Coroner Referrals of Suspected Neglect, While Few in Number, Indicated Serious Care Problems

Of the approximately 4,000 nursing home deaths investigated by the  Pulaski County coroner from July 1999 through December 2003, the  coroner informed us that he identified and referred 86 cases (2.2 percent)  of suspected resident neglect to the state survey agency and the MFCU. Many of these  care indicators are similar to those examined during the state survey  agency’s annual inspection of every nursing home. 1). In some of the coroner’s photos, bone or ligament was visible, as were  signs of infection or dead tissue, indicating a serious stage IV pressure  sore (see table 3). 2). Eleven of the 12 referrals for one home  involved pressure sores. The State Survey Agency’s Investigation of Coroner Referrals Often Understated Neglect of Residents

According to Arkansas state survey agency officials, the agency received  36 coroner referrals of suspected resident neglect, less than half of the 86  referrals the coroner said he made. The agency’s investigations of these  coroner referrals often understated serious care problems—both when  neglect was substantiated and not substantiated (see app. In half of the referrals not substantiated by the state survey agency, either  the MFCU investigation found neglect or we questioned the basis for the  “not substantiated” findings, and our concerns were confirmed by a  professor of nursing with expertise in long-term care. Fewer than Half of the Coroner Referrals Were Received by the State Survey Agency

Although the Pulaski County coroner told us that he had referred 86 cases  of suspected resident neglect from July 1999 through December 2003,  Arkansas state survey agency officials said that they received fewer than  half (see table 4) and investigated all but one of the referrals they  received. For the remaining 11 substantiated coroner referrals, the state survey  agency cited either no deficiency for the decedent or cited a deficiency at  a level lower than actual harm for the predominant care problem identified  by the coroner, even though the MFCU’s investigations found neglect for  six of the decedents, in effect substantiating the existence of serious care  problems in these cases (see table 6). Both the MFCU and our expert noted omissions and contradictions in the  medical records of some of the 14 decedents, raising a question about the  state survey agency’s conclusions that the same records indicated care had  been provided. Other  care was also found negligent. CMS’s 1999 guidelines for complaint investigations instruct  state survey agencies to refer cases to another agency when it lacks  jurisdiction. We found the  same systemic oversight weaknesses in the Arkansas state survey agency’s  investigation of coroner referrals that our prior work on nursing home  quality of care identified nationwide. These oversight weaknesses include  (1) complaint investigations that understated the seriousness of the  allegations and were not conducted promptly; (2) annual standard survey  schedules that allowed nursing homes to predict when the next survey  would occur; (3) survey methodology weaknesses, coupled with surveyor  reliance on misleading medical records, that resulted in overlooked care  problems; and (4) a policy that did not always hold nursing homes  accountable for care problems identified after a resident’s death. 3). The Arkansas law also  confirmed the systemic weaknesses in state and federal oversight of  nursing home quality of care that we identified in prior reports. We confirmed that this additional referral  was not received or investigated by the MFCU. At that time, we will send copies of this report to the  Administrator of the Centers for Medicare & Medicaid Services and  appropriate congressional committees. California Nursing Homes: Federal and State Oversight Inadequate to  Protect Residents in Homes With Serious Care Problems.
Why GAO Did This Study

GAO was asked to assess the effectiveness of nursing home oversight by considering the effect of a unique Arkansas law that requires county coroners to investigate all nursing home deaths. Coroners refer cases of suspected neglect to the state survey agency and law enforcement entities such as the state Medicaid Fraud Control Unit (MFCU). The Centers for Medicare & Medicaid Services (CMS) contracts with survey agencies in every state to periodically inspect nursing homes and investigate allegations of poor care or neglect. MFCUs are charged with investigating and prosecuting resident neglect. GAO examined (1) the results of Arkansas coroner investigations, (2) the state survey agency's experience in investigating coroner referrals, and (3) whether weaknesses in state and federal nursing home oversight identified in prior GAO reports were evident in the survey agency's investigation of coroner referrals.

What GAO Found

According to the Pulaski County coroner, he referred 86 cases of suspected resident neglect to the state survey agency for the period July 1999, when the Arkansas law took effect, through December 2003. Agency officials said that other state coroners referred four cases during this time period. Importantly, these 86 referrals constituted just 2.2 percent of all nursing home deaths the coroner investigated. However, the referrals included disturbing photos and descriptions of the decedents, suggesting serious, avoidable care problems; more than two-thirds of the 86 referrals listed pressure sores as the primary indicator of neglect. Some photos of decedents' pressure sores depicted skin conditions so deteriorated that bone or ligament was visible, as were signs of infection and dead tissue. The referrals involved 27 homes, over half of which had at least 3 referrals. Arkansas state survey agency officials told GAO that they received 36 (fewer than half) of the Pulaski County coroner's referrals. The 50 referrals not received described decedents' conditions similar to those the survey agency did receive. Of the 36 referrals for alleged neglect that it received, the survey agency complaint investigations substantiated 22 and eventually it closed the home with the largest number of referrals. However, the agency's investigations often understated serious care problems--both when neglect was substantiated and when it was not. For 11 of the 22 substantiated referrals, the state survey agency either cited no deficiency for the decedent or cited a deficiency at a level lower than actual harm for the predominant care problem identified by the coroner. In contrast, MFCU investigations of many of the 11 referrals found the homes negligent in caring for decedents, and the MFCU reached settlements with the owners of several homes. In half of the 14 referrals not substantiated, the MFCU or an independent expert in long-term care either found neglect or questioned the "not substantiated" finding. Moreover, they found gaps and contradictions in the medical records for some decedents, raising a question about the survey agency's conclusions that the same records indicated appropriate care had been provided. GAO's prior work on nursing home quality of care found that weaknesses in federal and state oversight nationwide contributed to serious, undetected care problems indicative of resident neglect. GAO's review of the Arkansas survey agency's investigations of coroner referrals confirmed that serious, systemic weaknesses remain. Oversight weaknesses GAO previously identified nationwide and those it found in Arkansas included (1) complaint investigations that understated the seriousness of allegations and were not timely; (2) predictable timing of annual state surveys that could enable nursing homes so inclined to cover up deficiencies; (3) survey methodology weaknesses, coupled with surveyor reliance on misleading medical records, that resulted in missed care problems; and (4) a policy that did not always hold homes accountable for neglect associated with a resident's death.