(iStockPhoto)
by Charles Ornstein and Lena Groeger
In February 2011, a nursing home resident in Michigan wandered away in a blizzard, unnoticed by staff. He was wearing only pajama pants, a sweater, canvas shoes and a knit cap. A technician driving to work found him half an hour later at a busy intersection, wet and covered with snow, government inspectors wrote.
Five months later, a resident at a different Michigan nursing home climbed out of a secured window in the home’s locked dementia ward, hitchhiked a ride and was picked up by police hours later in a restaurant some 65 miles away. Nursing home staff did not even realize he was missing, inspectors found.
Were these incidents, known as “elopement,” isolated? Or do they suggest a pattern? Until recently, no one could really say how often such incidents occur.
Now, ProPublica has an app for that.
Drawing on government reports posted online last month, today we are launching Nursing Home Inspect — a tool that allows anyone to easily search and analyze the details of recent nursing home inspections, most completed since January 2011. As of today, that includes nearly 118,000 deficiencies cited against 14,565 homes, but we will add more each month as new reports become available.
Users can search across all the reports by any keyword, such as elope — a feature the federal government’s official nursing home website doesn’t have. The results can then be sorted by both the severity of the violation and by state.
Although more elderly people are choosing to live at home or in assisted-living facilities, about 1.5 million people still live in nursing homes, according to the 2010 Census. Of those, more than 1.2 million were 65 and older.
For decades, federal auditors have flagged dangerous and neglectful conditions in U.S. nursing homes and faulted the government’s oversight. As the examples above suggest, the problems haven’t gone away.
Arguing that awareness is an answer, advocates for nursing home residents have long pressed oversight agencies to make inspection reports readily available to the public. But until last month, consumers, researchers and journalists had to file formal Freedom of Information Act requests to view them — or visit in person, because homes are required by law to make them available.
Having the reports searchable online will help identify problematic trends and encourage homes to make needed fixes faster, advocates say.
“It presents a tremendous opportunity to examine the scope of serious nursing home problems such as understaffing and misuse of antipsychotic drugs, and to see what, if anything, is being done about them,” said Michael Connors, an advocate with California Advocates for Nursing Home Reform.
Nursing home industry officials agree that inspection reports are valuable for consumers, but they say the reports leave out important information.
“One of our concerns is that it doesn’t acknowledge the things that the facilities are doing well,” said Lyn Bentley, senior director of regulatory services at the American Health Care Association, the industry trade group.
How Many Elopements?
Nursing homes are inspected on both a regular schedule and when there is a complaint. Inspectors typically work for state agencies paid by Medicare. If they find problems, known as deficiencies, they rank them on a scale of A to L, the most severe. The vast majority are either labeled D or E.
One regularly cited deficiency involves unsafe wandering, a well-known problem that can result from inadequate supervision. A report this year in the journal Annals of Long Term Care, citing earlier research, said up to 31 percent of nursing home residents with dementia wander at least once.
Nursing Home Inspect turned up hundreds of such cases.
A search for elope and variations returned 949 inspection reports that mention the term. Michigan had the most of any state — 84. (Users note: A hit on the word “elope” doesn’t always mean a resident wandered off, only that the word is included in a report. See our tips for interpreting search results.)
Hillcrest Nursing and Rehabilitation Community in North Muskegon, Mich., where the resident wandered away during a blizzard last year, was cited for deficiencies on three other occasions from May to October 2011.
Gary Vandenberg, a spokesman for the home’s parent company, Atrium Centers, said inspectors found no problems at Hillcrest during a follow-up review in November 2011. The chain provides elopement training at all its facilities, he said.
Jon Look, administrator of the Michigan home where the resident with dementia climbed out a window, said alarms have been added to every window and every door. No resident has wandered off since, said Look, who started in his role this June at the Iosco County Medical Care Facility in Tawas City, Mich.
“We’re charged with protecting our residents, and that is something we take very seriously certainly at this nursing facility,” Look said. At the same time, he said Michigan inspectors identify more problems at homes and levy higher fines than in other states — a contention federal statistics support.
Queries for other terms also returned hundreds of results.
A search for injuries produced 7,912 results. MRSA, a drug-resistant staph infection, yielded 514 entries. The word ignore is found 275 times, and entrapment, which can happen if a resident gets stuck in bed rails, brought 194 matches. (Again, not all the search results indicate a problem. See our tip sheet.)
States Aren’t All the Same
Nursing home industry officials caution against drawing conclusions from what’s in inspection reports. Echoing Look, they say that inspectors in different regions of the country have different thresholds for issuing a citation, and that could unfairly make one state’s homes appear worse than another’s.
“If an individual walks out the front door and turns around and walks back in, some states will consider that an elopement,” said Bentley, of the industry group. “In other states, it’s not considered to be elopement unless somebody leaves the building, leaves the grounds and there’s a negative outcome.”
To be sure, audits have found variation in how inspectors handle nursing home complaints. A report last year by the Government Accountability Office found that nationwide, of the nearly 50,000 complaints investigated in 2009, 19 percent were substantiated and resulted in at least one citation.
In 19 states, though, more than 30 percent of complaints resulted in at least one deficiency. And in five states, the proportion was less than 10 percent.
Advocates for residents say nursing homes should focus on fixing their own problems instead of pointing fingers at others. “It’s not a defense for facilities to say that other facilities have not been cited for this,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy in Washington, D.C.
If anything, Edelman said, auditors have found that inspectors cite too few problems and rate their severity too low.
Nursing Home Inspect allows users to more easily compare how one state’s K-rated deficiency, for example, stacks up against another’s.
Worries About Antipsychotics
For years, regulators, consumer advocates and officials in the nursing home industry have tried to keep an eye on problems by analyzing data about the number and types of violations found and their severity.
Federal officials have used such scope and severity data as part of campaigns to reduce the use of physical restraints and to encourage homes to cut back on antipsychotic drugs, said Thomas Hamilton, director of survey and certification at the Centers for Medicare and Medicaid Services (CMS).
Of particular concern is the use of antipsychotics to subdue residents with dementia, because the drugs can increase the risk of death in such patients.
But this data is nowhere near as detailed as the inspection report narratives, which were first released last month by CMS. Until recently, even internally, Medicare officials haven’t been able to search the text of all inspection reports to look for patterns, Hamilton said.
Advocacy groups are eager to dig into the reports.
Inspectors “don’t do a perfect job,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York. “They don’t do a consistent job. [But] they’re the only independent authority coming into nursing homes looking at this.”
Despite the value of these reports, CMS has not posted narratives from historical inspections. Only the most recent periodic survey report is online, along with complaint investigations from the past 12 months. As time goes on, CMS plans to have three years’ worth of reports for every home.
For privacy reasons, the reports released by Medicare do not include residents’ names and have been redacted to hide medications, diagnoses, room numbers and certain dates.
In many cases, CMS has also obscured residents’ gender, referring to everyone as female — even in cases in which gender may make a difference, such as sexual assault. Officials said they intend to change this in the near future and list the correct gender in the reports.
Advocates are pushing the government to redact less information from the reports so they can look at problems with specific medications.
“It’s really crucial for the public, and it’s really crucial for us, the people who do policy work,” Mollot said. “How are you going to know anything if the name of the drug is redacted?”
CMS’ Hamilton defended the current approach but said the agency will continue to review the information and work with advocates.
“As we make more information publicly available in searchable databases,” he said in a statement, “we must be careful to prevent various pieces of information from being combined in a way that would violate the privacy or confidentiality of those residents.”
