Serious gaps in the quality of care of nursing home patients are missed or minimized by state inspectors, according to a May Government Accountability Office report.
Among findings, the report found that state inspectors had missed at least one condition that endangered patients, including malnutrition, overuse of medications, abuse, and severe bedsores, in 15 percent of inspections across the US between 2002 and 2007. In nine states — Alabama, Arizona, Missouri, New Mexico, Oklahoma, South Carolina, South Dakota, Tennessee, and Wyoming — state inspectors had missed at least one serious problem in 25 percent of the inspections. In 2007 alone, one in five of US nursing homes were cited for serious deficiencies.
In response, the authors of the report recommend, among other corrective strategies, that the Centers for Medicare and Medicaid Services (CMS), which sets federal standards for nursing homes and covers more than two-thirds of its residents, improve the training of its inspectors and require regional CMS offices to investigate and track problems when they occur.
Moreover, Iowa Senator Charles E. Grassley (Republican), a member of the Senate Committee on Finance, and Wisconsin Senator Herb Kohl (Democrat), chairman of the Senate Special Committee on Aging, who requested the report, have introduced a bill that raises fines for violations of federal standards: Serious deficiencies, currently $10,000, would be increased to $25,000, and the penalty for lapses in care that resulted in the deaths of patients would be $100,000.
Several geriatricians and neurologists, who were not involved with the report, commented that fines will not deter gaps in nursing care as long as the facilities suffer from low funding and poorly trained personnel.
“Increased fines and inspections won't help unless you give nursing homes the tools they need to make changes,” said David J. Casarett, MD, assistant professor of geriatric medicine at the University of Pennsylvania School of Medicine and a staff physician with the Center for Health Equity Research and Promotion at the Philadelphia Veterans Affairs Medical Center.
Kenneth M. Heilman, MD, director of the University of Florida Cognitive and Memory Disorder Clinics and professor of neurology and clinical psychology, suggested that each nursing home should have a board of governors, comprised of relatives of patients in that particular nursing home and medical professionals who are not employed by the nursing home (such as a physician, nurse, and occupational or physical therapist). This board should be responsible for developing an inspection plan using guidelines developed by the state or federal government, he said, and should involve inspections for weight loss, bed sores, and serious conditions that could result in patient harm.
“For example, medications such as haloperidol and benzodiazepines are frequently overly used so that patients at nursing homes remain almost in a vegetative state and thus place little demands on the personnel,” Dr. Heilman said. “Any family member, friend, or caregiver should be able to place a complaint to this board,” resulting in an investigation. On a regular basis, the board would report its activities to government agencies that regulate nursing homes.
It should be a priority for nursing homes to develop programs for rehabilitation for patients with disabilities, said Dr. Heilman. He added that even if disabilities cannot be reversed, nursing homes should teach patients alternative strategies to deal with their conditions while limiting pain and promoting comfort.
Dr. Casarett remarked that neurologists who care for nursing home residents should develop relationships with staff at the nursing homes they use and get to know their strengths and weaknesses. “Ideally, they should work with a few nursing homes to help them improve the quality of patient care,” he said. With a growing aging population and correspondingly high numbers of people living with dementia and other chronic neurologic conditions, the state of nursing home care should be a concern of neurologists, he added.