Why do neglect and abuse persist in some of America’s nursing homes?

The story is an old one and never seems to change – the shame of America’s nursing homes.

After Hurricane Irma hit Florida in early September, nursing homes once again were in the news for delivering questionable care. This time, Florida and national media reported that 12 residents, some as old as 99, died at the Rehabilitation Center at Hollywood Hills because the facility lost power, a portable cooling system malfunctioned, and those who died succumbed to the intense heat. The response in Florida was swift – the kind of reaction I’ve seen repeated over the decades whenever serious lapses in care have resulted in horrific deaths for the most helpless and vulnerable Americans.

Florida Sen. Bill Nelson labeled the deaths “‘an inexcusable tragedy’ and called on authorities to get to the bottom of it.” The Hollywood Police Department and the health care and elder protection service administrators began investigations. The state Agency for Health Care Administration froze new admissions. The mayor of Miami-Dade "said he would pursue local legislation requiring generators strong enough to operate air conditioners at government-subsidized senior housing if state lawmakers don’t act.” He added that the process of evacuating elderly sick residents “is too daunting” after a severe hurricane hits. “It’s much easier to provide logistics for refueling generators than it is to provide care for tens of thousands of people,” he explained.  Duh!   

Gov. Rick Scott weighed in, too. He called on emergency workers to check all nursing homes and assisted living facilities and ordered an investigation into what he called an “unfathomable” situation. He said he was “demanding answers” and ordered new rules requiring facilities to buy generator capacity by Nov. 15.  Yes, that’s the same Gov. Scott who after taking office in 2011 significantly rolled back oversight of the industry and cut the number of hours of direct care given to residents. He also halved the number of inspections at assisted living facilities that give specialty care and signed bills that gave greater protection from lawsuits to owners of nursing homes and assisted living facilities. As the Tampa Bay Times and Miami Herald reported, Scott’s Agency for Health Care Administration last year paid $22,000 for redaction software to strike critical words from state inspection reports that residents’ families use to check on the quality of care given their loved ones.  In other words, the state wanted to keep them in the dark about bad care.

The industry is already pushing back against Scott’s new generator rule. Their complaints are familiar. It would cost too much. They need more time to come up with the money to comply. They agree it’s a good idea to keep residents safe, but owners “have concerns about the practical implications of the rule,” said one trade group executive.

Too many times, this knee-jerk outrage by politicians results in nothing, and the facilities prone to bad practices keep on repeating them.  An errant nursing home cleans up its act, behaves for awhile and then reverts to the same or different bad practices. In the business it’s called “yo-yo compliance.” A facility gets reprimanded by the state or the Centers for Medicare and Medicaid Services, maybe it pays a small monetary penalty, and sends staff for more training. The facility may get a new owner who pledges to do better. Down the road the residents still suffer.

The story of bad nursing homes is one reporters have not ignored. Newspaper and magazine exposés over the decades and more recently online sites like ProPublica have chronicled almost unspeakable abuse, poor care, lax regulation, and sometimes have helped fuel sentiment for corrective legislation, which more often than not gets watered down in the legislative process. That’s happened in Florida. Mary Ellen Klas, the Miami Herald’s bureau chief in Tallahassee, and the Herald senior investigative reporter Carol Marbin Miller reported the governor’s hypocrisy and have written several other stories since the hurricane struck.

Klas told me in the mid-2000s after other hurricanes hit the state, the legislature tried to mandate that nursing homes have generators.  A watered down bill calling for a pilot program passed the House but died in the Senate. “That was to me a very good example of how this industry has a lot of clout,” she said.

Whether Scott or Florida legislators cave to the industry is unknown at the moment, but my own experience covering nursing homes and that of other reporters, who for decades have been on this story, have found the industry usually prevails. The nursing home industry is a powerful force in Florida and nationally. They have the ability to push back against the great work many reporters have done.  

A decade ago a facility in the Midwest didn’t like being on a watch list Consumer Reports had created and to negate those findings it distributed its own satisfaction survey to show the community and families how good the nursing home was. “Sometimes it’s dispiriting to read another report about nursing home problems – and it’s dispiriting to write them, too. But not writing about them simply isn’t an option,” says ProPublica senior reporter Charles Ornstein. And there are stories aplenty to investigate. The HHS inspector general’s office has just reported that 25 percent of the cases about possible sexual and physical abuse against nursing home residents apparently was not reported to police because Medicare hasn’t enforced a law requiring immediate notification. The IG’s office also reported nursing home complaints are rising and some states aren’t properly investigating them on time. 

There’s something more, though, that gets in the way of real public outrage that might ignite major change. We as a country are not very interested in old people except as a part of a commercial transaction. What gizmo, device, or medical service can we sell to them? When it comes protecting 85-year-olds from nursing home abuse, we’re less interested. A Texas regulator once told me when I asked about a particularly bad facility, “If this were a child care center, things would be cleaned up really fast.”

Veteran health care journalist Trudy Lieberman is a contributing editor at the Center for Health Journalism Digital and a regular contributor to the Remaking Health Care blog.

[Photo: Jack Taylor/Getty Images]