Nursing Homes: Improved Oversight Needed to Better Protect Residents from Abuse

Nursing homes provide care to about 1.4 million nursing home residents—a vulnerable population of elderly and disabled individuals. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs.

GAO was asked to review abuse of residents in nursing homes. Among other objectives, this report: (1) determines the trends and types of abuse in recent years, and (2) evaluates CMS oversight intended to ensure residents are free from abuse.

GAO reviewed CMS's policies, analyzed CMS data on abuse deficiencies from 2013 through 2017, the most recent data at the time of our review, and interviewed officials from CMS and state survey agencies in five states, as well as other key stakeholders in those states such as ombudsmen and law enforcement officials. The states were selected for variation in factors such as number of nursing homes and role of other state agencies in abuse investigations.

The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state's homes and to investigate complaints and incidents. GAO analysis of CMS data found that, while relatively rare, abuse deficiencies cited in nursing homes more than doubled, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. GAO also reviewed a representative sample of abuse deficiency narratives from 2016 through 2017. Physical and mental/verbal abuse occurred most often in nursing homes, followed by sexual abuse, and staff were more often the perpetrators of the abuse deficiencies cited. CMS cannot readily access information on abuse or perpetrator type in its data and, therefore, lacks key information critical to taking appropriate actions.

GAO also found gaps in CMS oversight, including:

Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement.

Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all of the state survey agencies in GAO's review said the facility-reported incidents can lack information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.

GAO is making six recommendations, including that CMS: require state survey agencies to submit data on abuse and perpetrator type; require state survey agencies to immediately refer to law enforcement any suspicion of a crime; and develop guidance on what abuse information nursing homes should self-report. HHS concurred with all of GAO's recommendations and identified actions it will take to implement them.

Nationwide, more than 15,500 nursing homes participating in the  Medicare and Medicaid programs provide care to about 1.4 million elderly  or disabled nursing home residents. These residents often have physical  and cognitive limitations that can make them particularly vulnerable to  abuse. Abuse of nursing home residents can occur in many forms— including physical, mental, verbal, and sexual—and can be committed by  staff, residents, or others in the nursing home. Little is known about the  full scope of nursing home abuse, as incidents of abuse may be  underreported. Any incident of abuse is a serious occurrence and could  result in potentially devastating consequences for residents, including  lasting mental anguish, serious injury, or death.

Federal law mandates that nursing homes receiving Medicare and  Medicaid payments must ensure that residents are free from abuse. To  help ensure this, the Centers for Medicare & Medicaid Services (CMS),  an agency within the Department of Health and Human Services (HHS),  defines the quality standards that nursing homes must meet in order to  participate in the Medicare and Medicaid programs. To monitor  compliance with these standards, CMS enters into agreements with  agencies in each state government—known as state survey agencies— and oversees the work the state survey agencies do. This work includes  conducting required evaluations—referred to as standard surveys— approximately once each year of all nursing homes in a state that  participate in the Medicare or Medicaid programs, as well as investigating  both complaints from the public and facility-reported incidents regarding  resident care or safety. When a state survey agency finds a nursing  home out of compliance with a federal standard, the home receives a  deficiency citation, also known as a deficiency.

In addition to state survey agencies, other state-based agencies are  charged with protecting nursing home residents from abuse. These  agencies’ roles, missions, and standards of evidence for determining  whether or not abuse occurred can vary by state. For example, Adult  Protective Services may also help ensure nursing home residents receive  quality care in a safe environment by investigating allegations of abuse.  Law enforcement can also play a role in protecting nursing home  residents from abuse and, in addition, Medicaid Fraud Control Units  (MFCU) in each state are tasked with investigating and prosecuting a  variety of health care-related crimes.

