Missouri nursing home evaluators fail seniors by missing serious problems.
When America’s nursing home evaluators inspect nursing homes, they routinely miss serious problems. That's what the Government Accountability Office says. These serious problems can put our family and our friends that live in nursing homes in real, immediate danger.
Missouri’s nursing home evaluators are among America's worst. They performed worse than most other states’ evaluators, missing serious violations in more than 28% of the inspections that were reviewed by the federal government.
With that percentage, Missouri DHSS earned the third worst score in the nation for missing serious problems -- problems like malnutrition, bedsores, overuse of prescription medications and abuse.
Staff failures, not staff shortages, got Missouri the third worst score in the nation. When Missouri DHSS failed to detect these violations, it wasn't because of staff or resource shortages. Missouri DHSS missed these violations during required state licensing inspections.
During these state licensing inspections, DHSS sends a full team of nursing home investigators into a facility looking for problems. Yet the Government Accountability Office (GAO), found that DHSS missed so many violations so often.
Sunday, February 15
Section 2:
Missouri DHSS admits it fails to investigate resident and family complaints in a timely manner.
The Missouri Elder Abuse and Neglect Hotline was set up to allow the public to report abuse and neglect to the Missouri Department of Health and Senior Services.
But in addition to failures during their planned, coordinated licensing inspections, Missouri DHSS often fails to investigate Missouri Elder Abuse and Neglect Hotline calls in a timely manner.
Pam Clark, a DHSS regional manager, admitted to the Post-Dispatch in 2003 that she and her staff often fail to quickly follow up on complaints from families and from nursing home residents. She blamed staff shortages.
But whether it's a failure to investigate reported violations promptly, or a failure to detect violations during investigations, evidence shows that Missouri DHSS is serving us poorly. The evidence shows Missouri DHSS isn't protecting seniors the way it should.
The Missouri Elder Abuse and Neglect Hotline was set up to allow the public to report abuse and neglect to the Missouri Department of Health and Senior Services.
But in addition to failures during their planned, coordinated licensing inspections, Missouri DHSS often fails to investigate Missouri Elder Abuse and Neglect Hotline calls in a timely manner.
Pam Clark, a DHSS regional manager, admitted to the Post-Dispatch in 2003 that she and her staff often fail to quickly follow up on complaints from families and from nursing home residents. She blamed staff shortages.
But whether it's a failure to investigate reported violations promptly, or a failure to detect violations during investigations, evidence shows that Missouri DHSS is serving us poorly. The evidence shows Missouri DHSS isn't protecting seniors the way it should.
Section 3:
The New York Times, Government Accountability Office, and St. Louis Post-Dispatch detail the Missouri DHSS failures referenced in SECTIONS 1 & 2.
- The New York Times: On 5/15/2008, citing a May 2008 GAO report, the New York Times wrote: “Nursing home inspectors routinely overlook or minimize problems that pose a serious, immediate threat to patients, Congressional investigators say in a new report. … [Investigators] from the Government Accountability Office, say they have found widespread ‘understatement of deficiencies,’ including malnutrition, severe bedsores, overuse of prescription medications and abuse of nursing home residents.” The Times article specifically mentions Missouri as among America’s 9 worst at missing these problems.
- The GAO: That same May 2008 GAO report found 9 states missed serious violations in more than 25% of surveys reviewed. Missouri was one of those 9 states, missing serious violations 28% of the time. This failure rate gave Missouri the third worst score in America. See page from GAO report: (unable to post PDF at present)
- The St. Louis Post-Dispatch: Missouri also has a history of failing to promptly investigate complaints of abuse, neglect, and other regulatory violations. In a 2003 Post-Dispatch article a DHSS regional manager was quoted: "'We're way behind in our complaint investigations,' said Pam Clark, regional manager for the state Division of Health Standards and Licensure in St. Louis. 'Through triage, we're spending time in the bad facilities and praying that we don't miss something.' …Clark said those [complaints] alleging imminent danger are reviewed within 24 hours but general complaints - such as ‘the place stinks and every time I come in Mom's wet’ - must wait.”
Section 4:
Questions: How many have been hurt by DHSS failures? And what don't we know?
How many Missouri seniors have been harmed by DHSS’s failures? How many have suffered because DHSS failed to detect serious violations during inspections, or to properly investigate abuse, neglect, and other complaints of regulatory violations?
And if these are the problems that the government knows about, that the government has made public, but that the government hasn’t fixed…
What else is DHSS failing to do when they regulate Missouri nursing homes?
