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United States General Accounting Office: 


Before the Special Committee on Aging, U.S. Senate: 

For Release on Delivery: 
Expected at 1:30 p.m. 
Monday, March 4, 2002: 

Nursing Homes: 

Many Shortcomings Exist in Efforts to Protect Residents from Abuse: 

Statement of Leslie G. Aronovitz: 
Director, Health Care—-Program Administration and Integrity Issues: 


Mr. Chairman and Members of the Committee: 

I am pleased to be here today as you discuss the issue of abuse in 
nursing homes. The 1.5 million elderly and disabled individuals 
residing in U.S. nursing homes constitute a population that is highly 
vulnerable because of their physical and cognitive impairments. 
Residents typically require extensive assistance in the basic 
activities of daily living, such as dressing, feeding, and bathing, 
and many require skilled nursing or rehabilitative care. Residents 
with dementia may be irrational and combative. This combination of 
impairments heightens the residents' vulnerability to abuse and 
impedes efforts to substantiate allegations and build cases for 

Our work for this committee on nursing home care quality has found 
that oversight by federal and state authorities has increased in 
recent years.[Footnote 1] During these years, however, the number of 
homes cited for deficiencies involving actual harm to residents or 
placing them at risk of death or serious injury remained unacceptably 
high--30 percent of the nation's 17,000 nursing homes. Concerns exist 
that too many nursing home residents are subjected to abuse-—such as 
pushing, slapping, beating, and sexual assault-—by the individuals 
entrusted with their care. You therefore asked us to examine efforts 
by nursing home oversight authorities to protect residents against 
physical and sexual abuse. My remarks today will focus on (1) inherent 
difficulties in measuring the extent of the abuse problem, (2) gaps in 
efforts to prevent and deter resident abuse, and (3) the limited role 
of law enforcement in abuse investigations. My comments reflect the 
findings of a report we are issuing today. The report is based on our 
visits to three states with relatively large nursing home populations 
and discussions with officials at the Centers for Medicare and 
Medicaid Services (CMS)-—the federal agency charged with oversight of 
states' compliance with federal nursing home standards.[Footnote 2] 

In brief, the ambiguous and hidden nature of abuse in nursing homes 
makes the prevalence of this offense difficult to determine. CMS 
defines abuse in its nursing home regulations and the states we 
visited maintain definition consistent with the CMS definition. 
However, the states vary in their interpretation and application of 
the definitions. For example, nurse aides in two of the states we 
visited who struck residents were not considered abusive by state 
survey agency officials under certain circumstances, whereas the third 
state's nurse aides under similar circumstances were consistently 
cited for this offense. Incidents of abuse often remain hidden, 
moreover, because victims, witnesses, and others, including family 
members, are unable to file complaints or are reluctant for several 
reasons, including fear of reprisal. When complaints and incidents are 
reported, they are often not reported immediately, thus harming 
efforts to investigate cases and obtain necessary evidence. 

Despite certain measures in place at various levels to prevent or 
deter resident abuse, certain gaps undermine these protections. For 
instance, states use a registry to keep records on nurse aides within 
the state, but these state registries do not include information about 
offenses committed by nurse aides in other states. Unlicensed or 
uncertified personnel, such as laundry aides and maintenance workers, 
are not listed with a registry or with a licensing or certification 
body, allowing those with a history of abuse to be employed without 
detection, unless they have an established criminal record. In 
addition, in the states we visited, nursing homes often did not notify 
state authorities immediately of abuse allegations. Moreover, states' 
efforts to inform consumers about available protections appeared 
limited, as the government agency pages in telephone books of several 
major cities we visited lacked explicitly designated phone numbers for 
filing nursing home complaints with the state. 

