We wanted to share American Association for Justice’s comments to Center for Medicare Services (CMS), on the potential review of 42 CFR 483 Subpart B.   If the Agency is going to change  regulations affecting the quality of health care in nursing homes, they should be focusing on patient safety and increased accountability through such things as eliminating arbitration clauses and eliminating over medication problems better know as chemical restraints.


A California appeals court has reinstated a lawsuit claiming the owner of Covenant Care (which owns and operates 16 Alameda County nursing homes) fails to meet California nurse-staffing standards.   A group of patients filed suit claiming Covenant Care nursing homes had violated the statutory staffing standards at least 35 percent of the time over a four-year period.

A Superior Court judge had ruled with Covenant Care lawyers that only state regulators had the authority to enforce a requirement that skilled nursing homes provide 3.2 hours of care per day to each patient.  However, patients can sue nursing home operators for failing to meet the California standards.  Lack of adequate staffing causes less quality of care and increases the risk of health care violations.  The vast majority of nursing homes do not meet minimum adequate staffing levels.

See articles at the Insurance Journal and Mercury News.

The News-Messenger had a good article on how new regulations in Ohio will require nursing homes to show that they’re providing quality and comfortable care for their residents or risk losing  funding.  Future funding for nursing homes could be tied to whether they reduce the number of times their residents go to the hospital, for instance, or increase the number of bathrooms that are wheelchair accessible.

For now, effective July 1, nursing homes must meet any five out of 20 standards or risk losing nearly 10 percent — $16 per patient per day — of their full Medicaid payments for services they provide.  Some of the standards are based on staffing levels, facilities and resident satisfaction.

A new report has been completed by nursing home expert Charlene Harrington and her colleagues at the University of California, San Francisco, showing trends in U.S. nursing homes by state for 2005 through 2010. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S. Centers for Medicare and Medicaid Services.

The average nursing home received almost 10 deficiencies for poor quality of care and almost one-fourth of nursing homes had deficiencies that caused actual harm or jeopardy to residents. Moreover, continued wide variations in staffing, residents, quality of care and deficiencies were found across states. 

. The highlights of the new report for all US nursing homes show that:

Facility Characteristics
• In calendar year 2010, 15,622 nursing homes with 1.66 million beds were surveyed by state agencies.

• Of the 1.4 million residents in nursing homes, 63.4 percent had their care paid by Medicaid, 22.2 percent had care paid directly out of pocket or by private payers, and 14.4 percent of residents were paid by Medicare in 2010.

• The number of for-profit nursing homes increased from 66 percent of all homes in 2005 to 67.6 percent in 2010, while the number of non-profit nursing homes and public homes declined slightly. Nursing home chains were 54.7 percent of the total homes in 2010, showing a 4 percent increase over 2005.

Quality of Care
• Across the country, about 146,000 deficiencies were issued to nursing homes for violations of federal regulations in 2010, indicating many quality problems in the nation’s nursing homes.

• In 2010, 23 percent of the nation’s nursing facilities received deficiencies for poor quality of care that caused actual harm or jeopardy to residents.  

• In 2010, 43 percent of nursing homes failed to provide adequate infection control and 43 percent failed to ensure a safe environment for residents to prevent accidents. Violations of food sanitation regulations were found in 39 percent of nursing homes and 34 percent received deficiencies for failure to meet quality standards.

• In 2010, 30 percent of nursing homes received deficiencies for failure to meet professional standards, 28 percent for failure to provide comprehensive care plans, 23 percent for giving unnecessary drugs, 21 percent for poor clinical records, 20 percent for failing to ensure resident dignity, 20 percent for poor housekeeping, and 19 for failure to prevent pressure sores.

The average number of registered nurse (RNs) hours per resident day increased by 18 percent between 2007 and 2010 (from 0.6 to 0.7 hours). The number of licensed practical nurses (LPNs/LVNs) increased by 14 percent and total nurse staffing increased by 5 percent between 2005 and 2010. The increase in staffing may be attributable to the rating of nurse staffing on the government’s Medicare Nursing Home Compare system introduced in 2008.

