Report FINDINGS Page 2
Missed Violations -Nursing Home Danger
The report finds that New York has a poor record of enforcing nursing home standards. On each of the four measures of enforcement effectiveness, the report finds significant deficiencies in the state’s performance. According to federal inspectors who have accompanied state inspectors on nursing home inspections, state inspectors have committed “egregious omissions” and missed “overwhelming evidence of widespread quality of care problems.”
A. New York Inspectors Missed Many Serious Violations
January 1999 and August 2000. An analysis of these surveys indicates that state inspectors have
missed many violations of federal health and safety standards. During the state inspections of the
six nursing homes, the state inspectors found only 24 violations of federal health and safety
standards. In comparison, when the federal inspectors visited the same nursing homes, they
found 61 violations of the standards, over 150% more than the state inspectors.
Number of Actual Harm Violations
The most serious violations in nursing homes are those that cause actual harm to residents
or have the potential to cause death or serious injury. The state inspectors did an especially poor
job detecting these violations. During the state inspections of the six nursing homes, the state
inspectors found only four actual harm violations. In comparison, when the federal inspectors
visited the same nursing homes, they found 14 violations that caused actual harm to residents.
The federal inspectors thus found more than three times as many serious violations in these
nursing homes as the state inspectors
Figure 1: Federal Inspectors Found Over Three Times as Many Actual Harm
Violations as State Inspectors
An examination of the actual inspection reports reveals that the state inspectors missed
many disturbing violations. In two of the six comparative surveys, federal inspectors filled out a
form that asked whether the state inspectors should have found the violations found by the
federal team.8 Federal inspectors determined that state inspectors should have found 18 of the 21
violations found by the federal teams.9 However, state inspectors found only one of these
Violations Found
Many of the violations missed by state inspectors represent troubling quality of care
problems. For example, the federal inspectors found:
• State inspectors failed to cite one of these facilities for leaving residents in more pain than
necessary. One resident was subject to episodes of screaming behavior. Nurses
explained that pain medication reduced the screaming behavior, yet the facility had
discontinued it. Another resident grimaced and told the nurse that “it hurts” when her
dressings were changed, yet the facility failed to address the resident’s pain. Federal
inspectors found that this violation caused actual harm to residents.11
• State inspectors failed to cite the same facility for not providing proper nutrition to its
residents. This poor care caused one resident to lose over 20% of her body weight, falling
to as low as 85 lbs. and eventually requiring hospitalization. Federal inspectors found
that this violation caused actual harm to residents.12
• State inspectors also failed to cite this facility for its improper use of physical restraints,
such as vest restraints. Federal inspectors noted that the facility had “failed to
demonstrate that [the] restraints were not used for staff convenience.” Federal inspectors
found that this violation had the potential to cause more than minimal harm to residents.13
• State inspectors failed to cite the other facility for failing to notify the Department of
Health about allegations of staff abuse of a resident14 and for failing to screen five of
seven new employees for a history of abuse, neglect, or mistreatment of residents.15
Federal inspectors found that these violations had the potential to cause more than
minimal harm to residents.
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