We have previously reported on problems in nursing home quality,  including problems protecting residents from abuse and weaknesses in  CMS’s oversight. For example, in multiple reports dating back to 1998, we  have identified weaknesses in federal and state activities designed to  correct quality problems in nursing homes. Specifically, in a 2002 report,  we found that CMS needed to do more to protect nursing home residents  from abuse and made five recommendations to help CMS facilitate the  reporting, investigation, and prevention of abuse in nursing homes. More  recently, in April 2019 we reported that CMS had failed to address gaps in  federal oversight of nursing home abuse investigations in Oregon that  persisted for at least 15 years until the Oregon state survey agency  changed its practices in October 2018. Further, a 2017 HHS Office of the  Inspector General (OIG) report found that CMS does not have adequate  procedures in place to ensure incidents of potential abuse in nursing  homes are identified and reported. In addition, news reports have  described concerning examples of incidents where nursing home  residents were abused.

You asked us to review abuse of nursing home residents including,  among other issues, what CMS data reveal about the prevalence of  abuse and the extent to which CMS oversees nursing homes. In this  report, we:  1.  determine the trends and types of abuse occurring in nursing homes  2.  describe the risk factors for abuse and challenges facing stakeholder  agencies involved in investigating abuse in nursing homes, and  3.  evaluate CMS oversight intended to ensure that nursing home  residents are free from abuse.

To determine the trends and types of abuse occurring in nursing homes in  recent years, we reviewed CMS guidance and analyzed CMS data from  2013 through 2017, which represented the most recent data for a 5-year  period at the time of our review. First, we reviewed the CMS State  Operations Manual in effect during our period of review to determine the  federal standards and associated deficiency codes related to resident  abuse. We focused our analysis on the deficiency code to be used by  state surveyors when a nursing home fails to keep a resident free from  abuse, which encompasses mental/verbal, sexual, or physical abuse.

We analyzed data provided by CMS to identify the number and severity of  abuse deficiencies cited by surveyors in all 50 states and Washington  D.C. between 2013 and 2017. We then tracked (1) whether these abuse  deficiencies originated from a standard survey, complaint investigation, or  facility-reported incident investigation and (2) the enforcement actions  associated with these abuse deficiencies. Furthermore, we determined  the number of nursing homes that had one or more abuse deficiencies  from 2013 through 2017, as well as the homes with repeated abuse  deficiencies in multiple years and the characteristics of those homes.

Finally, because abuse and perpetrator type are not readily identifiable in  CMS’s data, we identified this information by reviewing a randomly  selected representative sample of 400 abuse deficiency narratives written  by state surveyors from 2016 through 2017 that describe the  substantiated abuse. Specifically, two separate reviewers independently  analyzed the text of each narrative and determined if the abuse was  physical, mental/verbal, or sexual and whether the perpetrators were  staff, residents, or others based on narrative descriptions written by state  surveyors. Any disagreements between the two reviewers were  resolved by a third independent reviewer. We assessed the reliability of  each of the datasets by checking for missing values and obvious errors  and discussing them with CMS officials who were knowledgeable about  the data. In the course of this assessment, we found some data  limitations. Specifically, CMS officials told us that some state survey  agencies may not have entered all facility-reported incidents into the CMS  database while other state survey agencies did. In a recent 2019 report,  we also found that the Oregon state survey agency was not entering all  abuse-related complaints or facility-reported incidents into the CMS  database—a problem that could exist in other states. In addition, CMS  officials told us that it is possible there are additional incidents that may not have been represented in the abuse deficiency data during the period  of our review. Specifically, CMS officials noted that some incidents  resulting from resident altercations—particularly those that do not show a  willful intent to harm—may not be cited as an abuse deficiency by some  state survey agencies. We therefore consider the number of abuse  deficiencies that resulted from complaints or facility-reported incidents to  be a conservative estimate. After reviewing the possible limitations of  these data, we determined the data were sufficiently reliable for the  purposes of this reporting objective. (See app. I for additional details on  the scope and methodology of our data analyses.)

