Problems with oversight, staffing contribute to low quality ranking of Missouri nursing homes
While reading nursing home complaint reports, the last descriptor that tends to come to mind is “home.”
Instead, one resident of a St. Louis skilled nursing facility uses some other words.
The resident wished to remain anonymous but can be vouched for by St. Louis area senior advocates. She described a recent night where, having just returned from the hospital, she was unable to sleep because a resident in a nearby room was screaming for water all night.
She says the care has gotten better since she arrived last year, but that she prefers to rely on herself rather than ask the staff for help. They tend to act annoyed, roll their eyes, or talk down to the other residents, she says. Several times a week, she says she doesn’t get pain medications to manage her chronic illness symptoms.
Sometimes, it feels like “a battle trying to get them to help you.”
This story is far from unique. Nursing homes across the state have experienced chronic understaffing and can struggle to provide quality care. However, the mechanism that states use to closely monitor and penalize underperforming facilities only allows a few facilities to be scrutinized at a time, leaving other, equally poor facilities operating without adequate inspection.
This, combined with a backlog in regular health inspections, or surveys, has created an environment that allows poor care quality, and sometimes abuse, to continue for years with few consequences.
In a 2023 AARP report, Missouri was ranked 48th in the country for nursing home quality.
What are Special Focus Facilities?
Under the Social Security Act, each state is required to designate a specific number of the poorest performing facilities as Special Focus Facilities (SFF). Facilities in the SFF program are then required to be inspected at least every six months, which is more frequently than federal law requires normally. Missouri has three SFF slots and 15 SFF candidates.
An SFF candidate is a facility that meets the requirements to be a special focus facility but is on the waiting list to be on the program. This means that there are potentially 15 or more homes that are performing as badly as the SFF candidates but are not being held accountable in the same way.
While a part of the SFF program, a facility is supposed to demonstrate “good faith” efforts to improve. If they fail to improve over a “prolonged period of time,” they may be expelled from Medicare. In order to graduate from the program, facilities must pass two consecutive health surveys, and following graduation they will be monitored more closely for three years. As of November, the three special focus facilities in Missouri have been on the list for at least a year, and one has been on the list for more than two years.
In 2022, the Biden administration announced a renewed effort to improve nursing home care quality, citing the need revealed by the pandemic death toll (almost a quarter of all COVID-19 deaths in the U.S. were among nursing home residents and staff, according to data referenced by the White House fact sheet).
Among the many reforms, the White House announced changes that would allow the SFF program to scrutinize more facilities and enforce tougher standards, including more severe financial penalties for being out of compliance, penalties which had been rolled back under the Trump administration. CMS is also meant to research and establish a minimum nursing home staffing requirement, a measure which is closely tied to a facility’s ability to provide quality care.
Green Park Senior Living, a St. Louis nursing home, is an SFF candidate that has not had a full health inspection in more than two years, although it has had 10 complaint or infection reports since the beginning of 2022. In January, a complaint report found 12 deficiencies, mostly relating to quality of life and care. In March, a complaint was investigated in which two CNAs attacked a resident after accusing the resident of stealing. The resident was struck “at least twice” according to the report. There have been two more complaint inspections since then.
Officials from Green Park did not return several requests for comment.
Dutchtown Care and Rehabilitation Center is another St. Louis facility that has been on and off the SFF candidate list. The facility had been on this list for more than a year as of last fall, but its last full health inspection was in December 2021. During this inspection, there were 29 deficiencies and a resulting fine of $197,582.
Since then, there have been four complaint reports, the most severe of which happened just over a month after the last health inspection. This report found, among other deficiencies, that there were instances where there were no nurses on duty. One night, there was no nurse on duty and patients reported being in distress. Several didn’t receive pain medication that they ordered.
Another was in respiratory distress and was not evaluated.
Another fell and was not properly assessed before being placed back in bed.
Another couldn’t sleep because of stress caused by medications that were not delivered.
Another was not given a change in dressing for a severe pressure ulcer.
When a similar situation occurred a few days later, according to the complaint report, the administrator required a Licensed Practical Nurse (LPN) to stay on shift. However, the LPN refused to administer medication and services to all the residents interviewed by the state surveyor.
The owners of Dutchtown Care Center also previously owned another facility that was closed early this year, Riverview Care Center. Residents of Riverview were moved to Dutchtown, the St. Louis Post-Dispatch reported in March.
In November, Dutchtown was removed from the SFF candidate list. Dutchtown declined the Missourian’s request for a comment.
Lack of accountability
Jonathan Steele, founder of a Kansas City law firm that focuses exclusively on nursing home abuse and neglect, agrees that the state designated special focus facilities are “the worst of the worst.” However, because there are so few of these facilities, he has only dealt with them in a couple of cases. Most of the time, his clients are coming from homes that don’t have any regulatory citations.
“There’s lots and lots and lots and lots of facilities that are providing way below any standard of care that someone would expect,” Steele said. These facilities get “slaps on the wrists” from inspectors, are forced to submit a plan of correction, and are left alone regardless of whether they successfully fix the issue, Steele said.
Steele sees lawyers like himself as the last line of defense to try and hold nursing homes accountable. He emphasizes that the blame is largely on owners of the businesses, not on the largely understaffed and overworked personnel on the ground.
The most common types of cases that Steele and his firm deal with are related to bedsores and falls. These incidents happen most often because of a lack of staff. As such, the most promising course of action for a real solution, Steele said, is the introduction of a minimum staffing ratio. Currently, no such ratio exists at the federal level.
“The (current) regulation is you have to have sufficient staff to meet the needs of your residents, whatever that is,” Steele said. “And so until the federal government actually implements a real minimum staffing ratio, you’re going to be hard pressed to see a lot of change.”
