Nursing Homes Are Criticized

More than three-quarters of California nursing homes fail to meet federal standards, and more than four in 10 homes violate a state law mandating minimum nurse-staffing levels, according to a comprehensive review of the state’s nursing-home quality.

The 32-month study by the nonpartisan California HealthCare Foundation also found tremendous instability in the work force: Nearly eight in 10 nursing staff members left their jobs from 2000 to 2001.

At the same time, the foundation has launched a Web site that provides detailed information on all 1,406 nursing homes in the state. The site, www.calnhs.org, compares their performance on specific measures (such as nursing staff turnover) by assigning stars, with one star representing the worst homes and three the best.

Taken together, the study and the Web site represent the most ambitious effort in California to measure the quality of nursing homes and to spur improvement. Before now, information on such homes was limited, scattered and sometimes left families choosing haphazardly.

“I was surprised that things weren’t better than they were,” said lead researcher Charlene Harrington of UC San Francisco’s School of Nursing. “We just found a lot of quality problems in the nursing homes. It’s really pretty depressing.”

The foundation review arrives amid a broad push for greater accountability from nursing homes, which house more than 100,000 Californians and generate $5.6 billion in revenue each year.

State Atty. Gen. Bill Lockyer has sought to penalize problem homes, filing 131 criminal complaints in the past fiscal year.

“The quality of care in many of our state’s nursing home facilities is reaching a level of crisis,” said Collin Wong, director of the Bureau of Medi-Cal Fraud and Elder Abuse within the attorney general’s office.

“The same corporate culture and ethics that led to Enron, Worldcom and Arthur Andersen’s demise is no less present in the corporations that own and operate our nursing homes.”

On Tuesday, hours after the foundation released its report, state health officials announced their own three-step program to improve nursing-home care. The plan involves expansion of a statewide consumer assistance center, increased monitoring of nursing homes and higher financial penalties for violations.

Next month, the U.S. Centers for Medicare & Medicaid Services will launch a nationwide quality initiative, paying for full-page newspaper ads to publicize how the largest nursing homes in each region score on such measures as controlling patient pain and preventing bedsores.

“If you fly into L.A., you can find the best hotel to stay in or the best hamburger joint, but you can’t find the best nursing home,” said Tom Scully, the agency’s administrator. “It’s irrational to me that there’s no consumer information” on nursing homes.

Another part of the campaign by Scully’s agency is to pay regional consultants to help nursing homes improve, he said.

Industry officials said the foundation’s report and Web site are useful overall. But they said it’s unfair to view a home as problematic just because it doesn’t comply with every federal standard. A home can be cited for a serious deficiency if a tissue is left on the floor or if the water temperature is off by 2 degrees.

“I don’t think the public would define ‘serious deficiencies’ the way inspectors do,” said Betsy Hite, public affairs director of the California Assn. of Health Facilities. “I’m not sure we’re really giving the consumer an actual idea of the quality of care in a home.”

Hite also took issue with the foundation’s conclusion that about 44% of homes are in violation of the state’s minimum nursing staff standards, which call for residents to receive at least 3.2 hours of attention per day on average. Because of a severe nursing shortage, it took some homes extra time to comply with the regulation, which took effect in January 2000 and wasn’t enforced until April of that year.

Industry officials say the best way to judge a home is by visiting it, talking with the administrator and taking a tour.

But Gwen McDonough, 62, said there is only so much one can tell from a visit. Her family visited Canoga Care Center in Canoga Park before moving her late husband, Joseph, there in 1998. The nurses looked sharp. There was no foul odor. She checked her husband in.

“They tell you to look for a place where the nurses seem professional and nice and the hallways don’t smell of urine,” she said.

Joseph McDonough soon developed severe sores and an infection because his bed was too small for his 6-foot 2 frame, the family’s lawyer said. The back of his ankles rubbed against the particle board at the foot of the bed, causing wounds that went to the bone--an injury that required a long hospitalization.

After McDonough died of pneumonia at home, the family sued the center, alleging that it provided poor care, and settled for $1 million.

The home’s lawyer said it settled to avoid the expense and risk of a trial. “The law is stacked against nursing homes,” said downtown attorney Vincent D’Angelo, who represented the nursing home. “The risk is so great of a really sensitive jury, and a runaway jury verdict for the patient is sometimes certain. It makes settlement almost mandatory.”

According to the California HealthCare Foundation’s new Web site, inspectors found 22 federal deficiencies at Canoga Park during 2001-02, some deemed “serious” and one “very serious.”

That’s worse than the state average of 14. They also recorded 12 state citations but levied no financial penalties.

The authors of the foundation report culled statistics from nine public databases, including inspections and financial reports.

The foundation found that nonprofit homes devoted more staff attention to each patient and had far fewer deficiencies than for-profit competitors. In addition, hospital-based nursing facilities performed better than free-standing ones.

The foundation also found that better staffing generally meant better care.

Nursing homes that reported 4.1 hours of care per resident per day provided significantly better services, including feeding assistance, helping residents out of bed and incontinence care.

Inspectors at 30 randomly selected homes found that residents did not receive as much care as their charts indicated; staff members overreported the number of times they turned patients to prevent bedsores, helped them eat and helped them use the bathroom.

“Because of staffing limitations, nursing aides chart that things happen more consistently than they actually do,” said John Schnelle, a UCLA medical school professor who worked on the project.

In fact, Schnelle said he wouldn’t put a relative in a California nursing home, if he could avoid it. “I think it’s really problematic,” he said.

The foundation’s effort, though the most thorough so far, has limitations, some experts say. The Web site, for example, doesn’t measure quality of life and satisfaction.

“We have a long history of experimenting with various kinds of report cards in the health business, and the history is very dismal,” said Dr. Robert Kane, a University of Minnesota School of Public Health professor of long-term care and aging. “I don’t think that simply raising people’s anxieties about the quality of care is the same thing as improving it.”

The Web site also lacks some publicly available information. It does not include convictions or prosecutions against nursing homes, nor does it allow consumers to request the top-performing nursing homes in each category.

And it does not include details of each deficiency, instead using the generic and sometimes bureaucratic language.

For instance, Orchard Gables Convalescent Hospital in Hollywood is listed with no deficiencies or citations by state health inspectors. But the home’s former owner last year pleaded guilty to embezzling money from a resident, and she was sentenced to electronic monitoring and ordered to pay a fine. The nursing home has since changed hands.

“This is really a work in progress,” said Ann Monroe of the foundation’s quality initiative, which she directs. “What we’re trying to do is give people more information than they had before on making such an important decision.”

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Facts and Resources

The California HealthCare Foundation released a comprehensive study Tuesday of the state’s 1,406 nursing homes. Among the findings:

* About 44% of the nursing homes in California did not meet the state’s minimum nurse-staffing standards in 2000-01. The standards call for each resident to receive 3.2 hours of nurse attention per day.

* Nursing homes had an average nursing staff turnover rate of 78%.

* Only 23% of nursing homes were in full or substantial compliance with federal regulations governing their operations. An additional 62% had serious deficiencies, 12% very serious deficiencies, and 3% gave “substandard care.”

* Nonprofit homes had higher staffing levels and fewer deficiencies than their for-profit counterparts. Hospital-based nursing facilities similarly performed better than free-standing homes.

Resources for nursing home residents and families:

California HealthCare Foundation nursing home search: www.calnhs.org.

Long-Term Care Ombudsman Program: (800) 510-2020 or www.aging.ca.gov.

California Advocates for Nursing Home Reform: (800) 474-1116 or www.canhr.org.

Medicare program: (800) 633-4227 or www.medicare .gov.