New LTCCC Report Suggests Many Nursing Homes Treat Residents Worse Than Animals

A new report by the Long Term Community Care Coalition asks the question: “Can animals in a zoo or kennel expect better treatment and conditions than that which many human nursing home residents actually receive?” Noting that its goal is not to trivialize the experiences of nursing home residents or animals, the report seeks to demonstrate how nursing homes are subject to systemic accountability failures, resulting in rampant abuse and neglect that “not only fall below the federal nursing home standards of care, but also below accepted standards for the humane treatment of animals.”

The report compares conditions in eleven key areas of interest: freedom from abuse and neglect; general care and treatment; sufficient staffing with appropriate skills and competencies; nutrition and hydration; safe food handling; medical supervision; simulating and safe environment; freedom from restraints; treatment of injuries; appropriate medications; and infection control and prevention. Below is what the LTCCC found in each of those categories.

Freedom from Abuse and Neglect

The standards for animal care observed by zoos include a prohibition of physical abuse, deprivation of food or water, spraying with a hose, and other varieties of negative reinforcement to handle primates. Meanwhile, federal law forbids zoos from depriving animals of food or water “to train, work, or otherwise handle animals.” Federal law also stipulates that animals must be handled “as expeditiously and carefully as possible in a manner that does not cause trauma, overheating, excessive cooling, behavioral stress, physical harm, or unnecessary discomfort.” Finally, zoos are forbidden from using physical abuse in the handling of their animals.

As for nursing homes, the report notes that residents have a federally provided right to freedom from abuse and neglect, but also that federal standards to prevent abuse “are often poorly enforced by the state and federal oversight agencies.” For instance, a 2010 study reported that 10% of people aged 60 years or older suffer “some form of elder abuse in a given year.” Those forms include emotional, physical, sexual, and financial abuse. More recently, a 2019 report by the Government Accountability Office stated that nursing home abuse citations increased by more than 100% from 2013 to 2017. Elder financial abuse and fraud, according to the LTCCC report, “costs older Americans between $2.9 billion to $36.5 billion annually.” Meanwhile, a 2019 report by the Department of Health and Human Services Office of the Inspector General concluded that nursing homes had not reported to state authorities 84% of the sample of 7,831 incidents of potential abuse and neglect. That same report stated that about 20% of “Medicare claims for emergency room visits from  nursing homes were the result of potential abuse and neglect.”

General Care and Treatment

As for zoos, the LTCC report notes that American Association of Zoo Veterinarians guidelines require the use of “current professionally accepted methods of diagnosis and treatment” whenever zoo animals are given medical treatments or procedures. Those same guidelines mandate the availability of veterinary coverage 24 hours a day, seven days a week. They also require that animals be “well cared for and presented in a manner reflecting modern zoological practices.”

Nursing homes similarly have strong federal standards governing resident care, although the LTCCC states that these are “poorly enforced.” For instance, a federal study published in 2014 reported that “one in three Medicare beneficiaries who go to a nursing home for rehab are harmed within an average of about two weeks of entering a facility.” According to that report, it cost Medicare about $2.8 billion in one year to pay for hospital care associated with this harm, “more than half (59 percent) of which was preventable.” Nursing homes are also home to “largely preventable” pressure ulcers, from which almost 90,000 residents suffer daily, according to the LTCCC. The report cites a 2019 news report about a nursing home that did not provide one of its residents with essential pressure ulcer care: the wounds, according to that article, “seemed bigger and deeper… [a] new wound teemed with maggots… Another patient’s family found them in bed ‘covered in dried feces and soaked in urine.’ It happened multiple times a week.”

