(This article appeared previously on Kaiser Health News.)
The call from the nursing home came just before dawn, jolting Martha Sherwood awake.
During the night, fire ants had swarmed over her 85-year-old mother, injecting their stinging venom into Natalie Sealy’s face, arms, hands and chest.
“She was just lying there being eaten alive,” said daughter Billie Pender, who said she and her sister had repeatedly complained about a broken windowsill in their mother’s room at Parkview Nursing and Rehabilitation Center in Lockhart, Texas. The Sept. 2, 2014 attack devastated Sealy, a retired bank teller with dementia. “She went steadily downhill,” dying in late March, said Sherwood, who brought a lawsuit against the home. The home’s owners deny the allegations.
Their mother had chosen the for-profit facility two years earlier because it was near her adult children. The family didn’t know that Parkview scored poorly on staffing and other quality measures. This year, Medicare rates it one star out of a possible five stars — the lowest rating possible — on Nursing Home Compare, which was designed by the federal government to help consumers choose a long-term care facility.
Too Few Options
The problem for Sealy’s family and residents of many parts of the country is they have few, if any, higher-rated options if they want their loved ones close by. In 11 states, 40 percent or more of nursing homes get the two lowest ratings, according to an analysis by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
Texas has the highest percentage of one-and two-star homes in the country: 51 percent of its nursing homes are rated “below average,” or “much below average,” on Nursing Home Compare, according to the analysis. Louisiana is close behind at 49 percent, with Oklahoma, Georgia and West Virginia tying for third at 46 percent.
Other states with at least 40 percent of homes ranked at the bottom two rungs include North Carolina, Tennessee, Kentucky, Ohio, Pennsylvania and New York.
Stars are awarded based on government inspection reports, staffing levels and self-reported quality measures, including the percentage of residents who develop bed sores or who are injured in falls. Earlier this year, the government added quality criteria and as a result, many nursing homes dropped a star or more.
Nursing Home Compare is not the only guide to long-term care facilities. In fact, Medicare urges consumers not to rely solely on the website, but to gather information from a variety of sources, including visits to the facility. That’s because the star ratings, which launched in 2008, cannot consider all the factors important to a particular family, such as the availability of specialty care or the home’s distance from family members — a key issue because frequent visits correlate with better outcomes.
Differing Views of the Ratings
The nursing home industry criticizes the variability of state inspections, which it says make cross-region comparisons difficult. Advocates raise concerns about Medicare’s reliance on self-reported quality data.
Many of these nursing homes are making profits, but they put profits over staffing.
— Charlene Harrington, University of California, San Francisco
Nonetheless, consumer groups say the stars offer a good starting point. “I’d stay away from anything that had one or two stars,” said Brian Lee, executive director of Families for Better Care, a Florida-based advocacy group for nursing home residents.
Sealy’s family didn’t have that option, however, if she was going to stay by her daughters in Lockhart, a small town about 30 miles south of Austin.
Nine of the 10 nursing homes within a 25-mile radius get only one or two stars. Only one home — about 20 miles away in San Marcos — garners three stars. Not a single home in that radius earns four or five stars — the highest Medicare rating, although nearly half of nursing homes nationally get those scores.
Moving farther away would have made it “impossible to go visit her every day,” Sherwood said.
‘Why Are We Allowing These Providers To Continue?’
Despite decades of scrutiny, the large percentage of low-ranked homes in Texas and across a broad swath of the country from the Deep South, through the Ohio Valley and into the Northeast shows that quality in the nation’s nearly 15,500 nursing homes remains highly variable.
“Conditions are not changing rapidly enough,” said Robyn Grant, director of public policy at the National Consumer Voice for Quality Long-Term Care. “We hear frequently about poor nursing homes and usually they’ve been poor for a long, long time. Why are we allowing these providers to continue?”
Consumer advocates cite several culprits for poor care: Not enough staff and weak state and federal staffing rules, low pay for workers resulting in high turnover, feeble financial penalties and reluctance by state officials to close problem homes for fear of displacing residents.
States that set higher staffing standards tend to score better on quality measures, said Charlene Harrington, a University of California, San Francisco, researcher who has spent her career studying nursing home quality.
Ideally, she said, homes should provide about four hours of direct care to each resident every day, with some of that delivered by registered nurses. But no state requires that.
Federal law requires that a registered nurse be on duty at least eight hours a day, and that a licensed vocational nurse always be on hand. About 26 states have additional standards, which are generally a ratio of residents to staff, or hours of care per day. Texas does not set specific staffing ratios for nurses’ aides and other non-licensed staff, except in specialized Alzheimer’s units.
“The nursing home industry has been able to block [stronger] federal staffing standards and in many cases state staffing standards,” Harrington said.
For-profit nursing homes also tend to get lower quality scores than nonprofits, according to several studies.
Nursing Homes Blame Underfunding
Nursing home industry officials say they are improving quality, citing reduced use of antipsychotic drugs and new efforts to address employee turnover.
In their view, the chief problem is insufficient Medicaid payments, which make it harder to hire and keep staff.
“We’ve been chronically underfunded for 20 years,” said George Linial, president and CEO of LeadingAge, an advocacy group whose members include nonprofit nursing homes in Texas.
While it varies by home, Linial and others said about 70 percent of Texas nursing home residents are on Medicaid.
“How can a nursing home that’s getting paid $135 a day per resident afford to pay someone a decent wage?” he asked.
Medicaid payments by the state of Texas for nursing home care are among the lowest in the country, averaging $133 a day per resident in 2014, according to a report prepared for the American Health Care Association, a federation of nursing homes, assisted living centers and other long-term care providers.
Patient advocates are skeptical of arguments about inadequate financing, saying staffing can be good in some homes and poor in others when they operate in the same state and receive similar Medicaid payments.
“Many of these nursing homes are making profits, but they put profits over staffing,” said Harrington of the University of California.
The debate over profits is complicated because it’s difficult to track profits and revenue, since many nursing homes are owned by private corporations or limited partnerships with complex ownership structures.
“There’s plenty of profit being made by these facilities, but they’re shoveling it out through management contracts to themselves,” said Charles Brown, a partner in the law firm Brown, Wharton & Brothers, which is representing Sealy’s family in their lawsuit against Parkview.
Facility Has ‘A Lot of Good People’
A casual visitor to Parkview Nursing and Rehabilitation Center might have no clue about its low ratings on Nursing Home Compare. It’s a pleasant-looking facility, with colorful paper decorations made by local schoolchildren adorning its lobby and awards proclaiming it the winner of the local newspaper’s survey for “Best Nursing Home in Caldwell County.”
Administrator Lane Allen is clearly proud of the facility and his staff: “There are a lot of good people [working] in a very tough environment.”
Asked about the ant attack, Allen said, “there are two sides to every story,” but declined to elaborate. He referred questions to corporate officials, who declined to comment citing the pending lawsuit.
Putting Changes Into Law
Lawmakers in several states, including Washington and Connecticut, are debating proposals to raise staffing standards to boost care. Washington’s would require almost three and a half hours of direct care staffing per resident starting in July and large urban nursing homes would need an RN on duty 24 hours a day. Connecticut’s proposal calls for 2.3 hours of staff time per resident each day, up from 1.9 hours.
Sealy’s daughters are hoping the legal system will keep someone else’s mother from suffering as their mother did.
“Things happen, I understand,” says Sherwood. “But when they happen from being negligent, or not doing proper maintenance, [people] should be held accountable.”
KHN’s coverage of aging and long term care issues is supported in part by a grant from The SCAN Foundation.
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