GAO Finds Smoke, Stirs Fire Over State’s Nursing Homes

The halls reek of urine. Old people lie helpless in their beds hour after hour, soiled diapers unchanged.

These were the smells and sights at a nursing home in Huntington Beach visited by federal government investigators last year as part of an intensive nine-month probe that is likely to touch off the biggest national nursing home controversy in years.

After reviewing inspection reports from all 1,370 California nursing homes, the General Accounting Office came to the conclusion that nearly one in three of the facilities is plagued by “serious or potentially life-threatening problems” for the residents.

Malnutrition, dehydration, urinary tract infections and bedsores that become gaping infected wounds are among the ailments suffered by residents of nursing homes. Most of them are impoverished, elderly patients--typically women over the age of 80--who are too ill mentally or physically to care for themselves.

“We’re not talking high-tech treatments here, we’re talking about basic care you would give your dog,” said one investigator.

The searing details in the GAO report--derided by many in the nursing home industry as political scapegoating--will be discussed Monday as the Senate Special Committee on Aging opens hearings on the enforcement of federal rules that mandate high-quality care in nursing homes. A copy of the report was obtained by The Times.

The Clinton administration claimed last week that only 1% of the nation’s nursing homes were “poor performers,” with serious health and safety flaws threatening their patients. The White House vowed to improve enforcement.

California Seen as Care Bellwether

But one committee staffer, reviewing the GAO report, said that if California, which has a reputation as a tough enforcement state, has such widespread problems, then “it is hard to believe that things are better elsewhere.”

California was picked for the GAO probe because of allegations, delivered last year to the Senate Aging Committee chairman, Sen. Charles E. Grassley (R-Iowa), that patients were dying of neglect. Astonished by the GAO finding that a third of the state’s nursing homes have serious violations, Grassley is now thinking about expanding the probe into a nationwide inquiry.

“The GAO report is shocking,” said Grassley. “Enforcement is lax: Neglect a nursing home resident, get a slap on the hand. That’s our system.”

But in the meantime, the nursing home industry challenged the GAO report, arguing that it is geared toward cheap headlines instead of systemic problems. “We have very serious reservations about the accuracy, the completeness and the methodology used in the [GAO] analysis,” said Gary Macomber, executive vice president of the California Assn. of Health Facilities, which represents about 1,500 long-term care facilities.

GAO Accused of Inflating Problems

Macomber, responding to a draft of the GAO report, said GAO researchers had grossly inflated estimates of homes with serious problems, creating “new categories” of danger such as brooms leaning against the wall and failing to thoroughly review medical records. “It was a pretty poorly done piece of work,” he said.

The federal government, which spent $32 billion in 1995 in Medicare and Medicaid payments to help pay bills of people in nursing homes, is supposed to ensure patients’ proper care and treatment. But despite additional millions of dollars funneled to states to pay for nursing home inspections, the federal enforcement system may simply be failing in its basic mission to “protect residents against harm and neglect,” said the committee’s ranking Democrat, Sen. John B. Breaux (D-La).

The Senate hearings are likely to kick off a national debate about the nursing home industry and the families who depend on it.

Critics wonder: If the nursing homes have difficulty providing clean and effective care now, when they have 1.6 million residents in 17,000 homes nationwide, what happens when the baby boomers flood the facilities? The nursing home population nationwide is expected to explode to 4 million residents by the year 2030, as masses of boomers, slowed by physical and mental ailments, will need nursing care.

Also at issue is the accuracy of states in reporting violations--and the responsiveness of the federal government in addressing them.

Charlene Harrington, a researcher at UC San Francisco who studies nursing homes and will testify this week, found in a study that California inspectors are tougher on nursing homes than their counterparts elsewhere. In 1996, for example, California gave a perfect score to just 4% of nursing homes, while New York reported that nearly a third of its nursing homes were flawless during inspections.

Washington provides most of the money, and California’s Department of Health Services hires the inspectors who investigate nursing homes. The 400 inspectors in the state must follow a federal rule book. But the final enforcement responsibility--to levy fines or refuse to admit new patients or take away government funding--is up to the federal government.

And the GAO found that when the state inspectors found problems, the “federal government “generally took a lenient stance toward many of these homes.” And the agency was careful to note that “although our report focuses on nursing homes in California, the problems we identified are indicative of systemic survey and enforcement weaknesses.”

Grassley called for the GAO investigation last fall after a Palo Alto lawyer claimed nearly 22,000 nursing home patients in California may have died from preventable conditions such as malnutrition and infections between 1986 and 1993. Attorney Von Packard and his colleagues, who specialize in class-action and government fraud lawsuits, based their findings on a review of data from 300,000 death certificates.