Local and state enforcement authorities have played a limited role in 
addressing incidents of abuse. Several local police departments we 
interviewed had little knowledge of the state survey agencies' 
investigation activities at nursing homes in their communities. Some 
noted that, by the time the police are called, others may have begun 
investigations, hampering police efforts to collect evidence. Even the 
involvement of Medicaid Fraud Control Units (MFCU)—the state law 
enforcement agencies with explicit responsibility for investigating 
allegations of patient neglect and abuse in nursing homes—is not 
automatic. MFCUs get involved in resident abuse cases through 
referrals from state survey agencies. However, as demonstrated in the 
states we visited, the extent to which a state's MFCU investigates 
cases varies according to the referral policies at each state's survey 
agency. Our review of alleged abuse cases suggests that the early 
involvement of the state MFCU can be productive in obtaining criminal 

In its federal oversight role, CMS could do more to ensure that 
nursing home residents are protected from abuse. Requirements for 
screening and hiring prospective employees, involving local law 
enforcement promptly when incidents of abuse are alleged, and ensuring 
the public's access to designated telephone numbers are among the 
protections that CMS could strengthen. Our report makes 
recommendations addressing these requirements. 


To help ensure that nursing homes provide proper care to their 
residents, a combination of federal, state, and local oversight 
agencies and requirements is in place. At the heart of nursing home 
oversight activities are state survey agencies, which, under contract 
with the federal government, perform detailed inspections of nursing 
homes participating in the Medicare and Medicaid programs. The purpose 
of the inspections is to ensure that nursing homes comply with 
Medicare and Medicaid standards. CMS, in the Department of Health and 
Human Services (HHS), is the federal agency with which the states 
contract and is responsible for oversight of states' facility 
inspections and other nursing-home-related activities.[Footnote 3] By 
law, CMS sets the standards for nursing homes' participation in 
Medicare and Medicaid. 

State survey agencies also investigate complaints of inadequate care, 
including allegations of physical or sexual abuse. Once aware of an 
abuse allegation, nursing homes are required by CMS to notify the 
state survey agency immediately. They must also conduct their own 
investigations and submit their findings in written reports to the 
state survey agency, which determines whether to investigate further.
Certain federal and state requirements focus on the screening of 
prospective nursing home employees. CMS requires nursing homes to 
establish policies prohibiting employment of individuals convicted of 
abusing nursing home residents. Although this requirement does not 
include offenses committed outside the nursing home, the three states 
we visited—Georgia, Illinois, and Pennsylvania—do not limit offenses 
to those committed in the nursing home setting and have broadened the 
list of disqualifying offenses to include kidnapping, murder, assault, 
battery, or forgery. 

As another protective measure, federal law requires states to maintain 
a registry of nurse aides—specifically, all individuals who have 
satisfactorily completed an approved nurse aide training and 
competency evaluation program.[Footnote 4] This requirement is 
consistent with the fact that nurse aides are the primary caregivers 
in these facilities. Before employing an aide, nursing homes are 
required to check the registry to verify that the aide has passed a 
competency evaluation.[Footnote 5] Aides whose names are not included 
in a state's registry may work at a nursing home for up to 4 months to
complete their training and pass a state-administered competency 
evaluation. CMS' nursing home regulations require states to add to the 
registry any findings of abuse, neglect, or theft of a resident's 
property that have been established against an individual. The 
inclusion of such a finding on a nurse aide's record constitutes a 
lifetime ban on nursing home employment, as CMS regulations prohibit 
homes from hiring individuals with these offenses. As a matter of due 
process, nurse aides have a right to request a hearing to rebut the 
allegations against them, be represented by an attorney, and appeal an 
unfavorable outcome. Other nursing home professionals who are 
suspected of abuse and who are licensed by the state, such as 
registered nurses, are referred to their respective state licensing 
boards for review and possible disciplinary action. 

Among the local and state law enforcement agencies that may 
investigate nursing home abuse cases are the MFCUs. MFCUs are state 
agencies charged with conducting criminal investigations related to 
Medicare and Medicaid. Generally, MFCUs are located in the state 
attorney general's office, although they can be located in another 
state agency, such as the state police. Part of their mission is to 
investigate patient abuse in nursing homes. MFCUs typically receive 
abuse cases from referrals by state survey agencies. If criminal 
charges are brought, prosecuting attorneys within the MFCU or 
attorneys representing the locality take charge of the case. 

