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. ***