Sufficient Staffing with Appropriate Skills and Competencies

Zoo standards mandate the employment of “an adequate number of trained paid and unpaid staff to care for the animals and to manage the institution’s diverse programs.” They further recommend the employment of a full-time veterinarian on staff, or if this is unnecessary given the size of the zoo, a consulting and/or part-time veterinarian, who must make a minimum of two monthly inspections and be available to respond quickly to emergency situations. Zoos with part-time veterinarians must also have at least one staffer acting as a “veterinary program coordinator,” supervising the program under the veterinarian’s direction. Zoos with elephants must have “at least two qualified elephant keepers… present during any contact with elephants in order to allow a second person to intervene if required.” Husbandry and care employees must be supervised, and both trainers and handlers must meet certain professionally recognized standards.

Nursing homes, meanwhile, are federally required to keep a registered nurse on duty seven hours a day, and to maintain “sufficient care staff to meet every resident’s care, monitoring, and psycho-social needs.” However, according to the LTCCC, many nursing homes are “woefully understaffed,” because there is little universal understanding of what “sufficient staff” means. The report cites a 2001 study by the federal government that found “a typical resident needs at least 4.1 total staff hours per day,” and more recent effort suggesting 4.5 hours. Still, many nursing homes do not allocate resources well enough to meet this standard, and data suggests “the average nursing home maintains only 3.4 total care staff hours per day.” A report published by the New York Times in 2017 stated that day-to-day staffing fluctuates frequently, and that on the average nursing home’s least-staffed day, “on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.” More recently, in 2019, a study by Health Affairs concluded that 75% of nursing home facilities are “almost never in compliance” with what federal authorities expected their Registered Nurse staffing levels to be, and that reduced staffing levels on weekends increased the risks that residents suffered negative incidents like “falls and medication errors.”

Nutrition and Hydration

Federal law, the LTCCC report notes, requires that zoos daily feed guinea pigs and hamsters food that is “free from contamination, wholesome, palatable and of sufficient quantity and nutritive value to meet the normal daily requirements for the condition and size of the guinea pig or hamster.” When feeding animals publicly, zoos are required to provide appropriate meals that meet the animals’ nutritional needs and diet. Professional standards also stipulate that zoos maintain written nutritional programs that provide for each species behavioral and nutritional needs, and that their diets “meet the quality and quantity necessary” to satisfy their dietary and psychological needs.

Similarly, federal standards require that nursing homes provide residents with meals that are “healthy, appropriate for the individual, and appetizing,” and further that residents are ensured a dignified dining experience. Still, the LTCCC notes, inadequate food and drink is “a common problem” among nursing home residents, with researchers finding that “64 to 80 percent” of residents’ food and fluid consumption at mealtimes fell below federal standards. Research has also found that 46% of long-term care residents “had impending or current dehydration.” The report cites the example of an Ohio nursing home resident suffering from dementia who experienced more than 5% weight loss in a single month “month)” due to the facility’s failure to carry out a dietician’s order to provide snacks to counter decreases in her weight.”

Safe Food Handling

The Animal Welfare Act requires zoos to store food in facilities protected against spoilage, deterioration, and infestation or contamination by “vermin.” Food must be stored in containers with tight lids or covers, or in the containers they were received in, according to the AWA, and perishable food must be refrigerated. The AWA also mandates the cleaning and sanitizing of “used primary enclosures and food and water receptacles” before they are used to house, feed, or water new dogs or cats, or groupings thereof.

As for nursing homes, federal code stipulates that facilities must obtain food from “government approved sources,” and store, prepare, distribute, and serve that food in compliance with professional safety standards. Still, a 2018 survey by Centers for Medicare and Medicaid Services “found that food storage was the second-most cited deficiency in nursing homes.” It found in a separate study that 80% of non-foodborne outbreaks in the US occur in long-term care facilities, where residents are “highly vulnerable to viral infections,” such as the norovirus.

Medical Supervision

Federal law requires the housing, feeding, and non-medical care of zoo animals to be directed by an attending veterinarian or scientist with training and experience in the care of the species in question. Zoos must ensure that an attending veterinarian performs on-site assessments of cetaceans at least once a month, and a complete physical examination at least twice a year.