Ambiguous and Hidden Nature of Nursing Home Abuse Makes Extent of 
Problem Difficult to Measure: 

The problem of nursing home abuse is difficult to quantify and is 
likely understated for several reasons. First, states differ in what 
they consider abuse, with the result that some states do not count 
incidents that CMS or other states would count as abuse. Second, 
powerful incentives exist for victims, their families, and witnesses 
to keep silent or delay the reporting of abuse allegations. Third, 
some research focuses on citations of nursing homes for abuse-related 
violations, which are maintained in a CMS database, but these data 
reflect only the extent to which facilities fail to comply with 
federal or state regulations. Abuse incidents that nursing homes 
handle properly are not counted, because no violation has been 
committed that warrants a citation. 

States Do Not Share Common View of Resident Abuse: 

Some states may not be citing nurse aides for incidents that other 
states would consider abuse. Based on the definition of abuse in the 
Older Americans Act of 1965,[Footnote 6] CMS defines abuse as "the 
willful infliction of injury, unreasonable confinement, intimidation, 
or punishment with resulting physical harm, pain or mental anguish." 
[Footnote 7] States maintain their own definitions that are consistent 
with the CMS definition. Our review of case files showed that states 
interpret and apply these definitions differently. 

For example, on the basis of the abuse cases reviewed, we noted that 
Georgia survey agency officials were less likely to determine that an 
aide had been abusive if the aide's behavior appeared to be 
spontaneous or the result of a "reflex" response. The Georgia 
officials told us that, to cite an aide for abuse, they must find that 
the individual's actions were intentional. They said they would view 
an instance in which an aide struck a combative resident in 
retaliation after being slapped by the resident as an unfortunate 
reflex response rather than an act of abuse. Among the Georgia case 
files we reviewed, we found 5 cases in which the aides struck back 
after residents hit them or otherwise made physical contact. In all 
five cases, Georgia officials had determined that the aides' behavior 
was not abusive because the residents were combative and the aides did 
not intend to hurt the residents. 

In Pennsylvania, officials emphasized other factors to determine a 
finding of abuse. They said that establishing intention was important, 
but they would be unlikely to cite an aide for abuse unless the aide 
caused serious injury or obvious pain. Our review of Pennsylvania 
files indicated that most of the aides that were found to have been 
abusive had, in fact, clearly injured residents or caused them obvious 
pain. In several cases reviewed in which residents were bumped or 
slapped and reported being in pain as the result of aides' actions, 
the survey agency officials decided not to take action against the 
aides because, in their view, the residents had no apparent physical 

In contrast, the Illinois survey agency considers any nonaccidental 
injury to be abuse. Thus, incidents not considered abusive in Georgia 
and Pennsylvania—reflex actions and incidents not involving serious 
injury or obvious pain—could be considered abusive in Illinois. In the 
17 Illinois case files we reviewed involving either combative 
residents or residents who did not suffer serious injury, officials 
found that aides had been abusive. When Illinois handled a case 
similar to a Georgia case in which a nursing home employee witnessed a 
nurse aide strike a combative resident, the state not only included 
this information in the individual's nurse aide registry file, it also 
referred the matter to the state's MFCU, resulting in a criminal 
conviction.[Footnote 8] 

CMS officials indicated that states may use different definitions of 
abuse, as long as the definitions are at least as inclusive as the CMS 
definition. The officials agreed that intent is a key factor in 
assessing whether an aide abused a resident but argued that intent can 
be formed in an instant. In their view, an aide who slaps a resident, 
regardless of whether it was a reflexive response, should be 
considered abusive. In light of these different perspectives, we have 
recommended that CMS clarify the definition of abuse to ensure that 
states cite abuse consistently and appropriately. 