How many Missouri seniors have been harmed by DHSS’s failures? How many have suffered because DHSS failed to detect serious violations during inspections, or to properly investigate abuse, neglect, and other complaints of regulatory violations?
And if these are the problems that the government knows about, that the government has made public, but that the government hasn’t fixed…
What else is DHSS failing to do when they regulate Missouri nursing homes?
Section 5:
What we know.
We know nursing home abuse and neglect often isn't reported, but even when it is reported, abuse and neglect rarely lead to punishment: Missouri DHSS's own statistics show that only 10% of claims of abuse, neglect, and other regulatory violations actually result in DHSS citing a facility. With total investigations nearing 6000 a year in 2005, that’s only around 600 citations each year.
We know that even when teams of DHSS investigators inspect nursing homes, they regularly miss serious problems: The GAO established that Missouri ranks near the bottom because its nursing home evaluators missed serious problems in 28% of reviewed inspections.
And we know that DHSS is slow to investigate problems and even slower to cite nursing home for those problems: As referenced in SECTION 3, DHSS regional manager Pam Clark told the Post-Dispatch that they’re way behind in complaint investigations. She says that because they are so far behind, they investigate the most serious claims first, while the others get to wait.
But even with DHSS saying they make complaints of serious, immediate harm their priority, 9 of 10 investigations end up with nothing happening to the nursing home.
Do you think it’s likely that 5400 or so of the nearly 6000 Elder Abuse and Neglect Hotline calls and other complaints are baseless, or does DHSS under-cite in its nursing home complaint investigations?
We know nursing home abuse and neglect often isn't reported, but even when it is reported, abuse and neglect rarely lead to punishment: Missouri DHSS's own statistics show that only 10% of claims of abuse, neglect, and other regulatory violations actually result in DHSS citing a facility. With total investigations nearing 6000 a year in 2005, that’s only around 600 citations each year.
We know that even when teams of DHSS investigators inspect nursing homes, they regularly miss serious problems: The GAO established that Missouri ranks near the bottom because its nursing home evaluators missed serious problems in 28% of reviewed inspections.
And we know that DHSS is slow to investigate problems and even slower to cite nursing home for those problems: As referenced in SECTION 3, DHSS regional manager Pam Clark told the Post-Dispatch that they’re way behind in complaint investigations. She says that because they are so far behind, they investigate the most serious claims first, while the others get to wait.
But even with DHSS saying they make complaints of serious, immediate harm their priority, 9 of 10 investigations end up with nothing happening to the nursing home.
Do you think it’s likely that 5400 or so of the nearly 6000 Elder Abuse and Neglect Hotline calls and other complaints are baseless, or does DHSS under-cite in its nursing home complaint investigations?
Section 6:
Questions: How often do they fail to investigate? And how often do they ignore evidence of violations?
If Missouri DHSS performs so poorly that they are slow to investigate, slow to cite, and slow to catch problems that the Federal investigators find, are we even sure they investigate every complaint? If they’re so busy, do some complaints that DHSS manager Pam Clark says will have to wait just never get looked into at all?
How often does DHSS simply fail to ever investigate a report of abuse or other problems?
And when DHSS does investigate, are there cases when Missouri DHSS ignores its statutory obligations or actually twists the situation to excuse nursing home abuse, neglect, or other regulatory violations?
How often does that sort of misconduct happen in the 90% of investigations that yield no citations?
If Missouri DHSS performs so poorly that they are slow to investigate, slow to cite, and slow to catch problems that the Federal investigators find, are we even sure they investigate every complaint? If they’re so busy, do some complaints that DHSS manager Pam Clark says will have to wait just never get looked into at all?
How often does DHSS simply fail to ever investigate a report of abuse or other problems?
And when DHSS does investigate, are there cases when Missouri DHSS ignores its statutory obligations or actually twists the situation to excuse nursing home abuse, neglect, or other regulatory violations?
How often does that sort of misconduct happen in the 90% of investigations that yield no citations?
Section 7:
Heat deaths in 2001, Post-Dispatch investigation in 2002, but little has changed.
In 2003 the St. Louis Post-Dispatch wrote:
“Nursing home regulation attracted public attention after four women died in April 2001 at Leland Health Care Center in University City. They died of heat exhaustion when the temperature in their rooms reached 95 degrees.
Last year, a Post-Dispatch investigation found that thousands of America's nursing home residents are dying from preventable causes and that those who allow the neglect to go on often face little or no penalty.
