    home. 45 days 144 days Questionable infection control practices.
    Two roommates died within days of each other of complications of
    infections. One roommate was admitted to the home with gangrene
    between two toes and an ulcer on her foot, but with no oozing or
    infection. Despite being diabetic, which required close monitoring
    of her feet, the home did not change the dressings as her
    physician ordered. The resident's foot began to ooze and became
    swollen. A culture was taken and the resident was moved to another
    room without explanation. Twenty- five days after being admitted
    to the nursing home, she was returned to the hospital where she
    died 6 days later. The resident's roommate, who entered the home
    11 days after the resident, was a diabetic with open wounds on

    her feet and legs when she was admitted. Twelve days after being
    admitted, the roommate had an elevated temperature. Despite her
    family's request to have her hospitalized, her doctor prescribed
    liquid Tylenol. That same day, she experienced breathing problems,
    was given antibiotics for an infection, and died. Michigan Home 2

    45 days 122 days Resident was not repositioned timely, developed
    pressure sores, and was neglected, resulting in dehydration
    requiring hospitalization. 45 days 111 days Resident's condition
    declined visibly in a short period of time resulting in her
    becoming lethargic, weak, and listless. The complainant suspected
    dehydration even though she was taken to the hospital and not
    treated for dehydration. Later that week, the home advised the
    complainant that the resident had perked up and that she would
    have dressings applied to her feet because of skin breakdowns.
    During a 4- hour visit 2 days later, the complainant contends that
    staff did not reposition the resident during this 4- hour period
    and that the dressings promised earlier had not been applied.
    (continued)

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

    Page 46 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days since complaint was received a Summary of
    allegation( s)

    45 days 73 days Complaint discussed treatment of several different
    residents over the past several years. One resident was dropped on
    the floor during the middle of the night, suffered knee damage,
    and was placed back in bed. She moaned with severe pain until the
    day shift nurse found her at 7: 00 a. m. She was sent to the
    hospital where her knee, although severely damaged, could only be
    bandaged. She died days later. A second resident received the
    wrong medication that burned

    her mouth, throat, and lower regions causing discomfort for many
    weeks. She was later dropped while being weighed. A third resident
    entered the home with no visible skin problems but developed
    bedsores that led to the amputation of a limb.

    45 days 54 days Resident's feeding tube was running and vomit was
    evident in her mouth and on her hands and face. She was found
    lying in a urine- soaked sheet, and a pressure sore was also urine
    soaked. She also had skin tears, but no wound care was performed.
    On the day she was admitted, she received no insulin as scheduled.
    The staff reportedly said that there was no insulin in the nursing
    home at that time.

    Michigan Home 3

    45 days 139 days The home failed to assess a resident's injury in
    a timely manner. The resident fell at 12: 30 p. m. suffering a
    broken left hip, but was not transferred to the hospital until the
    next day. 45 days 67 days A resident sustained a fracture of
    unknown origin to the right hip. Neglect is alleged. 45 days 63
    days A resident sustained a fracture of her wrist while taking a
    shower without supervision. Michigan Home 4

    45 days 195 days Family member found a portable X- ray company
    taking X- rays of resident without an explanation. The floor nurse
    said the resident's knee was swelling. X- rays revealed a fracture
    in the knee. Family questions if resident was properly restrained.
    The hospital physician felt the resident was either dropped or
    fell down. The home staff stated they thought the resident might
    have bumped the side rail. The family also felt the resident was
    not receiving required assistance with eating. 45 days 119 days
    During lunchtime an employee of the nursing home slapped a
    resident who needs assistance with eating. 45 days 96 days A
    resident was not adequately groomed (soiled clothing), did not
    receive services ordered by a

    physician, was harmfully neglected, and suffered a preventable
    injury. Michigan Home 5