People May Be Unable or Reluctant to Report Abuse Allegations: 

The physical and mental impairments typical of the nursing home 
population handicap residents' ability to respond to abuse. Some 
residents lack the ability to communicate or even realize that they 
have been abused, while others are reluctant to report abuse because 
they fear reprisal. For these reasons, elder abuse in nursing homes is 
likely underreported or often not reported immediately. In some cases, 
residents are unable to complain about what was done to them. In other 
cases, family members may hesitate to report their suspicions because 
they fear retribution or that, if reported, the resident will be asked 
to leave the home. In still other cases, facility staff fear losing 
their jobs or recrimination from coworkers, while facility management 
may not want to risk adverse publicity or sanctions from the state. In 
our file reviews, we saw evidence that family members, staff, and 
management did not immediately report allegations of abuse. (See 

Figure: Examples of Allegations Not Immediately Reported: 

[Refer to PDF for image: text box] 

* A resident reported to a licensed practical nurse that she had been 
raped. Although the nurse recorded this information in the resident's 
chart, she did not notify the facility's management. The nurse also 
allegedly discouraged the resident from telling anyone else. About 2 
months later, the resident was admitted to the hospital for unrelated 
reasons and told hospital officials she had been raped. Once hospital 
officials notified the police, an investigation was conducted and 
revealed that the resident had also informed her daughter of the 
incident, but the daughter dismissed it. The resident later told 
police that she did not report the incident to other staff because she 
did not want to cause trouble. The case was closed because the 
resident could not describe the alleged perpetrator. However, the 
nurse was counseled about the need to immediately report such 

* An aide, angry with a resident for soiling his bed, threw a pitcher 
of cold water on him and refused to clean him. Another aide witnessed 
the incident. Instead of informing management, the witness confided in 
a third employee, who reported the incident to the nursing home 
administrator 5 days after the abuse took place. The aide who threw 
the water on the resident was fired and was cited for resident abuse 
in the state's nurse aide registry. 

* Nursing home management failed to promptly notify the state survey 
agency of an incident in which an aide slapped a resident and visibly 
bruised the victim's face. Although the home investigated the 
situation and took appropriate action by quickly suspending and 
ultimately firing the aide, it did not notify the state survey agency 
until 11 days after the abuse took place. 

Source: Case files from state survey agencies in Georgia and 

[End of figure] 

Data on States' Nursing Home Citations Provide Little Information 
About Resident Abuse: 

Data from states' annual inspections of nursing homes, while a source 
of information about facility compliance with nursing home standards, 
provide little precision about the extent of care problems, of which 
resident abuse-related problems are a subset. Abuse-related violations 
committed by nursing homes include failure to protect residents from 
sexual, physical, or verbal abuse; failure to properly investigate 
allegations of resident abuse or to ensure that nursing home staff 
have been properly screened before employment; and failure to develop 
and implement written policies prohibiting abuse. 

In 2000, we reported on the wide variation across states in surveyors' 
identification and classification of serious deficiencies—conditions 
under which residents were harmed or were in immediate jeopardy of 
harm or death.[Footnote 9] The extent to which abuse-related 
violations are counted as serious deficiencies depends on how the 
surveyor classifies the severity of the deficiency identified. In our 
analysis, the problem of "interrater reliability"—that is, individual 
differences among surveyors in citing homes for serious deficiencies—
was one of several factors contributing to the difference of roughly 
48 percentage points across states in the proportion of homes cited in 
1999 and 2000 for serious deficiencies. The variation ranged from 
about 1 in 10 homes cited in one state to more than 1 in 2 homes cited 
in another. 

We also found that one state's tally of nursing homes with serious 
deficiencies would have been highly misleading as an indicator of 
serious care problems. Of the homes the state surveyed during the 1999-
2000 period, it found 84 to be "deficiency free." However, when we 
crosschecked the annual inspection results for these homes with the 
homes' history of complaint allegations, we found that these 
deficiency-free homes had received 605 complaints and that significant 
numbers of these complaints were substantiated when investigated. This 
discrepancy illustrates the difficulty of estimating the extent of 
resident abuse using nursing home inspection data. 