As the LTCCC explains, nursing homes are federally required that nursing homes must “ensure that the medical care of each resident is supervised by a physician… [and to] be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 thereafter.” They must also allow residents to choose their attending physicians. Nonetheless, it explains, residents “too often” do not have access to a doctor, “especially one of their choosing.” In 2018, for instance, nursing homes received 3,876 citations for “failing to provide sufficient nursing and physician services.” On top of that, according to the LTCCC, there is an average of 300 yearly citations “for failure to administer a nursing home in a way that maintains” resident well-being, and there were 938 citations in 2018 for a failure to ensure the competency of care staff.

The report cites one particular instance of competency issues: a physician at Humboldt House Rehabilitation and Nursing Center, a for-profit nursing home and Buffalo, New York, who “inappropriately administered insulin injections to a diabetic resident despite a hospital discharge note stating, “PLEASE AVOID GIVING THIS PATIENT INSULIN,” in capital letters.” According to the LTCCC, the physician said he had not read the discharge summary, and further “blamed a nurse for inaccurately reading to him the resident’s discharge directives.” The facility received a fine from the federal government of $47,827.

Stimulating and Safe Environment

Federal requirements state that zoo animals’ physical environments “must be enriched by providing means of expressing noninjurious species-typical activities,” with the particular form of enrichment determined by each species’ needs. Special considerations must also be given to some species of nonhuman primates, as well as animals displaying indicators of psychological distress, animals in approved research,”; individually housed nonhuman primates unable to see and hear nonhuman primates of their own compatible species; and apes that weigh more than 110 pounds. Furthermore, enclosures used to transport nonhuman primates are required to be of a size that allows each individual to “turn around freely in a normal manner and to sit in an upright, hands down position without its head touching the top of the enclosure.” Marine mammals, meanwhile, must be provided with enough space “to make normal postural and social adjustments with adequate freedom of movement.” Professional standards stipulate that animals are to be housed in enclosures that keep them safe and meet both physical and psychological needs. Finally, the LTCCC notes that professional standards require zoos to keep animals safe from adverse weather conditions.

Nursing homes, meanwhile, are required by various federal standards to provide safe environments that meet residents’ physical and psycho-social needs and goals, regardless of “cognitive status or physical abilities.” Still, the report states, nursing homes have fallen short of these standards in numerous respects. For instance, a study by the Centers for Disease Control found that roughly 50% of nursing home residents have been diagnosed with depression, which is about double the rate in adult day services centers and residential care communities. A study in 2018 compared three nursing home facilities and concluded that residents spent less time in their rooms when the facility’s residential offerings were “the least homelike.” Earlier studies found that residents suffering from dementia “spend the majority of their time engaged in no activity at all,” even though, according to the 2018 study, residents tend to participate in activities when nursing homes provide such.

Freedom from Restraints

Zoo industry guidelines state that the restraint of animals absent sedation or anxiety medications “anxiolytics should be limited to short, nonpainful procedures or longer procedures in species that are exceptionally tolerant to manual restraint.” Federal law, meanwhile, forbids the use of restraint devices on nonhuman primates except in cases where health reasons or research purposes require it, and even in those cases “restraint must be for the shortest period possible.”

As for nursing home residents, federal law guarantees them the right to freedom from the use of physical or chemical restraints “imposed for purposes of discipline or convenience, and not required to treat the resident’s medical symptoms.” Still, according to the LTCCC, physical and chemical restraints are a cause of preventable suffering and death in nursing homes. For instance a 2012 report by the New York Times found that there were roughly 550 bed rail-related deaths between 1995 and 2012. Bed rails pose an increased risk of harm and death for some residents, according to the LTCCC: “Residents may harm themselves when attempting to climb over, under, through, or around bed rails. Without a proper assessment, bed rails may place residents in immediate risk of serious injury or death.” Meanwhile, about 20% of residents are given “powerful and dangerous anti-psychotic drugs,” in spite of FDA warnings against the use of such drugs on elder people suffering from dementia. A report by Human Rights Watch found that US nursing home facilities “administer antipsychotic drugs to over 179,000 people who do not have diagnoses for which the drugs are approved.” As the LTCCC explains, many facilities use these drugs to restrain individuals rather than providing them with appropriate care and services.