Studies have shown facilities with more RN staffing have higher quality of care on average. The average staffing levels are below the level recommended by experts which is 0.75 RN hours per resident day and 4.1 total hours of nurse staffing per resident day.

Resident Characteristics
• Although the present of residents reported with pressure sores declined by 13 percent from 2005 to 2010, about 90,000 residents (6.5 percent) have pressure sores. Most pressure sores can be prevented with adequate nursing care.


Press of Atlantic City wrote an article discussing the dismal record of New Jersey nursing homes. Seven New Jersey nursing homes received the lowest quality ratings from the federal government last year based partly on state inspections in 2009 and 2010. Inspection reports show that residents in the worst-rated homes live in dirty conditions, endure verbal and physical abuse, and are neglected.

Hundreds of violations of rules that govern quality of care, safety and sanitation were found by inspectors during the past two years at the 60 nursing homes in Atlantic, Cape May, Cumberland and Ocean counties. The reports are used by the U.S. Department of Health and Human Services to develop consumer ratings of one to five stars for nursing homes. The majority of area facilities – 65 percent – are rated three stars or lower, federal data show, and half are in the bottom two levels.

A review of more than 1,800 pages of New Jersey Department of Health and Senior Services inspection reports from 2009 through April 2011 for 10 nursing homes showed that residents are routinely found living in dirty conditions, endure verbal and physical abuse, and are subject to neglect. Other violations include staff giving out the wrong medications, residents being strapped into wheelchairs and ignored for hours, theft, untreated infections, falls resulting from fragile residents being left unattended, and fire- and building-code violations.

State reports provide details of problems found during inspections. Some residents live in fear of reprisal if they complain about conditions.

A recurring theme was a failure to investigate or report incidents of abuse. Another recurring problem was failure to properly administer medication.  The medication error rate is not supposed to exceed 5 percent. A November inspection found an 18 percent error rate at South Jersey Extended Care. Our Lady’s Residence had a 14 percent error rate. Lincoln Specialty Care was at 9 percent, and Arcadia was at 8 percent. In one case at South Jersey Extended Care, a resident was supposed to get morphine every three hours for rectal pain, but went days without it because there was none.

A nurse and an aide allegedly told a resident who wanted help getting out of bed frequently overnight that she could not get up before 4 a.m. The inspection report states the staffers threatened to take away her wheelchair, withheld snacks and threatened to keep her in bed longer if she complained. The report states the resident shook in fear in the presence of the nurse and aide.

There are 367 nursing homes in New Jersey charging an average of $250 per patient per day, said Paul Langevin of the Health Care Association of New Jersey, a trade group of 185 homes.  Most homes are for-profit businesses run by companies that have multiple facilities. Costs of more than $90,000 per patient per year are often paid through Medicare and Medicaid, so tax dollars pay much of the bill.

Knoxville News Sentinel reported the decision by Tennessee Department of Health to suspend new admissions to Colonial Hills after a complaint investigation found violations that put residents in "immediate jeopardy."   The 203-bed Colonial Hills cannot admit new residents until the violations are corrected and has to post a copy of the order of suspension at its public entrance, "where it can be plainly seen."

The most serious violations were discovered in April and May when at least four patients taking the blood thinner Coumadin (warfarin) were also given antibiotics that cause serious side effects when given with Coumadin. One resident was hospitalized with a "massive gastrointestinal bleed" as a result of an antibiotic given for a urinary tract infection interacting with Coumadin, the survey said. Because nurses didn’t know to watch for interactions, the report said, they "failed to identify and act upon" the bleed.

Investigators said nurses who dispense medication should have been trained to tell on-call physicians that a patient is on Coumadin. They cited Colonial Hills for failing to train the nurses about drug interactions with Coumadin.  Colonial Hills was also cited for nurses’ failure to properly monitor blood thinner levels in some residents. Investigators also found that four of 13 residents interviewed could not reach their water, and five of the 13 could not reach the call button to summon nursing help.