Gaps Exist in Efforts to Prevent or Deter Resident Abuse: 

Nursing home residents' inability to protect themselves accentuates 
the need for strong preventive measures to be in place in both nursing 
homes and the agencies overseeing them. Although certain measures are 
in place, we found them to be, in some cases, incomplete or 
insufficient. In the states we visited, efforts to screen employees 
and achieve prompt reporting fell short of creating a net sufficiently 
tight to protect residents from potential offenders. 

Sources Used to Screen Prospective Employees Do Not Contain Complete 
or Up-to-Date Information: 

Nursing homes have available three main tools to screen prospective 
employees: criminal background checks conducted by local law 
enforcement agencies, criminal background checks conducted by the 
Federal Bureau of Investigation (FBI), and state registries listing 
information on nursing home aides, including any findings of abuse 
committed in the state's facilities. The information included in these 
sources, however, is often not complete or up to date. 

State and local law enforcement officials in the three states we 
visited conduct background checks on prospective nursing home 
employees, but these checks are made only state wide. Consequently, 
individuals who have committed disqualifying crimes—including 
kidnapping, murder, assault, battery, and forgery—may be able to pass 
muster for employment by crossing state lines. On request, the FBI 
will conduct background checks outside the prospective employee's 
state of residence, but in some states these requests are rarely made, 
according to an FBI official. 

Some states allow individuals to begin working before facilities 
complete their background checks. Pennsylvania permits new employees 
to work for 30 days and Illinois, for 3 months, before criminal 
background checks are completed. In contrast, Georgia requires that 
background checks be completed within 3 days of the request and 
interprets this requirement to mean that the checks must be completed 
before prospective employees may assume their duties. 

Of the three states we visited, only Illinois requires that the 
results of criminal background checks on prospective nurse aides be 
reported to the state survey agency, which enters the information in 
the registry. A 1998 survey conducted by BIB' Office of Inspector 
General reported that Illinois was the only state with this 
requirement.[Footnote 10] Nursing homes in Illinois checking the state 
registry are able to determine if an aide has a disqualifying 
conviction well before an offer of employment is made and a criminal 
background check is initiated. Alternatively, the survey agencies in 
states without this requirement do not have the information necessary 
to warn their respective nursing home communities about inappropriate 
individuals seeking employment. 

Nurse aide registries, designed to maintain background information on 
nursing home aides, also contain information gaps that can undermine 
screening efforts. To cite an individual in the state's registry for a 
finding of abuse, authorities must first establish a finding, notify 
the individual of the intent to "annotate" the registry, and if the 
individual requests, hold a hearing to consider whether the finding is 
warranted. Specifically, the individual must be notified in writing of 
the state's intent to annotate the registry and be given 30 days from 
the date of the state's notice to make a written request for a 
hearing. Because the hearing may not be completed for several months 
after it is requested and decisions may not be rendered immediately, 
additional time may elapse. As with background checks, state 
registries do not track an aide's offenses committed at nursing homes 
in other states. 

Our analysis of nurse aide records from 1999 indicated that hearings 
to reconsider an abuse finding added, on average, 5 to 7 months to the 
process of annotating an individual's record in the state registry. 
During this time, residents of other nursing homes were at risk 
because, even if an aide was terminated from one home, the individual 
could find new employment in other homes before the state's registry 
included information on the individual's offense. Thus, because of the 
amount of time that can elapse between the date a finding is 
established and the date it is published, the use of nurse aide 
registries as a screening tool alone is inadequate. 

Facilities can screen licensed personnel, such as nurses and 
therapists, by checking the records of licensing boards for 
disciplinary actions, but screening other facility employees, such as 
laundry aides, security guards, and maintenance workers, is limited to 
criminal background checks. Unless such employees are convicted of an 
offense, problems with their prior behavior will not be detected. No 
centralized source contains a record of substantiated abuse 
allegations involving these individuals. Even when abuse violations 
identified through nursing home inspections are cited, they result in 
sanctions against the homes and not the employees. We identified 10 
uncertified and unlicensed employees in the 158 cases we reviewed who 
allegedly committed abuse. One of the 10 pled guilty in court, thus 
establishing a criminal record. However, the disposition of five of 
these cases left no way to track the individuals through routine 
screening channels. Three of the nine—all of whom were dismissed from 
their positions—were investigated by law enforcement but were not 
prosecuted. Two others were also terminated by their nursing home 
employers but were not the subject of criminal investigations. (In 
these cases, physical abuse was alleged but the residents did not 
sustain apparent injuries.) The remaining four cases involved 
instances in which the allegations proved unfounded or the evidence 
was inconsistent; the individuals were thus not tracked, as 