To describe the risk factors for abuse and challenges facing stakeholder  agencies involved in investigating abuse in nursing homes, we  interviewed officials from a non-generalizable sample of five state survey  agencies—Delaware, Georgia, Ohio, Oregon, and Virginia. We selected  these states for variation in geography, whether the states’ Adult  Protective Services has oversight over nursing home residents, the  number of nursing homes in each state, CMS regional oversight, and  congressional interest. In addition to speaking to officials from state  survey agencies, we interviewed other stakeholders in these states,  including officials from each state’s long-term care ombudsmen, law  enforcement, MFCUs, and, when appropriate, Adult Protective Services.  We also visited nursing homes and spoke to administrators and clinical  staff in each state. We selected these nursing homes to obtain variation in  factors such as bed count and profit or not-for-profit status. We asked  stakeholders to describe the risk factors for abuse and the challenges  involved in investigating abuse in nursing homes. In addition, we  interviewed officials from national organizations with knowledge of  nursing home abuse issues including the American Health Care  Association, National Consumer Voice, and the National Adult Protective  Services Association to learn more about the risk factors for abuse and  the challenges facing stakeholders involved in investigating abuse.

To evaluate CMS oversight intended to ensure that nursing home  residents are free from abuse, we reviewed relevant federal laws and  CMS guidance, such as the State Operations Manual, that establishes  CMS and state survey agency oversight responsibilities for nursing  homes. We also interviewed officials at the CMS central office, the CMS regional offices that oversee the five state survey agencies in our review,  and the five state survey agencies themselves. We assessed CMS’s  oversight activities in the context of the federal standards for internal  control related to information and communications and monitoring.

We conducted this performance audit from October 2017 to June 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Nursing homes are required to keep residents safe from harm, but when  abuse is alleged, a combination of federal, state, and local agencies—as  well as the nursing homes themselves—play a role in investigating.

Federal laws establish minimum requirements nursing homes must meet  to participate in the Medicare and Medicaid programs, including  standards for the quality of care. These standards cover a variety of  categories, such as resident rights, quality of care, and quality of life. In  2016, CMS finalized a comprehensive update to its nursing home  standards to reflect new requirements and align requirements with current  clinical practices, among other things. The changes were implemented in  three phases, starting November 28, 2016.

The federal government and the states share oversight responsibility for  the nation’s nursing homes, with specific activities occurring at the  national, regional, and state levels.

CMS central office. At the national level, the CMS central office  oversees the federal standards nursing homes must meet to  participate in the Medicare and Medicaid programs. Primarily through  its State Operations Manual, the office establishes the responsibilities  of CMS’s regional offices and state survey agencies in ensuring that  federal quality standards for nursing homes are met.

CMS regional offices. CMS’s 10 regional offices oversee state  activities and report back to the CMS central office the results of their  efforts. Specifically, regional offices use the State Performance  Standards System to evaluate state surveyors’ performance on  factors such as the frequency and quality of state surveys.

State survey agencies. Under agreement with CMS, a state survey  agency in each state assesses whether nursing homes meet CMS’s  standards, allowing them to participate in the Medicare and Medicaid  programs. State survey agencies assess nursing homes using (1)  recurring standard surveys and (2) as-needed investigations.

Standard surveys. State survey agencies are required by federal  law to perform unannounced, on-site standard surveys of every  nursing home receiving Medicare or Medicaid payment at least  every 15 months, with a statewide average frequency of every 12  months. These surveys are a comprehensive assessment  designed to determine whether nursing homes are complying with  Medicare and Medicaid quality standards.

Investigations. In addition to standard surveys, state survey  agencies are required by federal law to investigate (1) complaints  submitted by residents, family members, friends, physicians, and  nursing home staff; and (2) “facility-reported incidents,” including  incidents involving abuse of residents, that are self-reported by the  nursing homes. State survey agencies review the information  provided through these complaints and incidents and determine if  an on-site investigation is required. During this unannounced  investigation, the state surveyors assess available evidence to  determine whether the allegation can be substantiated. These  investigations offer the state survey agency the opportunity to  identify and correct care problems in a more timely manner than  through the standard surveys.