    45 days 293 days Resident fell sometime during the evening or the
    early morning of the next day. The facility put her back in bed
    without ordering X- rays, even though she complained of pain in
    her leg. X- rays were not taken for 3 days and then were taken
    only upon the family's insistence. The resident was transferred to
    the hospital where it was determined that she had a shattered hip.
    45 days 255 days A resident fell from her bed and suffered
    injuries including a skin tear on her hand and an abrasion on her
    left temple. X- rays also revealed a fracture to her left hip. 45
    days 140 days Complainant alleged a series of problems with the
    care provided to her father: he had no access to water despite
    being diabetic and was often very thirsty; he frequently slipped
    down in his cardiac chair but was not offered a wheelchair because
    the home did not have one that would fit him; the home failed to
    provide an assessment of the resident's breast for breast cancer;
    his

    oxygen machine was broken but complainant suspects that the home
    nevertheless bills Medicare for oxygen; resident was advised that
    his family should come and help to feed him; the resident's
    belongings were missing and he was wearing the clothes of other
    residents; complainant was told by staff that the laundry in the
    home is done infrequently. (continued)

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

    Page 47 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days (workdays) since

    complaint was received a Summary of allegation( s)

    45 days 111 days During a 16- month period, the resident who is
    unable to turn in bed, speak, or move her right side suffered
    pneumonia, numerous bruises, cracked ribs, a broken hip, a broken
    shoulder, and a broken leg. Michigan Home 6

    45 days 252 days A resident was brought into the hospital and was
    not breathing, was severely dehydrated, and had acute rib
    fractures and pneumonia. 45 days 251 days A resident signed
    himself out of the home and did not return. 45 days 241 days The
    resident had an untreated pressure sore. The complainant indicated
    that the staff intentionally

    hid the resident's condition from her for possibly up to one year.
    Michigan Home 7

    45 days 292 days Resident ran a temperature of 100+ degrees for
    three days without the home contacting the family. The resident
    died from bronchial pneumonia and a closed- head injury. 45 days
    115 days Nursing staff failed to provide the resident with a
    breakfast tray. When the resident asked the

    nursing assistant for the tray, the nursing assistant responded
    because of your attitude, no one wants to give it to you. Do it
    yourself.

    45 days 105 days The home schedules only one aide per floor on the
    midnight shift. The home reuses the feeding tube bags between the
    residents. One resident was found to have maggots in the sores on
    his feet, but the home would not send him to the hospital because
    it was afraid the hospital would call the state. The Director of
    Nursing specifically told the staff that the resident was not to
    go anywhere because the state would be called in to investigate
    and we do not need that right now. Michigan Home 8

    45 days 116 days Resident sustained an injury (fracture of the
    femur) of unknown origin. 45 days 116 days Resident sustained an
    injury (femoral neck fracture) of unknown origin. 45 days 116 days
    Resident had a hematoma over her left eye, with bruising, as well
    as a black left eye. The cause of the injuries is unknown. 45 days
    103 days Resident sustained a fracture (left ankle and lower leg)
    of unknown origin. Michigan Home 9

    45 days 181 days Home was understaffed; a resident was found
    sitting in the dining room with wet pants; resident found in a
    gown with no underwear; resident's clothing missing; resident not
    helped to bathroom in a timely manner; no therapeutic activities
    for residents; meals are inadequate; a dog is allowed to roam
    through the nursing home; offensive odors in the home; resident
    has been injured as a result of falls. 45 days 165 days The
    resident was not allowed to take a leave of absence from the home;
    her privacy was not protected; she had a difficult time getting
    her personal expense money from the administration. 45 days 95
    days The resident fell out of a chair and was sent to the hospital
    where she received six stitches in the

    back of her head. This was the fourth time she had fallen. One of
    the falls resulted in permanent loss of vision in her right eye.
    The family also alleges that they have been denied access to her
    clinical records. (continued)