In 1998, the HHS Office of the Inspector General recommended 
developing a national abuse registry and expanding state registries to 
include not only aides but all other nursing home employees cited for 
abuse offenses.[Footnote 11] A firm that CMS (then the Health Care 
Financing Administration) contracted with in September 2000 is 
currently conducting a feasibility study regarding the development of 
a national registry that would centralize nurse aide registry 
information and include information on all nursing home employees. The 
contractor intends to report its findings in March 2002. 

Efforts to Alert Authorities of Abuse Incidents and Allegations Lack 
Sufficient Rigor: 

Enlisting the help of the facilities and the public to report 
incidents and allegations of abuse can supplement other efforts to 
protect nursing home residents. However, in the states we visited, 
nursing homes' performance in notifying the survey agencies promptly 
was well below par. In addition, access to information on phone 
numbers the public could use for filing complaints was limited.
In the three states we visited, nursing homes are required to notify 
their state survey agencies of abuse allegations immediately, which 
the agencies define as the day the facility becomes aware of the 
incident or the next day. Using this standard, we examined 111 abuse 
allegations filed by the three states' nursing homes. We found that, 
for these allegations, the homes in Pennsylvania notified the state 
late 60 percent of the time; in Illinois, late almost half of the 
time; and in Georgia, late about 40 percent of the time. Each state 
had several cases for which homes notified the state a week or more 
late and in each state at least one home notified the state more than 
2 weeks late. Such time lags delay efforts by the survey agencies to 
conduct their own prompt investigations and ensure that nursing homes 
are taking appropriate steps to protect residents. In these 
situations, residents remain vulnerable to additional abuse until 
corrective action is taken. 

As a nursing home resident's family and friends are another essential 
resource for reporting abuse to the state authorities, increasing 
public awareness of the state's phone number for filing complaints 
should be a high priority. CMS requires nursing homes to post phone 
numbers for making complaints to the state. However, in major cities 
of the states we visited, phone numbers specifically for lodging 
complaints to the state survey agency were not listed in the telephone 
book. This was the case in Chicago and Peoria, Illinois; in Athens and 
Augusta, Georgia; and in Philadelphia and Pittsburgh, Pennsylvania. 

At the same time, the telephone books we examined listed numbers in 
the government agency pages for organizations that appeared to be 
appropriate for reporting abuse allegations but did not have authority 
to take action. In the telephone books of selected cities in the three 
states we visited, we identified listings for 42 such entities that 
were not affiliated with the state survey agencies. Of these, six 
entities said they were capable of accepting and acting on abuse 
allegations. These included long-term care ombudsmen and adult 
protective services offices. The other 36 either could not be reached 
or could not accept complaints, despite having listings such as the 
"Senior Helpline" or the "Fraud and Abuse Line." Sometimes these 
entities attempted to refer us to an appropriate organization to 
report abuse, with mixed success. For example, calls we made in 
Georgia resulted in four correct referrals to the state survey 
agency's designated complaint intake line but also led to five 
incorrect referrals. Five entities offered us no referrals. 

Law Enforcement's Involvement in Protecting Residents Is Limited: 

The involvement of law enforcement in protecting nursing home 
residents has generally been limited. Owing to the nature of the 
nursing home population, developing adequate evidence to investigate 
and prosecute abuse cases and achieve convictions is difficult. The 
states we visited had different policies for referring cases to law 
enforcement agencies. 