If a surveyor determines that a nursing home violated a federal standard  during a survey or investigation, then a deficiency code specific to that  standard is cited. For instance, one deficiency code for abuse of residents  encompasses mental/verbal, sexual, or physical abuse; while a few  additional deficiency codes encompass abuse-related issues, such as a  failure by the nursing home to train staff on issues related to abuse. Cited  deficiencies are then classified into categories according to scope (the  number of residents potentially affected) and severity (the potential for or  occurrence of harm to residents). (See table 1.) State survey agencies  are required to enter data about deficiencies into CMS’s survey database.  For most deficiencies, the nursing home is required to prepare a plan of  correction, and, depending on the scope and severity of the deficiency,  surveyors may re-visit the facility to ensure that the nursing home has  implemented its plan and corrected the deficiency. In any instances  where surveyors substantiate the occurrence of resident abuse, the state  survey agency is required to refer the case to three entities: 1) local law  enforcement; 2) the MFCU, if appropriate; and 3) the state’s nurse aide  registry or other applicable professional licensure authority.

When nursing homes are cited with deficiencies, federal enforcement  actions—or penalties—can be imposed to encourage homes to make  corrections. In general, enforcement actions: (1) may be initially  recommended by the state survey agency, (2) are transferred to the CMS  regional office for review, (3) are imposed by the same CMS regional  office, and (4) are implemented—that is, put into effect. Depending on the  scope and severity of the deficiency cited, the CMS regional office may  impose certain enforcement actions so that they are implemented  immediately. However, for other enforcement actions, the regional office  may provide the nursing home with an opportunity to correct the  deficiencies, which, if corrected before the scheduled effective date, can  result in the penalty not being implemented. Penalties include directed in- service training, fines known as civil money penalties, denial of payment,  and termination from the Medicare and Medicaid programs, among  others. (See fig. 1.)

Reporting and Investigation of Abuse by Nursing Homes

When a nursing home becomes aware of an incident of alleged resident  abuse, the home must: immediately report the allegation to the state  survey agency and then conduct an investigation of the alleged incident.  Specifically, the process is as follows:

The nursing home must immediately report alleged abuse to the state  survey agency. After notifying the state survey agency, the nursing  home is also required to conduct its own investigation and submit its  findings in a written report to the state survey agency within 5 working  days of the incident.

Depending on the severity of the circumstances, the state survey  agency may visit the nursing home to investigate the incident or wait  until the nursing home submits its report.

Depending on the content of the report, the state survey agency may  request the home conduct additional work or the state survey agency  may investigate further on its own.

If the state survey agency opts not to investigate further, it may still  review the manner in which the home conducted its investigation  during the state survey agency’s next scheduled standard survey.

If a state survey agency determines that a nurse aide is responsible  for abuse, the agency must add this finding to the state’s nurse aide  registry—a registry that each state is required to maintain that lists all  individuals who have satisfactorily completed approved nurse aide  training and a competency evaluation program in that state. Nursing  homes are prohibited from employing a nurse aide with a finding of  abuse on the nurse aide registry.

Further, if there is a reasonable suspicion that a crime has occurred  that results in serious bodily injury, federal law requires certain  covered individuals at the nursing home to immediately report to law  enforcement in addition to the state survey agency.

Before employing a nurse aide, nursing homes are required to check  each relevant state’s registry to verify that the nurse aide has passed a  competency evaluation. All nursing homes must also verify with the  relevant state board of licensing the professional credentials of the  licensed personnel, such as registered nurses, whom they hire.

Other State and Local Agencies That May Investigate Abuse in Nursing Homes

In addition to state survey agencies, there are other state and local  agencies that may be involved in investigating abuse in nursing homes.  These other state and local agencies that investigate abuse in nursing  homes are generally focused on the different aspects of the specific  alleged abuse incident, in contrast to the state survey agency, which  focuses on the safety of individual residents, as well as on the facility’s  policies and procedures for preventing and effectively addressing abuse.  These other state and local agencies include:

Adult Protective Services. In some states, Adult Protective Services’  investigators are trained to provide protection and intervention for  older adults in nursing homes and can play a valuable role in helping  to protect residents from abuse.

Ombudsmen. Long-term care ombudsmen, who serve as advocates  for nursing home residents, may also investigate abuse complaints  made by or on behalf of residents.

Local law enforcement. Law enforcement may also play a role in  investigating alleged nursing home resident abuse. Specifically, local  police departments may learn of suspected instances of resident  abuse and conduct criminal investigations.