The home in University City escaped state fines because the operator later fixed the air conditioning and developed a plan for handling excess heat.”
The article goes on to say that the law has been changed, so that home might be fined today. But could those residents die in a Missouri home today? Yes.
DHSS still does a poor job, so nursing homes know they are safe failing to care for their residents.
Little has changed. But we can change that.
In 2003 the St. Louis Post-Dispatch wrote:
“Nursing home regulation attracted public attention after four women died in April 2001 at Leland Health Care Center in University City. They died of heat exhaustion when the temperature in their rooms reached 95 degrees.
Last year, a Post-Dispatch investigation found that thousands of America's nursing home residents are dying from preventable causes and that those who allow the neglect to go on often face little or no penalty.
The home in University City escaped state fines because the operator later fixed the air conditioning and developed a plan for handling excess heat.”
The article goes on to say that the law has been changed, so that home might be fined today. But could those residents die in a Missouri home today? Yes.
DHSS still does a poor job, so nursing homes know they are safe failing to care for their residents.
Little has changed. But we can change that.
Section 8:
How you can help change things:
Tell us what you’ve experienced.
Send us your story. We promise complete confidentiality. At this point we are simply seeking input -- input from those who may have struggled for justice and found themselves having to work against the Missouri Department of Health and Senior Services to have abusers and nursing homes held accountable for violations of the law.
Write us at: DHSScoverup@yahoo.com
See SECTION 12 for what to include in your e-mail.
Tell us what you’ve experienced.
Send us your story. We promise complete confidentiality. At this point we are simply seeking input -- input from those who may have struggled for justice and found themselves having to work against the Missouri Department of Health and Senior Services to have abusers and nursing homes held accountable for violations of the law.
Write us at: DHSScoverup@yahoo.com
See SECTION 12 for what to include in your e-mail.
Section 9:
What DHSS says.
What DHSS says about abuse and neglect:
· Abuse and Neglect are crimes.
· “ABUSE: the infliction of physical, sexual, emotional or financial injury or harm;”
· “NEGLECT: failure to provide services when such failure presents either an imminent danger to the health, safety, or welfare - OR - substantial probability that death or serious physical harm will result…”
· “DHSS has legislative responsibility for investigation of all allegations of abuse and neglect.”
· DHSS’s “investigation will focus on gathering all pertinent information…”
· Only 10% of abuse, neglect, and other complaints end in DHSS citing a nursing home.
Missouri DHSS PDF on nursing home abuse and neglect: (unable to post PDF at present)
Section 10:
What the law says.
What Missouri law and the federal regulations say:
This information comes from the Missouri Revised Statutes (which are our state laws). Links and lists from DHSS’s own document.
Chapter 198 RSMo
Convalescent, Nursing, & Boarding Homes
http://www.moga.mo.gov/STATUTES/C198.HTM
This chapter contains information on the following topics:
· Definitions,
· License, when required, duration, content, effect of change of ownership, temporary permits, penalty for violation
· Posting of Licenses
· Duty of department on receipt of application, duty upon denial, copying of records, inspection
· Department Inspections
· Confidentiality of Abuse & Neglect Reports
· Mandated Reporters
· Employee Disqualification List
· Chemical and physical restraints
· Resident Rights
· Grievances and Complaints
· Personnel Possessions & Funds of Residents
· Quarterly Accounting for Residents
Chapter 565. RSMo
Offenses Against The Person
http://www.moga.mo.gov/STATUTES/C565.HTM
This chapter contains information on the following topics:
· Definitions
· Elder Abuse first degree and penalty
· Elder Abuse second degree and penalty
· Elder Abuse third degree and penalty
· Investigation of Elder Abuse report
· Report of elder abuse, penalty, false reports, evidence of prior convictions
· Duty to report and immunity
· Financial Exploitation of elderly, disabled, penalty, definitions.
PDF of Federal nursing home regulations: (unable to post PDF at present)
What Missouri law and the federal regulations say:
This information comes from the Missouri Revised Statutes (which are our state laws). Links and lists from DHSS’s own document.