Residents' Impairments Weaken Law Enforcement's Efforts to Develop 

Critical evidence is often missing in elder abuse cases, precluding 
prosecution. Our review of states' case files included instances in 
which residents sustained black eyes, lacerations, and fractures but 
were unable or unwilling to describe what had happened. However, 
despite what appeared to be signs of abuse, investigators could 
neither rule out accidental injuries nor identify a perpetrator. 

The cases that are prosecuted are often weakened by the time lapse 
between the incident and the trial. Law enforcement officials and 
prosecutors indicated that the amount of time that elapses between an 
incident and a trial can ruin an otherwise successful case, because 
witnesses cannot always retain essential details of the incident. For 
example, in one case we reviewed, a victim's roommate witnessed an 
incident of abuse and positively identified the abuser during the 
investigation. By the time of the trial nearly 5 months later, 
however, the witness could no longer identify the suspect in the 
courtroom, prompting the judge to dismiss the charges. Law enforcement 
officials told us that, without testimony from either a victim or 
witness, conviction is unlikely. Similarly, resident victims may not 
survive long enough to participate in a trial. A recent study of 20 
sexually abused nursing home residents revealed that 11 died within 1 
year of the abuse.[Footnote 12] 

Local Law Enforcement Authorities in States Visited Not Frequently 
Involved With Nursing Home Abuse Incidents: 

In the states we visited, local law enforcement authorities did not 
have much involvement in nursing home abuse cases. Our discussions 
with officials from 19 local law enforcement agencies indicate that 
police are rarely summoned to nursing homes to investigate allegations 
of abuse. Of those 19 agencies, 15 indicated that they had little or 
no contact with their state's survey agency regarding abuse of nursing 
home residents in the past year. In fact, several police departments 
we interviewed were unaware of the role state survey agencies play in 
investigating instances of resident abuse. Several of the police 
officials we met with noted that, even when the police are called, 
other entities may have begun investigating, hampering further 
evidence collection. 

Involving law enforcement authorities does not appear to be common for 
abuse incidents occurring in nursing homes. Facility residents and 
family members may report allegations directly to the facility. There 
is no federal requirement compelling nursing homes that receive such 
complaints to contact local law enforcement, although some states, 
including Pennsylvania, have instituted such requirements. 

MFCUs Not as Involved as Their Mission Would Suggest: 

The involvement of MFCUs—-the state law enforcement agencies whose 
mission is to, among other things, investigate allegations of patient 
neglect and abuse in nursing homes—-is not automatic. MFCUs get 
involved in resident abuse cases through referrals from state survey 
agencies. Each of the states we visited had a different referral 
policy. In Pennsylvania, by agreement, the state's MFCU typically 
investigates nursing home neglect matters, while local law enforcement 
agencies investigate nursing home abuse. In contrast, the survey 
agencies in Illinois and Georgia both refer allegations of resident 
abuse to their states' MFCUs, but these two states' referral policies 
also differ from one another. 

Of the cases we reviewed in Illinois, the survey agency consistently 
referred all reports of physical and sexual abuse to the state's MFCU, 
regardless of whether the source of the report was an individual or a 
nursing facility. The Illinois MFCU, in turn, determined whether the 
cases warranted opening an investigation. The Georgia survey agency, 
on the other hand, screened its allegations before referring cases to 
the state's MFCU, basing its assessment of a case's merit on the 
severity of the harm done and the potential for the MFCU to obtain a 
criminal conviction. 

Our review of case files from Illinois and Georgia suggests that the 
more the state's MFCU is involved in resident abuse investigations, 
the greater the potential to convict offenders.[Footnote 13] (This 
case file review consisted of only those cases that were opened in 
1999 and closed at the time of our review.) The Illinois MFCU obtained 
18 convictions from 50 unscreened referrals. In Georgia, however, 
where the survey agency tried to avoid referring weak cases to the 
state's MFCU, 14 of 52 cases were referred and 3 resulted in 
convictions. The state's small number of convictions from the cases 
opened in 1999 was not consistent with the expectation that 
prescreened cases would have greater potential for successful 
prosecution.[Footnote 14] 

In 2000, the Georgia survey agency substantially changed its MFCU 
referral policy, leading to a four-fold increase in the state's total 
number of referrals from the previous year. The policy change followed 
a meeting between survey agency and MFCU officials, at which the MFCU 
indicated a willingness to investigate instances that the survey 
agency had previously assumed the MFCU would have dismissed—such as 
incidents involving nursing home employees slapping residents. 