Lack of Autopsy Data Hinders Investigators

Without autopsy information about residents who had died, the GAO said, “we cannot be conclusive” about whether “unacceptable care may have contributed directly to individual deaths.” Some Alzheimer’s disease patients, for instance, lose ability to swallow, making it difficult to fault a nursing home for a death certificate finding of malnutrition.

The GAO report is based in part on independent inspections of two nursing homes, observation of a state inspection at a third home and review of inspection and medical reports from 15 other facilities. The GAO hired Dr. Andrew Kramer’s team of the University of Colorado Center on Aging to conduct the two on-site inspections in California, accompanying state inspectors on visits.

At one facility, California state inspectors “missed numerous major quality-of-care problems, very severe problems--pressure sores, nutrition,” Kramer said. He refused to name the nursing home, but state officials identified it as Huntington Valley Nursing Center in Huntington Beach.

According to the state inspection report, Huntington’s problems were relatively minor--a failure to issue a discharge notice for a patient, a slightly elevated rate of medication errors, a failure to store food properly.

In a prepared statement Friday, SunRise Healthcare Corp., which owns Huntington Valley and is a subsidiary of Sun Health Care Group, said that they “are committed to providing the highest quality care” and “work diligently to ensure compliance with all state and federal regulations.” The facility is preparing a plan to correct problems identified by state inspectors.

Brenda Klutz, the deputy director of licensing and certification for the state Department of Health Services, said her agency was appalled that the GAO did not share its concerns about Huntington Valley until June. In response, she said, state officials revisited and, like the GAO, found serious problems. Huntington had undergone “a rapid and marked decline in the last couple of months,” she said.

Kramer’s group also joined state inspectors at the Westgate Convalescent Center in San Jose. The California inspectors found some deficiencies in patient care, including a failure to respect patient privacy and dignity, but Kramer said they still missed other serious care deficiencies. Responding to the state inspection, Westgate disputed the report’s findings.

Current System Hasn’t Worked

The current system, in which homes are given so much leeway in responding to serious problems, “absolutely” hasn’t worked, said Klutz.

“We are just locked into this system,” Klutz said. The offending homes “throw consultants at it for a couple of months, get the problems to a lower level of severity, then they know we are not coming in again unless we get a complaint or it’s time for the next [annual] survey.

“We are really frustrated that we have roller-coaster facilities” whose performance repeatedly goes up and down, she said.

Explaining why the state so seldom takes action against nursing homes, Klutz said her agency is merely following “the federal process.” When a facility is substantially out of compliance with federal regulations but the situation is not an emergency, state officials are required to allow the home 30 to 90 days to correct it.

In Orange County, a Times review of inspection reports, lawsuits, medical records and death certificates from 1996 and 1997 found that nursing homes here that repeatedly broke the rules usually drew light punishments.

For example, 18 Orange County homes were cited for poor care last year. Half were threatened with a loss of Medicare funds but only three homes actually had their funding cut off.

Regulators also noted 12 questionable deaths. Only one resulted in the maximum $25,000 fine. Officials said the others did not warrant a large fine or they did not have the resources to investigate whether patient care was a factor.

California on July 1 began trying something new, Klutz said, targeting its enforcement efforts on the two most serious nursing home offenders in each of 13 districts.

‘Why Try to Tarnish the Industry?’

Paul Willging, executive vice president of the American Health Care Assn., a national trade group, also took exception to the GAO study. “I think the GAO was trying to find a bigger number, to look for a big story,” he said. “Why try to tarnish the industry?” The government should concentrate its inspection and enforcement resources on the “bad guys,” he said.

“Target the bad homes and shut them down,” agreed Sheldon Goldberg, head of the American Assn. of Homes and Services for the Aging, which represents nonprofit facilities. “We know who they are and they know who they are.”

Patricia McGinnis, head of the watchdog group California Advocates for Nursing Home Reform, said politicians have been too eager to please the nursing home industry. The result, she said, is that aggressive federal legislation passed in 1987, intended to boost nursing home quality, has been “watered down” by subsequent federal policies, and enforcement has been underfunded.

In California, McGinnis said, state regulators have been largely hamstrung. “I think Brenda [Klutz] is sincerely trying to do a good job,” she said. “On my worst day i wouldn’t want to be a nursing home surveyor. You are damned if you do and damned if you don’t.”

Rosenblatt reported from Washington and Marquis from Los Angeles.