MFCU. The state MFCUs typically learn of abuse allegations through  referrals from state survey agencies, which CMS requires if abuse is  substantiated. If, after investigating an allegation, the MFCU decides  that there is sufficient evidence to press criminal charges, it may  prosecute the case itself or refer the matter to the state’s attorney  general or a local prosecutor.

More Abuse Deficiencies Were Cited in Nursing Homes from 2013 through 2017; Physical and Mental/Verbal Abuse and Staff Perpetrators Were Most Common

Abuse Deficiencies Cited and the Number of Nursing Homes Involved More than Doubled from 2013 through 2017, with the Largest Increase in Severe Cases

Our analysis of CMS data found that from 2013 through 2017, abuse  deficiencies cited in nursing homes became more frequent, with the  largest increase in severe cases. While abuse deficiencies are relatively  rare—they comprise less than 1 percent of the total deficiencies in each  of the years we examined—they became more common over the 5-year  period. Specifically, the number of abuse deficiencies cited more than  doubled—from 430 in 2013 to 875 in 2017 (a 103.5 percent increase).  This trend for the abuse deficiencies is in contrast to the trend for all  deficiencies, which decreased about 1 percent between 2013 and 2017.  At the state level, 32 states had more abuse deficiencies cited in 2017  than 2013, six states had a consistent number, and the remaining 13 had  fewer. (See app. III for additional data on abuse deficiencies by state.)  Furthermore, abuse deficiencies cited in 2017 were more likely to be  categorized at the highest levels of severity—deficiencies causing actual  harm to residents or putting residents in immediate jeopardy—than they  were in 2013. Specifically, 42.6 percent of the 875 abuse deficiencies  were categorized as causing actual harm or posing immediate jeopardy to  residents in 2017, compared to 31.9 percent of the 430 abuse  deficiencies in 2013. (See fig. 2.)

In examining the types of survey or investigations conducted to identify  abuse deficiencies, we found that, from 2013 to 2017, the majority (about  two-thirds in each year) were identified through either a complaint  investigation or facility-reported incident investigation. In contrast, for all  types of deficiencies, we found the inverse—the vast majority were  identified through a standard survey. This demonstrates the unique and  significant role that complaint and facility-reported incident investigations  have in identifying abuse deficiencies, because they allow for the  identification and correction of abuse in a more timely manner than a  standard survey. In fact, for the deficiencies for which we were able to  identify the source, the percentage of abuse deficiencies identified  through facility-reported incident investigations increased from 42.3  percent of the 430 abuse deficiencies in 2013 to 47.4 percent of the 875  abuse deficiencies in 2017. Conversely, for all types of deficiencies, a  very small percentage resulted from facility-reported incident  investigations—about 5 percent or less each year. (See fig. 3.)

We found that enforcement actions—or penalties—were imposed and  implemented by CMS infrequently each year in response to abuse  deficiencies, and that fines were the most common type of implemented  penalty. Specifically, for each year from 2013 through 2017, we found that  about one-third of abuse deficiencies had an enforcement action imposed  but not implemented, and less than 8 percent of abuse deficiencies had  enforcement actions that were implemented against the nursing home.  This was fairly consistent over the 5-year period. For example, in 2017,  of the 875 abuse deficiencies cited, 275 (31.4 percent) resulted in  enforcement actions that were imposed but not implemented and 65 (7.4  percent) had enforcement actions that were implemented against the  nursing home. Furthermore, for abuse deficiencies cited at the most  severe levels—that is, those causing actual harm or immediate jeopardy  to residents—a smaller percentage of the deficiencies had an  enforcement action imposed but not implemented compared to all abuse  deficiencies, but a larger percentage were implemented. For example, in  2017, 373 of the 875 abuse deficiencies were cited at the most severe  levels; of those, 81 (21.7 percent) resulted in enforcement actions that  were imposed but not implemented, and 51 (13.7 percent) were  implemented against the nursing home. Regardless of the severity, the  predominant reason that CMS did not implement imposed enforcement  actions was because the nursing home came into compliance prior to the  implementation date of the penalty.