The timeliness of referrals made to the MFCU may also play a role in 
achieving favorable results. Of the 64 cases referred in the two 
states, we determined that the Illinois survey agency referred its 
cases to the MFCU earlier than did Georgia's Illinois referred its 
cases, on average, within 3 days after receiving a report of abuse, 
whereas Georgia referred its cases, on average, 15 days after learning 
about an allegation. 

Concluding Observations: 

The problem of resident abuse in nursing homes is serious but of 
unknown magnitude, with certain limitations in the adequacy of 
protections in the states we visited. Nurse aide registries provide 
information on only one type of employee, are difficult to keep 
current, and do not capture offenses committed in other states. At the 
same time, local law enforcement authorities are seldom involved in 
nursing home abuse cases and therefore are not in a position to help 
protect this at-risk population. MFCUs, which are likely to have 
expertise in investigating nursing home abuse cases, must rely on the 
state survey agencies to refer such cases. When a state's referral 
policy is overly restrictive, the MFCU is precluded from capitalizing 
on its potential to bring offenders to justice. 

Several opportunities exist for CMS to establish new safeguards and 
strengthen those now in place. Our report includes recommendations for 
CMS to, among other things, clarify what is included in CMS' 
definition of abuse and increase the involvement of MFCUs in examining 
abuse allegations. Without such improvements, vulnerable nursing home 
residents remain considerably ill-protected. 

Mr. Chairman, this concludes my prepared remarks. I will be pleased to 
answer any questions you or the committee members may have. 

Contact and Acknowledgments: 

For further information regarding this testimony, please contact me or 
Geraldine Redican-Bigott, Assistant Director, at (312) 220-7600. Sari 
Bloom, Hannah Fein, and Lynn Filla-Clark made contributions to this 

[End of section] 


[1] U.S. General Accounting Office, Nursing Homes: Sustained Efforts 
Are Essential to Realize Potential of the Quality Initiatives, 
[hyperlink,] (Washington, 
D.C.: 2000). 

[2] U.S. General Accounting Office, Nursing Homes: More Can Be Done to 
Protect Residents from Abuse, [hyperlink,] (Washington, D.C.: 2002). 

[3] CMS was formerly the Health Care Financing Administration (HCFA) 
and was renamed in June 2001. 

[4] In certain instances, some individuals would be exempt from this 
training, such as student nurses or nurses trained in another country. 

[5] Nursing homes in the states we visited have several means of 
checking the nurse aide registries to determine whether aides are in 
good standing and eligible for employment. Homes receive quarterly 
bulletins listing all disqualified aides in their state. In addition, 
they may obtain this information from the survey agency's website or 
by calling the survey agency. 

[6]] 42 U.S.C. § 2002 (1994). 

[7] 42 C.F.R. § 488.301 (2001). 

[8] As a result, the aide was sentenced to 2 years probation, directed 
to complete 100 hours of community service, and prohibited from 
employment that would involve contact with the elderly or people with 

[9] [hyperlink,]. 

[10] HHS Office of Inspector General, Safeguarding Long-Term Care 
Residents, A-12-9700003 (Washington, D.C.: Sept. 14, 1998). 

[11] HHS Office of Inspector General, A-12-97-00003. 

[12] Ann W. Burgess, Elizabeth B. Dowdell, and Robert A. Prentky, 
"Sexual Abuse of Nursing Home Residents," Journal of Psychosocial 
Nursing, Volume 38, No. 6, June 2000. 

[13] Because of Pennsylvania's referral policy, its MFCU files, with a 
few exceptions, did not include resident abuse cases. 

[14] Georgia's conviction results are lower than might be expected 
also given the state survey agency's practice of disregarding abuse 
allegations in which patient provocation is a factor. 

[End of section]