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

    Page 48 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days (workdays) since

    complaint was received a Summary of allegation( s) Michigan Home
    10

    45 days 320 days When resident returned to the home following
    amputation of part of his leg, the home did not take necessary
    precautions to ensure that the leg did not become infected. It
    became infected and more of the leg had to be subsequently
    amputated. He was also handled roughly, overmedicated, and his
    feeding tube was not kept clean. 45 days 320 days Although the
    resident could not get out of bed without assistance, the home
    informed the family that he had to be taken to the hospital
    emergency room because he had gotten out of bed and

    fallen. When the family saw him, his arm was completely black and
    blue. He was also constantly overmedicated. 45 days 292 days The
    resident was in the home for three months recovering from a
    stroke. Complainant alleges that the resident was left in soiled
    clothing for hours and was prescribed a mixture of medication that
    caused internal bleeding that led to a blood transfusion. The
    nursing home advised the resident on numerous occasions that
    insurance would cover all her costs and convinced her to remain in
    the home for the entire period of Medicare coverage. After leaving
    the home, she received a bill for $7, 000, which a credit agency
    is attempting to collect from her son. 45 days 292 days The
    resident was not properly groomed; food was observed in the
    heaters; staff did not answer call bells; staff harassed the
    resident and his family if they complained about care. 45 days 292
    days Resident developed pressure sores on both feet and had to
    have part of one leg amputated due to improper care of the sores.
    45 days 291 days The home was short of staff and was falsifying
    the books. 45 days 273 days Staff would not respond to the
    resident's buzzer; resident was often found sitting in urine and

    feces; a week before he died, he complained of an upset stomach
    and was vomiting, but staff told the family there was a virus
    going around and there was nothing to worry about; family was not
    informed of a change in his condition. 45 days 273 days Resident
    was not washed or shaved; his teeth were not brushed and his
    fingernails were dirty; call lights went unanswered. 45 days 189
    days The certified nursing assistants were not qualified to care
    for residents; staff failed to follow the

    care plan that requires two people to move this resident; the
    resident was left alone in the bathroom, fell down, struck her
    head, and suffered cracked ribs and various cuts and bruises. 45
    days 180 days Several residents fell out of bed one evening
    because the side rails were not put up; food was

    served cold and there was no staff person to help residents eat;
    the home was very short staffed and on several nights the
    complainant was the only nonresident adult in the wing; the
    resident's roommate was choking but no one responded when the
    complainant pulled the call light; during a shift change, all the
    nursing staff was gathered around the nursing station calling in
    lotto tickets. (continued)

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

    Page 49 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days since complaint was received a Summary of
    allegation( s)

    45 days 178 days A resident made the following allegations: her
    telephone was taken away; she did not receive adequate whirlpool
    baths ordered by her doctor; she did not receive two baths weekly;
    her food was cold and unpalatable; she was not allowed to attend
    the church of her choice; her discharge planning was inadequate.
    45 days 174 days The resident had injuries (bruises and swelling)
    of unknown origin. The home provided conflicting

    reports as to what may have happened. 45 days 172 days The food
    was not palatable; the home was short staffed; physical therapy
    provided was very limited; money was stolen from the night stand;
    beds did not raise up and down and the mattresses were very thin.
    45 days 168 days The resident had bed sores on his heels; he was
    refused readmission to the home following a hospital stay; he was
    not properly groomed (bathed and shaved); dirty bed linens were
    not changed; he was not turned; physicians did not visit residents
    but instead took the word of the nurses concerning residents'
    condition; resident was not timely transferred to the hospital for
    treatment, resulting in his death. 45 days 129 days A nurse
    verbally abused the resident. 45 days 76 days Staff failed to
    assess and monitor a resident who was later sent to the hospital
    for treatment of a

    seizure; they did not take proper precautions for pressure sores;
    they did not treat the resident with dignity and respect because
    they forced him to wear diapers. Michigan Home 11

    45 days 178 days The home did not check the blood sugar level of a
    diabetic resident for three days following his admission. On the
    third day he received two units of insulin when he should have
    received 100 units. When brought to the attention of the nurse,
    she said they were not supposed to check his blood sugar. The
    resident's wife insisted that the doctor be called, and it was
    determined that the resident's blood sugar was more than six times
    the normal amount. On the physician's order, the home gave him
    potassium pills to normalize his sugar level, but his heart rate
    went so high that he was taken to the hospital, where he died. 45
    days 96 days Nursing home staff would not permit the resident to
    leave the home to visit with his family. 45 days 55 days Resident
    fell out of bed and suffered a cut on her head. Staff bandaged the
    cut but because she

    had no other marks on her body and could move her arms and legs,
    X- rays were not taken. Three days later she was taken to the
    emergency room with elevated heart rate, blood pressure, and sugar
    level. The doctor in the emergency room ordered an X- ray after
    noticing that she cried and reached for her hip when he tried to
    turn her. The X- ray confirmed a hip fracture, necessitating hip
    surgery. The complaint also alleges that the resident previously
    had experienced dehydration and a urinary tract infection, had two
    hearing aids and her dentures lost in the home, and was discovered
    wearing another resident's dentures, which resulted in a sore
    mouth and an inability to eat. Michigan Home 12

