Federal officials have placed two Maryland nursing homes on a nationwide watch list that has been made public as a way to alert consumers and push owners to improve conditions.
The "Special Focus Facility" list currently comprises 131 nursing homes that have provided consistently poor care over three years. As a result, they must be inspected twice a year, instead of once, and face possible penalties. The Centers for Medicare & Medicaid Services began to publish the names online in November after criticism that the decade-old list had been provided to industry lobbyists and not to the public.
CMS released more data on troubled facilities in response to advocates for nursing home residents, said Bob Bronaugh, vice chairman of Voices for Quality Care, a nonprofit group based in Leonardtown. "It's a great tool to help family members in selecting a facility," he said.
In Maryland, ManorCare-Rossville in Baltimore County and the Waldorf Center in Charles County were listed because of serious violations of federal and state regulations, said Wendy Kronmiller, director of the state Office of Health Care Quality.
"There is a pattern of poor care that doesn't seem to lift itself," she said.
Her office, part of the Department of Health and Mental Hygiene, performs inspections and imposes sanctions. It has denied payments from Medicare and Medicaid for new admissions to the 172-bed ManorCare-Rossville as a result of the pattern of violations, Kronmiller said.
CMS placed the Baltimore County facility on the list in January. An update of the list posted last week has Manor Care-Rossville under the category "facilities that have not improved." In April, state inspectors returned to the nursing home and verified that it had corrected problems found in January. CMS notes that state governments enter inspections into CMS' databases and "data lags of up to several months can occur" from when inspections are conducted and updates are posted.
CMS also categorizes nursing homes that have "shown improvement." Facilities are removed from the list if they sustain "significant improvements in quality of care" for about a year, federal officials say.
Ohio-based HCR ManorCare said in a written statement that ManorCare-Rossville has made several management changes, including "adding tenured leadership to the administrative staff."
"ManorCare takes the survey process very seriously and has high standards for employees and the level of care they deliver," said a company spokeswoman, Kelly Kessler.
Heartland Healthcare, a Hyattsville nursing home also owned by HCR ManorCare, recently "graduated" after being on the list for 18 months.
Waldorf Center was listed early last month. Administrator Ed Curtis said Pennsylvania-based Genesis HealthCare has expanded the staff and spent $1.2 million on renovations since buying the Charles County nursing home in November 2006. "We have made drastic changes in the building," Curtis said.
Over the past two years, the state has fined Heartland Healthcare $25,000, Waldorf $23,000 and Rossville $9,000, Kronmiller said.
CMS would have more of the nation's roughly 16,000 nursing homes on the list if it had more funding for inspections, said agency spokeswoman Mary Kahn. The agency previously listed two nursing homes from each state but now bases the number on a state's total facilities.
"It is not intended to imply that the Special Focus list is all-inclusive," Kahn said. "There are lots and lots of nursing homes that have violations and histories of poor performance.
"We only have so much money. We're trying to rotate them on and off."
About half of nursing homes on the list significantly improve their quality of care within 24 to 30 months, and nearly 16 percent are terminated from the Medicare and Medicaid programs, according to CMS. That loss usually leads to a nursing home closing.
The federal government says nursing homes on the list were among the 5 percent to 10 percent with the worst inspection reports.
Maryland has 233 nursing homes. Each one is expected to furnish recent inspection reports to the public.
Some activists who track nursing home conditions say the federal government's decision to post the list online "needs to be tempered by an injection of reality."
They note that CMS places nursing homes on the list based on annual inspections over the most recent three years but that problems in many cases surfaced years earlier.
"How many patients and families suffered poor care in a nursing home that is just now being publicly identified as being poorly performing when the agency has known about it for several years," said Dennis Steele, a partner with MemberoftheFamily.net, a firm that analyzes inspection and complaint data about nursing homes.
A review of inspection reports for ManorCare-Rossville shows a pattern of the state finding problems, management outlining ways to solve them and then similar incidents occurring. Residents' names were not disclosed in those or other inspection reports examined by The Sun.
An inspection in January 2006 revealed a lack of precautions in the care of a 70-year-old woman with diagnoses that included right-side paralysis, high-blood pressure and depression. A review of her medical record found the staff had identified her as at risk for falling. A physician had ordered her bed to be in the lowest position, with mats to cushion a fall.
"However, on Dec. 12, 2005, the resident fell out of bed in the highest position and sustained a fracture to her right femur," inspectors said.
An inspection completed a year later found another failure to heed doctors' orders. The physician of a man admitted with multiple diagnoses, including heart disease and dementia, had ordered morphine for pain under circumstances that occurred Jan. 30, 2007.
A nurse's note at 11 a.m. said: "Resident noted to have labored breathing. [Oxygen] applied via mask @ 3 [liters]. Resident lethargic, unresponsive to tactile stimuli. MD notified. Orders obtained for Morphine 3 mg ... Pharmacy made aware of stat Morphine order ... "
The inspector wrote that the man died at 12:20 p.m.
The morphine had not arrived from the pharmacy, and the director of nursing said morphine was not available in the emergency drug box, according to the inspection.
The Waldorf Center has "multiple years of problems," said Kronmiller, with inspections over the past three years showing lapses such as a failure to report or investigate a serious incident and a failure to honor a directive.
About 4:30 a.m. Sept. 13, 2006, a Waldorf Center resident had to be rushed to the hospital for emergency treatment after he was found hanging from the overbed table in his room, a bedsheet tied around his neck. "Cardiopulmonary resuscitation was initiated," according to a state inspection conducted three months later in response to a complaint.
The resident had been admitted with a history of heart disease and a "change in mental status," the report said.
Inspectors wrote that administrators could not document that the incident had been reported to the state or investigated internally.
The next spring, the staff "failed to honor a resident's right to refuse treatment," an annual inspection found. The 76-year-old woman had been admitted to the Waldorf Center in 2006 with diagnoses including Alzheimer's and Parkinson's diseases. She had a 1997 medical directive stating that if she were about to die, she should not receive "life-sustaining procedures."
Yet in March 2007, at the direction of her daughter and a physician, she began receiving artificial hydration and nutrition through a gastronomy tube - treatments specifically banned in her directive.
"The failure to honor the resident's wishes involved multiple disciplines ... and was ongoing for a significant amount of time," the report states.
Kronmiller, the Maryland regulator, said both nursing homes have had examples of "garden-variety bad care."
For more information about nursing homes, go to the Web site of the Centers for Medicare & Medicaid Services at www.cms.hhs.gov/certification andcomplianc/12_nhs.asp. The site includes downloads of nursing homes on the Special Focus Facility list.