Violations in patient care at Medicare-approved nursing homes in Arizona continue rising with half involving serious incidents that endanger immediate patient care, data analyzed by Arizona Sonora News reveals.
Arizona is 37th in the nation for serious violations and ranks eight nationally in overall care, according to one non-profit organization’s analysis of the data.
The data cover approximately three years of state inspections of 147 mostly private facilities that rely on state and federal reimbursement to pay for care.
A problem is the nature of the data collected by the state. For example, the state requires a facility to report number of staffers but it doesn’t specify direct caregivers, so it cannot be determined how many patients any one caregiver serves.
Patients have been severely burned and some have escaped. Others have been given wrong or unnecessary medication, left alone with neglected bed sores and covered in their own waste. Lawyers and experts in the industry say it points to a future problem in nursing home care that will become more acute as the nation’s rapidly aging population moves to long-term care.
“People are getting away with far too much and … laws and penalties have to be tightened up,” said Brian Lee, executive director of Families for Better Care, a nonprofit group that advocates for better nursing home care nationwide. “Everyone should be held accountable to the highest standard when they are given the responsibility to take care of our loved ones.”
A challenge for many facilities is acquiring direct caregivers, primarily certified nursing assistants. Some lawyers and nursing home advocates question whether the 120-hour mandatory training is enough. To become licensed to cut hair in Arizona takes 1,600 hours of training.
Experts say caregivers are not trained for complex needs of patients. Many are overscheduled and registered nurses and licensed practical nurses are not always available to assist.
State law requires facilities to report cases of elder abuse, but the decision to report ultimately rests with administrators of the home. Very few cases are reported.
There are approximately 16,000 federally certified nursing home beds in the state of Arizona, according to recent data from the Centers for Medicare & Medicaid Services. Of those just more than 11,000 are occupied.
Although about 30 percent of beds in Arizona are free now, many more beds will be needed in the future to meet the needs of aging Baby Boomers. By 2050 the population of 65 and older will double, according to a recent report from the U.S. Census Bureau.
This raises questions about whether nursing homes will be able to meet the demands of the future elderly population.
“Many of the multi facility corporations that run long-term care facilities see the aging population as a boon to their business and they are expanding nationwide to meet the needs of older people,” said Joel Bunis, bureau chief of long term care licensing at the Arizona Department of Health Services.
But that doesn’t necessarily address quality of care issues in nursing homes.
“It really comes down to the care plan and what’s in the care plan,” Lee said. Additionally, Lee says that the Baby Boomers will have different demands and place new strains on nursing homes.
“They’re going to complain. I think it’s going to be different for nursing home managers and owners when they see Baby Boomers come in because I don’t think they’re going to stand
for or tolerate some of the crummy care that our nursing homes have put out for so long,” he said.
Arizona experienced a jump in severe violations in 2013. About half of the homes had one or more severe violations in the last three years according to the CMS data.
Although overall violations are up and severe violations have been relatively constant, Arizona is among the states with the most improved nursing home quality, according to Families for Better Care.
According to its analysis of the CMS data, Nursing Home Report Card, Arizona jumped 13 spots since 2013 and now ranks eighth in the nation for overall quality of nursing home care.
Although statistically Arizona’s overall care improved, it doesn’t necessarily mean that care became better, according to Lee who believes the reason is that quality care declined rapidly in other states.
Despite the improvement in Arizona’s overall ranking, the state ranks 37th in the nation in severe health deficiencies at nursing homes, according to Families for Better Care’s analysis of the CMS data.
Severe health deficiencies occur when a nursing home resident suffers physical harm, or when the potential for such harm to is immediate.
“Facilities are actually very good about disciplining their own personnel because the first thing they have to do is investigate it themselves and report to us what their investigation is,” said Bunis. “If it’s a big enough mistake we have to go out and revisit and if we find a similar thing that’s a huge problem for the facility and that’s why they tend to clean up whatever the problem was because they don’t want to get cited for it a second time.”
How Arizona’s Nursing Home Inspections Work
The Arizona Department of Health Services’ long-term care-licensing department conducts regular unannounced inspections of the homes, which occur every 12 to 16 months. Although the inspections are unannounced, administrators are aware of their window for inspections — once a facility hits the 12-month mark, they know an inspection will happen within a four month time period.
According to Bunis, the inspections are thorough. “I think if somebody wants to hide something, they might be able to but it would be very difficult,” he said. “They would have to go back and change medical records and it would involve fraud.”
Inspectors observe daily activities, review nursing home records, and may interview and staff, residents and family members if they wish, he added.
The scope and severity of deficiencies is defined by a national system used by all state inspection agencies. Surveyors judge the level of harm to residents and the scope of the problem.
*There were 125 level G violations and 193 F level violations at nursing homes in Arizona over the last three inspection cycles.
The DHS investigates complaints against facilities. The number of self-reported incidents is small. In the last year, the agency received more than 800 complaints, Bunis said, primarily from family members and Adult Protective Services.
According to the analysis of CMS data by Arizona Sonora News, during the last three inspection cycles facilities self-reported only 17 complaints versus 715 other complaints from residents, residents’ families and Adult Protective Services.
The state is unable to substantiate most of the complaints because residents frequently die or move to other facilities and many of the complaints cannot be verified because of the “he said” “she said” nature of the claims, Bunis added.
“Surveyors are overwhelmed and can’t do a robust and full investigation,” said H. Michael Wright, an attorney who handles nursing home and elder abuse cases in Arizona. “The reality is the DHS does not have adequate resources to fully survey and monitor quality of care in nursing homes.”