Chapter 198 RSMo
Convalescent, Nursing, & Boarding Homes
http://www.moga.mo.gov/STATUTES/C198.HTM
This chapter contains information on the following topics:
· Definitions,
· License, when required, duration, content, effect of change of ownership, temporary permits, penalty for violation
· Posting of Licenses
· Duty of department on receipt of application, duty upon denial, copying of records, inspection
· Department Inspections
· Confidentiality of Abuse & Neglect Reports
· Mandated Reporters
· Employee Disqualification List
· Chemical and physical restraints
· Resident Rights
· Grievances and Complaints
· Personnel Possessions & Funds of Residents
· Quarterly Accounting for Residents
Chapter 565. RSMo
Offenses Against The Person
http://www.moga.mo.gov/STATUTES/C565.HTM
This chapter contains information on the following topics:
· Definitions
· Elder Abuse first degree and penalty
· Elder Abuse second degree and penalty
· Elder Abuse third degree and penalty
· Investigation of Elder Abuse report
· Report of elder abuse, penalty, false reports, evidence of prior convictions
· Duty to report and immunity
· Financial Exploitation of elderly, disabled, penalty, definitions.
PDF of Federal nursing home regulations: (unable to post PDF at present)
Section 11:
Your rights
These two nonprofit organizations can help you understand how to work within the system as we work to change the system.
National Citizens’ Coalition for Nursing Home Reform (NCCNHR): http://www.nccnhr.org/
The Missouri long-term care ombudsman program. State Ombudsman: Carol Scott http://www.nursinghomeaction.org/static_pages/ombudsmen_list.cfm#Missouri
Regional LTC Ombudsman Programs map and list: http://www.dhss.mo.gov/Ombudsman/OmbudRegion.pdf
Regional LTC Ombudsman Programs:
Springfield: (417) 862-3598
Warrensburg: (660) 747-3107
St. Louis: (314) 918-8222 or (866) 918-8222
Kansas City: (816) 474-4240
Cape Girardeau: (573) 335-3331 or (800) 392-8771
Albany: (660) 726-3800
Columbia: (573) 443-5823
Note: The ombudsman program is a nonprofit organization that acts as a resource for residents of long-term care facilities and residents’ families.
While the state ombudsman Carol Scott works for the state of Missouri and is appointed by the governor, the regional ombudsman offices do not work for the state of Missouri.
DHSS Hotline: Missouri Elder Abuse and Neglect Hotline number: (800) 392-0210
These two nonprofit organizations can help you understand how to work within the system as we work to change the system.
National Citizens’ Coalition for Nursing Home Reform (NCCNHR): http://www.nccnhr.org/
The Missouri long-term care ombudsman program. State Ombudsman: Carol Scott http://www.nursinghomeaction.org/static_pages/ombudsmen_list.cfm#Missouri
Regional LTC Ombudsman Programs map and list: http://www.dhss.mo.gov/Ombudsman/OmbudRegion.pdf
Regional LTC Ombudsman Programs:
Springfield: (417) 862-3598
Warrensburg: (660) 747-3107
St. Louis: (314) 918-8222 or (866) 918-8222
Kansas City: (816) 474-4240
Cape Girardeau: (573) 335-3331 or (800) 392-8771
Albany: (660) 726-3800
Columbia: (573) 443-5823
Note: The ombudsman program is a nonprofit organization that acts as a resource for residents of long-term care facilities and residents’ families.
While the state ombudsman Carol Scott works for the state of Missouri and is appointed by the governor, the regional ombudsman offices do not work for the state of Missouri.
DHSS Hotline: Missouri Elder Abuse and Neglect Hotline number: (800) 392-0210
Section 12: Contact us
Write us your story at
DHSScoverup@yahoo.com
1. Please send the following information in your e-mail:
· Your name
· The nursing home resident’s name (optional)
· The nursing home resident’s relationship to you
· Resident’s age
· Your Location (nearest city is fine)
2. Then tell us what’s happened.
3. Please also describe what kind of evidence you may have: physical evidence (bruises, sores, weight loss, etc.) witnesses, other related situations, nurse’s notes, letters, pictures, facility orders, etc. Anything that you could provide to DHSS to corroborate what you're saying.
Thank you for your help,
The Missouri DHSS Coverup Site Administrator,
A concerned citizen and family member
DHSScoverup@yahoo.com
1. Please send the following information in your e-mail:
· Your name
· The nursing home resident’s name (optional)
· The nursing home resident’s relationship to you
· Resident’s age
· Your Location (nearest city is fine)
2. Then tell us what’s happened.
3. Please also describe what kind of evidence you may have: physical evidence (bruises, sores, weight loss, etc.) witnesses, other related situations, nurse’s notes, letters, pictures, facility orders, etc. Anything that you could provide to DHSS to corroborate what you're saying.
Thank you for your help,
The Missouri DHSS Coverup Site Administrator,
A concerned citizen and family member
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