For the elderly and their children, no two words unleash such a flood of emotions: terror, dread, bitterness, anger, anguish, anxiety.
Mention "nursing homes," and the horror stories quickly follow. You'll hear about filthy conditions, isolation, improper medication, neglect, verbal -- and occasionally even physical -- abuse.
But while a few county nursing homes have consistently fallen far short of state and federal standards, cases of neglect or serious abuse remain the exception at most.
Much more widespread are persistent staff shortages, sometimes forcing nurses and aides to work double shifts, and extraordinarily high burnout and turnover rates, says Dorothy Drummond, the long-term care ombudsman at the county Department of Aging.
Hospital placement specialists, the elderly and their relatives often struggle even to find a bed in an Anne Arundel County nursing home.
Meanwhile, the nursing homes themselves struggle to find staff to care for the influx of new patients.
Hoping to attract -- and retain -- good staff, nursing homes have gone so far as offering incentives such as free college education and a full week's pay for a weekend's work.
But such perks, along with tireless recruiting efforts, have done little to ease the shortages at most county nursing homes, Drummond says.
The work is hard, dirty and low-paid, particularly for unskilled nurses' aides, most of whom come to the job with a high school education and little or no formal training. With the population rapidly graying and insurance regulations sharply limiting hospital stays, staffers at the homes must care for more older, frail and chronically ill patients.
In Anne Arundel, it's even tougher than elsewhere to find good help.
The county's low unemployment rate, a dearth of affordable housing and the lack of public transportation combine to make unskilled, low-paid help among the hardest to find. Thus, nursing homes must compete with other employers for scarce applicants.
"In nursing homes, the work is hard physically, and it's hard emotionally, and people know they can get jobs that pay more without having to invest nearly that much emotionally," says Drummond, who investigates complaints and inspects county nursing homes.
Rapid turnover and shortages of competent staff, more than any other factors, lead to most complaints, Drummond says.
"It all comes down to retaining staff," she says. "People are just overworked and overreacting in situations because they're worn out and burned out and just at the end of their rope."
As a result, the number of complaints is growing.
Drummond says she is now looking into almost 90 complaints. They range from cold food and slow responses when patients press a call button to more serious complaints such as improper medication and verbal or physical abuse.
She resolves most without referring them to the state Department of Health and Mental Hygiene, which can impose sanctions such a ban on new admissions. Drummond says she calls in the state only in the more serious cases, or after a pattern of repeated violations of state or federal regulations.
Carol Benner, acting director of licensing and certification for the state Health Department, says state intervention usually brings quick compliance to correct deficiencies. Inspections of most Arundel nursing homes rarely reveal serious deficiencies, such as abuse or violations that could endanger patients.
But, Benner says, three Arundel homes have consistently failed inspections during the past three years: Fairfield Nursing Center in Crownsville, North Arundel Nursing and Convalescent Center in Glen Burnie and Pleasant Living Convalescent Center in Edgewater. All three have submitted required "correction plans" after inspections, Benner said.
* At the 142-bed Fairfield, Arundel's only non-profit nursing home, state officials temporarily banned new admissions in April for the third time since 1988. Officials also briefly stripped the home of its power to admit Medicare and Medicaid patients last year and the year before.
The sanctions came after investigators found a wide range of management and patient care deficiencies that endangered patients and even led to "life-threatening" situations seven times last year and once this year.
* North Arundel, a private, 121-bed nursing home, has repeatedly failed state inspections over the past two years. In October, investigators documented a pattern of violations, including improper medication, inadequate supervision and patient neglect. The nursing home could lose its Medicare and Medicaid support unless an unannounced visit shows significant improvements.
* The private, 120-bed Pleasant Living center has been cited repeatedly for irregular medication, patient neglect and deficient care provided by physicians. A March inspection revealed failure to investigate suspected physical abuse or report the cases to state and county officials or the police. Investigators also documented staffers' failure to follow physician's orders or to notify physicians of significant changes in patients' conditions.
The state inspects nursing homes at least once yearly and conducts follow-up reviews when necessary. But much of the burden of tracking complaints -- and trying to correct violations or refer them to state authorities -- falls on Drummond.
On top of dealing with scores of complaints about nursing homes at any given time, she also is charged with inspecting more than a dozen group homes that offer care to the elderly; overseeing training and continuing education for volunteers; coordinating public education and referrals for long-term care options; identifying and trying to remedy gaps in facilities, government or community services for long-term care; and advocating changes in legislation and policy to improve care.
The job description says a lot about what's wrong with regulation of nursing homes, says Drummond. Policies and regulations are geared toward crisis intervention, she says, not ensuring quality care.
"I'd like to feel like I'm doing more, but we're always putting out fires," Drummond says. "We're putting out fires instead of installing a sprinkler system. There's no time to work on the system, because we're constantly dealing with isolated complaints."
Maryland, Drummond says, is one of only three states that provide no state money for ombudsmen. Yet Maryland law requires counties to employ an ombudsman.
Besides more staff to monitor nursing homes, Drummond says fundamental changes in the regulatory system are in order. She says only measuring nursing homes based on a wide range of standards fails to answer key questions: Are the residents satisfied? If not, what can be done to change that?
Drummond says a new federal law, meant to shift much of the focus of regulation to the well-being of patients, is long overdue. But the legislation, which took effect Oct. 1, has been delayed because the federal Health Care Financing Administration has yet to publish final regulations.
The law, among other things, requires homes to perform detailed analysis of each patient's needs at least yearly and devise individual plans of care, emphasizing rehabilitation instead of only custodial care. The law also restricts the use of physical restraints or drugs that render patients practically immobile and often leave them extremely disoriented.
"What good is it for a nursing home to pass inspections if residents aren't happy?" Drummond asks. "Do we want to extend life so people can have five years tied up in a bed?
"We're way behind as a society. We should be honoring the old. We should be able to deal with them without just tying them up and forgetting them.
We should treat each of them as an individual."