Another issue with the CMS data is that it provides only a snapshot of how facilities have done recently and does not contain what Arizona attorney Gabriel Kory says is important information. For example, it doesn’t indicate whether a facility has been sued in the past, said Kory, who handles cases of nursing home abuse and neglect.
When cases involving nursing homes settle, the state Attorney General requires confidentiality and will not release settlement amounts. “If a case gets settled the public’s never going to know about it,” Kory added.
Staffing Issues at Nursing Homes
Although the CMS data shows overall nurse staffing levels, it doesn’t show how much direct care individual residents receive or how many staff are present at any particular time. Nursing homes report their own staffing data to the CMS, and only include staffing levels for the two-week time period before an inspection. CMS does not have a way to fully verify the staffing data reported by nursing homes. Kory says understaffing is one possible reason violations at nursing homes in Arizona are rising.
Another factor might be that Medicaid reimbursements fell due to the recession, according to Jennifer Carusetta, chief legislative liaison at Arizona Health Care Cost Containment System.
Nursing homes are funded through Medicare and Medicaid, through private insurance, and through private pay. When Medicaid cuts nursing home reimbursements, administrators have to make changes to their facilities accordingly, which can potentially impact staffing levels.
However the executive director at the Haven of Douglas nursing home, Leilani Eichman, says she makes cuts to ancillary departments, such as housekeeping and dietary departments first.
“You can do some trimming everywhere else but our care is always the last thing that gets cut.”
According to ASNS analysis of the CMS data, Haven of Douglas, LLC is one of the most understaffed nursing homes in the state. Those staffing levels will show improvement when the CMS data are updated, Eichaman said.
Finding and keeping skilled RNs is no easy task, she added. “A lot of times what you’ll find is an LPN will get their RN and then they want to go into hospital work or a specialty … they don’t want to stay in long term care as an RN.”
Rather than staffing issues, Eichman says she believes apathy and poor management on upper levels are the reason violations happen.
“There’s a lot of people that just don’t care,” Eichman said. “They’re in it for the job and it takes a very highly qualified specialized person to do this type of job.”
Bunis attributes violations to human beings making mistakes. When he investigates citations or complaints he looks to see if the incident is widespread within the facility or if it is an isolated incident. Most are isolated, he said.
Certified Nursing Assistants
Another reason for violations, according to Kory, is that staff members are not trained adequately.
“You’ve got folks that are hired to provide care in places like this for patients that have an acuity level – acuity level means level of sickness – that is way too high for their level of training,” Kory said. “So you end up with people who really have no business providing care for folks that are as sick as they are, and people end up getting hurt or killed.”
“I’m seeing more and more cases where very sick people aren’t being provided care by nurses, they’re being provided care by caregivers and as a result they uniformly are less trained, less educated, less knowledgeable and the result is they provide much poorer care,” Kory said.
Most fundamental care – bathing, cleaning, feeding and turning — comes from certified nursing assistant under the supervision and direction of nursing staff.
Becoming a certified nursing assistant in the state of Arizona requires only 120 hours of training, as opposed to 1,600 hours to acquire a cosmetology license.
In addition to the lack of training, certified nursing assistants don’t earn much. In Arizona, CNAs make about $25,000 a year, offering little incentive to draw in and retain career-oriented people.
At Desert Highlands Care Center in Kingman, Administrator Vickie Phillips is troubled by the lack of training, yet faces the challenge of finding certified assistants who complete the current educational regimen. She says she supports more training.
“I think not only would it help our elderly but it would also give respect to that profession.”
The lack of respect for the profession can have dire consequences, attorney H. Michael Wright said.
“If you don’t have enough CNAs or they’re not adequately trained or if they’re not adequately motivated, then patients fall through the cracks,” he said. “You have accident injuries, pressure ulcers, malnutrition, dehydration, infections — things like that that can arise in patients that are vulnerable.”
When staffing increases complaints filed against nursing homes declines, according to Lee, who said an extra 20 minutes of direct care for patients could prevent someone from being injured.
Lee believes the reason Arizona ranks highly among other states but also has many violations is that there might be a misrepresentation of data from the nursing homes.
“The Center for Public Integrity came out with an analysis that showed 80 percent of the nursing homes over-inflate their registered nurse hours for nursing homes,” Lee said. “So you have operators that are not being honest about how many staff are actually working in their buildings.”
Fines: What Can Be Done?
In order to improve care in nursing homes, Lee said each state should have a strict staffing standard that can be enforced by state inspectors. He also recommends steeper fines. Federal fines top out at $3,000 per day for non-immediate jeopardy and up to $10,000 for immediate jeopardy. The maximum state fine is $500 per instance. The fines are not enough for these companies to correct their mistakes, Lee added.
However, “the intent of the fines is to be punitive and not necessarily a deterrent,” Bunis said in an email. Steep fines might actually hurt the residents more because facilities might not have the ability to pay bigger fines and continue to operate, he said.
Additionally, many families consult the Five-Star Quality Rating System when choosing a nursing facility.
“The deterrent is not in the fines, but rather in the 5-star rating each facility receives … the lowering of the quality rating has more effect on a facility than does a monetary fine,” Bunis said.
Lee joins the call for more primary caregiver training. “What was a good standard 20 years ago just isn’t fit for today,” Lee said.
People these days are living longer and diseases are much more complex, he said.
“You really have to have a heart to work for the elderly, you have to have that passion and that want to be able to provide a service for them,” Phillips said. “I tell people if you don’t want to do this kind of work then it’s easy to go somewhere else and work in a restaurant.”
Eakin and Alawadhi are reporters for Arizona Sonora News, a service provided by the School of Journalism at the University of Arizona.