By Saul Friedman-Newsday
Politicians and other soothsayers tell us how as a nation we honor and care for the oldest generation, our parents and grandparents, many of whom are ill or frail and need some comfort, security and dignity in their last years.
If that is true, why is it that the residents of more than 4,000 of the nation's 16,000 nursing homes risk getting bedsores that can sicken, disable and kill, or find themselves in restraints when they have to go to the bathroom because there's not enough staff to look after them?
Here's one reason: Contrary to popular belief, many, if not most, for-profit nursing homes are potential moneymakers. And the smaller the underpaid and non-skilled staff is, the more money can be made. But although much of the money paid to nursing homes -- hundreds of millions of dollars -- comes from Medicaid and Medicare, the government often has no idea where and to whom these proceeds go.
These are among the conclusions of nursing home experts, and advocates and lawyers for residents, who have analyzed the latest data, completed in November, by the Centers for Medicare and Medicaid Services (CMS) but fully released just recently under pressure from Congress.
Entitled the "National List: Nursing Homes Targeted for High-Risk Pressure Ulcer [bedsores] and/or Physical Restraint Improvement," it names some 4,000 nursing homes that were found deficient last year in these two important categories of care.
The prevalence of bedsores and the use of restraints are indicators of neglect and insufficient staff.
Last month CMS followed up with names of 131 "Special Focus Facilities" (SFF), which CMS described as "nursing homes that have failed to improve significantly after being given the opportunity to do so." CMS added, "once a facility is an SFF, state survey agencies are responsible" for following up with frequent inspections until the facility shows improvement. If it doesn't, it could lose its accreditation.
The list of 4,000 homes targeted for improvement because of bedsores and restraints included more than 140 facilities in New York State. But only one New York home, in upstate Niskayuna, was included among the SFFs that were added to the list and have not shown improvement. Families may search lists at http://www.cms.hhs.gov/Quality ImprovementOrgs/Downloads/ NursingHomeChart.pdf and http://www.cms.hhs.gov/ CertificationandComplianc/Downloads/SFFList.pdf
More than 95 percent of U.S. nursing homes participate in Medicare and/or Medicaid, and in 2001, in response to widespread complaints about the conditions in many homes, CMS reported to Congress 91 percent of the facilities did not have sufficient staff to prevent harm to residents and 97 percent failed to comply with the Nursing Home Reform Law. The report, by a consulting firm, established the connection between good patient care and adequate, well-paid staffing.
"Strong evidence supports the relationship between increases in nurse staffing ratios and avoidance of critical quality-of-care problems," the report concluded. "A strong relationship was found between nursing assistant retention and whether facilities were" among the worst in providing quality care. It suggested modest increases in the salaries of registered nurses and overworked nurses' aides usually paid less than minimum wage.
A 2007 study, by the University of California at San Francisco, of nursing home staffing from 2000 through 2006 found that the average number of registered nurses in facilities had declined by 8 percent as the number of lower paid, less trained nursing assistants had increased and that deficiencies doubled in the 105 homes studied.
The study found that nearly 40 percent of all nursing homes had sanitary problems, and a third had quality-of-care problems. And the number of patients who were confined to their beds or chairs increased in relation to low staffing, an indication of poor quality care. Law professor Charlene Harrington, who ran the study, told members of Congress that under current law, nursing facilities and their owners need not account to Medicare and Medicaid for how they spend the money they are paid.
If the failure to hire sufficient and adequately trained staff is a matter of money, Toby Edelman, an attorney for the Center for Medicare Advocacy, a nonpartisan group, points out that nursing homes owned by Manor Care Inc. based in Toledo, the nation's largest nursing homes chain, were among the facilities cited as deficient by the CMS.
In December, Manor Care was acquired by the Washington-based private equity firm, Carlyle Group, for $6.3 billion.
According to Bloomberg News, it was the seventh buyout of a nursing home chain in 2007 and the eighteenth in four years. Advocates for patients and unions representing nursing assistants opposed the sale of Manor Care, predicting staffing would be further cut. Their fears were understandable, for The New York Times last September reported that as investment companies have acquired nursing homes, "they have often reduced costs, increased profits, and quickly resold facilities for significant gains" leaving residents "worse off."
Edelman said Manor Care's former chief executive, Paul Ormond, got as much as $186 million when his company was sold. "Using federal wage guidelines for nursing home workers," she wrote, "we calculated that Manor Care's 278 nursing homes could hire an additional 5,346 certified nurse aides or an additional 2,198 registered nurses [with that money]. Like all nursing home chains, most of Manor Care's revenues come from ... Medicare and Medicaid. How should our public dollars be spent? On one man's windfall, or certified nursing assistants and registered nurses in nursing homes?"