Colonial Hills is owned by Life Care Centers of America in Cleveland, Tenn. The company operates numerous nursing homes nationwide. Life Care facilities in Athens, Tenn., and Chattanooga also had admissions suspended in the last two years. The suspensions were lifted after problems were corrected.


Tulsa World and NewsOK had articles about the former nurse who has come forward to expose the abuse and neglect at Woodland View Care and Rehabilitation in Tulsa, Oklahoma.  The company cut corners on patient care – even running out of feeding tube formula for one patient – and that the company should cease operating in Oklahoma.  State inspectors cited Woodland View for more than 40 violations over the past year, including six that placed residents’ lives in immediate jeopardy, records show.  Violations included failure to protect residents from abuse, failure to provide pain medications and other treatments as ordered, failure to adequately treat bed sores, failure to provide sufficient staffing and failure to provide supervision to prevent accidents.

"They cut corners every chance they get … It’s ridiculous for a billion-dollar, nationwide company," said Latricia Hamblin, a licensed practical nurse who worked for seven years at the facilty. The nursing home’s publicly traded parent company, Sun Healthcare Group Inc., operates more than 200 facilities nationwide and reported nearly $2 billion in revenue last year.

Woodland refuses to acknowledge errors and accept responsibility.  Instead, they filed a lawsuit and allege that the inspectors inserted documents into a patient’s file, essentially accusing a state employee of trying to frame the nursing home.

Hamblin now works at another nursing home and left Woodland View after she became concerned she was jeopardizing her nursing license by staying. She said the facility was so short of staff that she was not able to get medicine distributed to patients within the required time frame.  Woodland View once ran out of feeding tube formula for a patient, and administrators didn’t place an order for the correct formula for several days.  The report also states that "pain medicines run out and (are) not being re-ordered so residents aren’t getting meds for pain days at a time … Residents stated the nursing staff was good but were overworked, overwhelmed and did three people’s jobs and did not get breaks."

Sun Healthcare Group has a history of problem including pleading no contest in California to a felony elder abuse charge when two residents died and six became ill at one of its homes during a heat wave. In 2005, California fined Sun $2.5 million after the state said the company violated a court order requiring it to improve quality of care at its homes.


Here is a great editorial from the Louisville Courier Journal about the need for nursing home reform and lobbyists’ influence.

The real priorities of the General Assembly are on shocking display in the battle over a nursing home reform bill. The measure, House Bill 157, which is intended to set minimum standards for staffing, is similar to laws that exist in 37 states.


But the reform bill’s co-sponsor told The Courier-Journal’s Laura Ungar that its chances seem dim this session.

Meanwhile, over the past decade the nursing homes’ trade group has showered a quarter of a million dollars on Frankfort lawmakers, some of whom are persuaded — surprise — that the reform is unnecessary.

The claim of trade group president Ruby Jo Cummins Lubarsky would be laughable, if it were not so sad. The nursing home bill, she says, is not needed because, “Numbers don’t equate to quality. Staffing is very important in a facility, and there is no incentive for a facility to not meet the needs of its residents.”

Ask anyone who has had a friend or relative in a nursing home whether the issue of staffing isn’t a major one. Even in the best-run homes, it’s not uncommon for aides to be surly, dilatory or lack basic communication skills. And residents, many of whom suffer deep depression, dementia and other conditions, are often incapable of being heard when they complain. The powerful stench of feces and urine often greet the visitor at the door. Residents may lie or sit for hours in wet diapers or on fouled sheets — simply because there is not enough help, or because it’s not responsive enough.

Many nursing homes benefit handsomely from Medicare and Medicaid tax dollars. Many are for-profit operations that cut back on staff to pump up the bottom line. Federal regulations are considered inadequate by knowledgeable observers and by all but 13 states.

The elderly in Kentucky deserve better than that. And the legislators holding the bill back should have them on their consciences.