For implemented enforcement actions, fines—known as civil money  penalties—were overwhelmingly the most common type of penalty  implemented against nursing homes with abuse deficiencies, increasing  from 69.6 percent of the 23 abuse deficiencies with implemented  enforcement actions in 2013 to 83.1 percent of the 65 in 2017. Denial of  payments for new Medicare and Medicaid admissions—another financial  penalty—was the second most common type of implemented  enforcement action, but decreased from 34.8 percent in 2013 to 13.8  percent in 2017. Mandatory termination is the most severe enforcement  action as it ends all payments for Medicare and Medicaid residents; it is  implemented very rarely, with only one abuse deficiency resulting in  mandatory termination of the nursing home across all 5 years. (See fig.  4.)

In addition, we found the number of nursing homes with abuse  deficiencies also more than doubled over the 5-year period. In 2013, 394  nursing homes (2.7 percent of all surveyed nursing homes) had at least  one abuse deficiency compared to 821 nursing homes (5.6 percent of all  surveyed nursing homes) in 2017. A nursing home may have more than  one abuse deficiency cited in a single year, such as from a standard  survey early in the year and then a complaint investigation later in the  year. We found that in 2013, of the 394 nursing homes that had a total of  430 abuse deficiencies cited, 85 of the homes had two or more abuse  deficiencies that year. In 2017, of the 821 nursing homes that had 875  total abuse deficiencies cited, 155 had two or more that year.

Further, across the 5-year period, we found that a small proportion of all  nursing homes with abuse deficiencies had them in multiple consecutive  years. Specifically, across all years, 2,214 total unique nursing homes  (13.6 percent of all surveyed nursing homes) had at least one abuse  deficiency. A small portion of these nursing homes had at least one abuse  deficiency in multiple consecutive years, indicating potential patterns in  abuse at these nursing homes. Specifically, 185 of the 2,214 nursing  homes with abuse deficiencies over the 5-year period—8.4 percent—had  an abuse deficiency in any 2 consecutive years. In addition, 25 of the  nursing homes—1.1 percent—had an abuse deficiency in 3 or more  consecutive years. (See fig. 5.)

Finally, we analyzed a selection of characteristics, including ownership  type and bed size, for these nursing homes that had abuse deficiencies  cited in multiple years and compared them to homes that had abuse  deficiencies cited in a single year and surveyed homes that did not have  any abuse deficiencies. We found that the nursing homes differed. For  example, while for-profit organizations—the largest ownership group  accounting for 67.9 percent of all surveyed nursing homes—owned 66.9  percent of nursing homes without any abuse deficiencies cited over the 5- year period, they accounted for 78.6 percent of nursing homes that had  abuse deficiencies cited in 2 or more years. In addition, nursing homes  designated as Special Focus Facilities—a CMS program that provides  increased oversight to homes with consistent poor performance— constituted 2.5 percent of all surveyed nursing homes compared to 1.9  percent of nursing homes without abuse deficiencies and 10.1 percent of  nursing homes with abuse deficiencies cited in 2 or more years. (See  table 2.)

Physical and Mental/Verbal Abuse Occurred Most Often, Followed by Sexual Abuse, and Staff Were More Often Perpetrators of Abuse in 2016 and 2017

Our analysis of a representative sample of CMS narrative descriptions— written by state surveyors—associated with abuse deficiencies cited in  2016 and 2017 found that physical and mental/verbal abuse occurred  most often in nursing homes, followed by sexual abuse. Further, staff  were more often the perpetrators of the deficiencies cited as abuse than  were residents or others. (See fig. 6.)

Physical abuse, which CMS defines as hitting, slapping, punching,  biting and kicking residents, was present in about 46 percent (+/- 5  percent) of the abuse deficiency narratives.

Mental/verbal abuse, which CMS defines as verbal or nonverbal  conduct that can cause a resident to experience humiliation and fear,  among other things, was present in about 44 percent (+/- 5 percent) of  the abuse deficiency narratives.

Sexual abuse, which CMS defines as non-consensual sexual contact  with a resident, was present in about 18 percent (+/- 5 percent) of the  abuse deficiency narratives.