    45 days 245 days A resident walked out of the home and was found a
    block away by a passerby. He had fallen and suffered a swollen
    eye, a bruised hand, and a knee abrasion. 45 days 217 days An
    employee was verbally abusive to a resident.

    45 days 137 days A resident developed a cut on his foot that
    became infected. It was left unchecked and spread into the bone.
    The heel had to be amputated. (continued)

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

    Page 50 GAO/HEHS-99-80 Nursing Home Complaints

    Priority Calendar days since complaint was received a Summary of
    allegation( s)

    45 days 82 days The resident had a condition that, if vomiting
    takes place, dictates that the resident should be taken
    immediately to the emergency room. Although the resident was
    suffering spells of vomiting, the nursing home failed to send her
    to the hospital until she was found unconscious. Following
    surgery, she improved, but died about a month later. Although
    peritonitis was listed as the cause of death, a doctor at the
    hospital told family members that if she hadn't been so dehydrated
    and malnourished, she would have been better able to fight off the
    infection. Michigan Home 13

    45 days 102 days An employee slapped a resident. 45 days 81 days
    The resident had bruises on her chin, her stomach, and her arms
    and legs; the home did not notify family when resident was hurt or
    sick; she suffered a head injury of unknown origin; the family had

    to request that she be hospitalized after she was ill for several
    weeks; she was so over- medicated that the doctor was unable to
    perform needed gall bladder surgery; she suffered a stroke but was
    not sent to the hospital until the family observed the problem and
    insisted on hospitalization. 45 days 55 days The home failed to
    provide proper dental care. The dental progress notes were
    inconsistent and of dubious accuracy. Despite the home's assurance
    to the complainant that its dentist was capable of providing care,
    the resident had to visit an oral surgeon to resolve the problem
    that had lasted for 15 months. Michigan Home 14

    45 days 145 days The resident was found on the floor bleeding from
    an injury to her head that required 17 stitches. In addition to
    the head injury, the resident had bruises on her face by her mouth
    and under her ear and her eyes were black and blue. The
    complainant feels she did not get a satisfactory answer from the
    home about the reason for the injury. 45 days 115 days This
    complaint included 28 separate allegations about the care provided
    to 17 residents. The

    allegations include: the administrator would not order needed
    equipment (such as recliners and geri- chairs) which forced the
    residents to stay in their beds; 90 percent of the home's beds are
    old and faulty (big gaps in the side rails); a resident got her
    head caught in the side rails, was sent to the hospital, and later
    died; side rail pads are not put on the beds; the nurses are not
    passing the

    medications; the administrator told staff to call EMS (the
    community emergency medical service) instead of 911 when a
    resident was nonresponsive, possibly to save money; one resident
    was gritting her teeth in the dining room and the director of
    nurses shoved her and her chair out of the dining room because she
    couldn't stand the sound; a resident was sent to the hospital due
    to malnutrition and dehydration and died two weeks later; a
    resident who entered the home with both legs is now a bilateral
    amputee because he developed pressure sores when staff failed to
    turn and reposition him or provide heel protection or foot
    elevation; a resident frequently complained of leg pains but his
    complaints were not addressed. It was later determined that he had
    deep vein thrombosis; a resident was frequently sleeping but no
    assessment or lab tests were performed to determine the problem;
    residents are restrained for convenience; as a result of
    understaffing, residents are not cleaned, changed, or provided
    oral care; a resident was admitted with no pressure sores, but
    developed sores on her heels and legs, became septic, and died; a
    resident with very bad teeth and gums has received no dental care;
    residents complain that their food trays

    are removed before they are finished eating. (continued)

    *** End of document. ***