Resistance to a minimum staffing ratio has been strong, something Steele attributes to lobbying on behalf of the medical industry. Owners argue that they can’t afford to hire more staff.
While many of the systemic issues facing nursing homes are national in scope, there are a few factors that Steele said makes prosecuting nursing homes particularly difficult in Missouri. In Missouri, there are no limit to caps in damages for any type of death except for those that arise out of medical malpractice. In Kansas and Oklahoma, where Steele’s law firm also practices, they can more easily take cases to trial because the threat of infinite risk incentivizes businesses to settle. However, in Missouri, the best they can usually do is get some settlement money because the cap makes trials impractical, which Steele thinks fails to hold anyone accountable.
“It is almost impossible, through the court system, to — what I would say — actually hold them accountable,” Steele said.
The question of why nursing home care quality is so low in Missouri is a perplexing one, even for those who have made it their life’s work to study it. Amy Vogelsmeier is an associate professor at MU Sinclair School of Nursing whose research focuses on nursing home safety.
She says that Missouri has resources that other states do not, including robust research through MU and the Quality Improvement Program for Missouri, a partnership between Sinclair School of Nursing and DHSS that has been providing resources confidentially to nursing homes since 1999. And yet, availability of these resources has not led to better quality.
In Vogelsmeier’s research, care quality issues largely boil down to staffing. One major area of research focuses on the importance of registered nurses. RNs are critical because they are more highly trained than other nursing home staff, not just in medical care, but also in leadership. Currently, nursing homes are only required to employ one RN for eight hours per day.
The pandemic has exacerbated a widespread RN shortage across the medical industry, which has impacted nursing homes. However, nursing homes have always struggled to recruit professional and licensed staff to a type of work that is notoriously difficult and can come with social stigma, Vogelsmeier said.
Pushing for more oversight
The nursing homes are not the only piece of the system debilitated by staffing shortages.
Shelly Williamson, administrator of the Section for Long Term Care Regulation at DHSS, testified in May at a U.S. Senate Special Committee on Aging hearing.
The bottom line of her testimony was a plea for more funding. State survey agencies simply do not have the required resources to monitor nursing homes and to keep patients safe, Williamson said. The workload expected of survey agencies has increased significantly since 2015, including increased standards for emergency preparedness and infection control that make inspections more rigorous and difficult to complete. However, state agencies “have not received a meaningful increase in federal funding to complete these critical oversight and responsibilities since 2015,” Williamson said in her testimony.
State agencies are plagued by staffing shortages and vacancies, and they lack the funding to increase incentives. The backlog in inspections and lack of funding could not come at a worse time, when the nursing home population is scheduled to increase and complaints are becoming more frequent. According to Williamson’s report, total complaints have increased by 45% since 2015, with those alleging serious injury, harm, impairment or death increasing by 102%.
Advocates are working toward a number of measures that would allow the state to monitor more facilities with more rigor, including expanding the number of facilities on the SFF list.
Ombudsman organizations operate at both the state and local levels, providing resources for elders and serving as advocates between nursing homes and residents. With a focus on resident rights, they help patients advocate for themselves while also advising willing nursing homes on best practices. If a facility is noncompliant, ombudsmen aren’t able to enforce policies, but they encourage residents to call the abuse hotline and in a last line of defense, ombudsmen are able to file complaints with the state.
Marjorie Moore is the executive director of Voyce, an organization which serves as the ombudsman for the St. Louis and northeast Missouri. She explains that ombudsmen fill a critical gap in the oversight state surveys can provide. Their staff and volunteers, who visit each facility a minimum of four times per year, are able to build relationships and trust more effectively than state inspection staff. Often, when state surveyors take the time to consult the ombudsman, the ombudsman might be able to provide insight into issues that the surveyors miss.
Issues at nursing homes can fall through the cracks of state inspections for a variety of reasons, Moore said. If there is no documentation to support a complaint, the state will conclude that claims related to abuse, neglect, or poor care quality are unsubstantiated. State inspectors are only able to talk to a small number of residents, and if a resident who has experienced abuse is unwilling or unable to make themselves heard, the issue could be easily missed by the surveyor.
A responsibility to care
Another factor that Steele says needs to be acknowledged is that while much data exists about comparative quality of nursing homes, families aren’t necessarily making decisions informed by this data.
“Choosing to put a family member in a nursing home is a hard enough thing to do. I mean, you give up all control. And you know that it's a helpless feeling,” Steele said. “Oftentimes, families have tried to take care of their mom or their dad, but they just don't have the bandwidth to do it.”
Many families are forced out of necessity to put their family members in the nearest home, regardless of its ratings. Or in other cases, families are pointed in the direction of particular homes by hospital social workers, who make recommendations based on which homes have built close relationships with the hospital.
When families make the hard decision to relinquish care of their loved ones, the homes that are taking over for them should keep their promises, Steele said.
Even so, Vogelsmeier argues that family presence can make a critical difference in a nursing home's ability to provide quality care. It’s best if families can visit homes and get a feel for the environment before sending a family member there. And while they’re living there, families can partner with staff by visiting regularly or by finding a trusted staff member to communicate with consistently.
“What we found out with COVID is that when families were not part of care delivery, they were missed,” Vogelsmeier said. “And so there's an opportunity to really recognize family members as partners in care, so that they can be in the present in the nursing home, assisting with care.”
People like Vogelsmeier, who has spent her career visiting and listening to nursing home staff, maintain that many of these workers care deeply about the work that they do, even though it is far from glamorous. She has witnessed meaningful relationships and genuine care between staff and workers.
“I've been in almost every nursing home in the state, and I never walk away thinking these people just don't care, because that's not the case,” Vogelsmeier said. “I see them really wanting to do the best job that they can, and to provide the best care that they can, but they're just up against a lot of limitations.”