Treatment of Injuries

When it comes to medical care of zoo animals, professional standards require, among other things, that elephants “be trained to accept regular skin care” and that staff must be trained to give them that care. Elephant skin “must be thoroughly inspected on a daily basis and cared for as needed through bathing, removal of dead skin, and treatment of dry skin or other skin problems,” according to those standards.

In nursing homes, meanwhile, residents must receive care of a professional quality that prevents bedsores / pressure ulcers from developing unless medically unavoidable, and that promotes the healing of existing pressure ulcers while preventing infection and preventing the development of new ulcers. Nonetheless, the LTCCC says, more than 93,000 current nursing home residents in the US, or about 7.3% of the population, suffer from pressure ulcers, and 85% are at risk of developing them. The report cites a few examples of substandard injury treatment in nursing homes: a for-profit Tennessee nursing home whose residents’ pressure ulcers were not prevented or treated, partly due to the facility’s “failure to notify a physician about newly identified pressure ulcers.”

Appropriate Medications

Industry standards require that written and formalized procedures be made available to care staff who provide drugs to animals for veterinary purposes, and that drugs be kept under appropriate security. Outdated medications are required to be marked and stored separately from other medications, and controlled substances “must be stored in a securely locked container of substantial construction.”

Whereas nursing homes are subject to “strong standards” requiring them to provide residents with appropriate medications, prevent errors, and avoid the use of antipsychotics, these standards “are poorly enforced by the state and federal oversight agencies” responsible for overseeing nursing homes. For instance, one review published in a medical journal found that “16 to 27 percent of residents” in nursing home studies had suffered from medication errors. A 2018 study, meanwhile, found that nursing home underreport the prescription of antipsychotic drugs, failing to identify as many as 6,000 residents quarterly who received such drugs in spite of their prescriptions being paid by Medicare. More recently, a 2019 study concluded that nursing home residents suffering from Parkinson’s disease and being administered inappropriate antipsychotic medications “had an increased risk of pneumonia” in comparison to residents being administered appropriate medications. The LTCCC also describes an incident at an Indiana nursing home in which a certified nursing aide allegedly give three residents her own prescription narcotic, Clonazepam, when they were “acting ‘disruptively.'”

Infection Control and Prevention

Industry standards concerning infection control at zoos stipulate, generally, the establishment and maintenance of “a complete and thorough veterinary program and common sense sanitary measures.” Zoos are required to have “adequate written protocols” to protect animals from exposure to pathogens, and to implement preventative methods such as vaccinations, testing, and parasite exams for all animals, under the supervision of a “qualified veterinarian.”

As for nursing homes, federal rules and regulations provide for the creation of infection control programs that ensure residents “a safe, sanitary, and comfortable environment in which residents reside and to help prevent the development and transmission of disease and infection.” But, again, these standards are not always adequately maintained. According to the LTCCC, infections result in about 388,000 annual deaths in long term care facilities. Inadequate infection control and prevention programs is “the number one cited deficiency” in nursing homes; improper hand-washing technique in particular is “the most common issue” under that umbrella. The 1.6-3.8 million annual infections in residential care facilities, per the LTCCC, cost from $673 million to $2 billion. Infection control failures are also under-penalized, according to a Kaiser Health News analysis finding that “one of 75 homes found deficient received a high-level citation that is likely to result in a financial penalty.”

More more information, check out the full LTCCC report here.

The attorneys at the Law Offices of Thomas L. Gallivan, PLLC work diligently to protect the rights of nursing home residents.  Please contact us to discuss in the event you have a potential case involving neglect or abuse.

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