Staff, which includes those working in any part of the nursing home, were  perpetrators in 58 percent (+/- 5 percent) of abuse deficiency narratives,  followed by resident perpetrators (30 percent +/- 5 percent) and other  types of perpetrators (2 percent +/- 5 percent). Other types of  perpetrators can include family members of residents or other visitors.

Further, our analysis of the narratives found that sexual abuse  perpetrated by residents (39 percent) occurred more frequently within our  sample than sexual abuse perpetrated by staff (10 percent) or others (17  percent). When staff were the perpetrators of abuse, we found within  our sample that mental/verbal abuse was the most common type of  abuse (60 percent), while physical abuse was most common in situations  where residents (59 percent) or others (67 percent) were the perpetrators.  For examples of the different types of abuse and perpetrators from our  analysis, see table 3 below. Within our sample of narratives,  mental/verbal abuse was less likely to be categorized by surveyors as  severe compared to physical and sexual abuse. Specifically, we found in  our sample that the proportion of mental/verbal abuse (30 percent)  categorized by state surveyors as severe—defined as actual harm or  immediate jeopardy—was smaller than the proportion of physical (40  percent) and sexual abuse (58 percent) categorized as severe. In  addition, we found that most of the mental/verbal (88 percent), physical  (91 percent), and sexual abuse (77 percent) narratives in our sample  were categorized by surveyors as “isolated” in scope.

Stakeholders Identified Resident Characteristics and Staffing Inadequacies as Risk Factors for Abuse, and Underreporting as among the Challenges to Investigating Abuse

Some Resident Characteristics and Inadequacies in Staffing, Training, and Staff Screening Can Increase Risk of Abuse

Stakeholder groups in most of the five states we interviewed—including  state survey agencies, Adult Protective Services, law enforcement,  MFCUs, ombudsmen, and nursing home administrators and clinical  staff—identified risk factors for abuse in nursing homes that included  resident characteristics, such as residents with infrequent visitors, and  nursing home staffing characteristics, such as insufficient staffing levels.  (See table 4 for a description of these risk factors.) Officials we  interviewed from national organizations with knowledge of abuse in  nursing homes also noted some of these same risk factors.

Resident characteristics. Stakeholders in each of our five selected  states noted that residents who do not have frequent visitors, are  cognitively impaired, or mixed with widely different age groups may be at  an increased risk for abuse.

Residents who do not have frequent visitors. Stakeholders in four  of the five states said that residents without regular visitors, such as  family, may be at an increased risk for abuse because regular visitors  could notice and report potential warning signs of abuse, such as  changes in their behavior or physical appearance.

Residents who are cognitively impaired. Stakeholders in each of  the five states said that cognitively impaired residents may be  especially vulnerable to abuse because they often cannot speak or  may have difficulty recalling recent events, and they are therefore less  likely to be able to remember or describe what happened. In addition  to noting that cognitively impaired residents may be at an increased  risk of abuse, some stakeholders said that some cognitively impaired  residents may be more likely to be perpetrators of abuse as their  condition can have behavioral symptoms, such as physical  aggressiveness.

Residents mixed with widely different age groups. Stakeholders in  four of the five states also noted that elderly nursing home residents  who are mixed with widely differing age groups, such as young adults  with mental illness, may be at a higher risk for incidents of abuse due  to the different characteristics of these groups. Combining these two  populations, which have differing needs, can also be challenging for  staff. For example, staff may have more experience caring for elderly  residents with complex needs, such as dementia, and they may not  have the necessary skills or training to care for needs of younger  residents, who require other types of complex care. This can create a  stressful environment for staff, which is a risk factor for staff as  potential perpetrators of abuse. Two stakeholders noted that younger  residents who may have mental illness can have conflicts with older  and frailer residents, potentially leading to abusive incidents between  residents.

Nursing home staffing characteristics. Stakeholders we interviewed in  each of our five selected states noted that nursing homes with insufficient  staffing, inadequate staff training, and inadequate staff screening may be  at risk for abuse.

Nursing homes with insufficient staff. Stakeholders in each of the  five states said that nursing homes with insufficient staff may be at  risk for abuse because there may not be enough staff attending to the  needs of residents. Stakeholders noted that nursing homes have  faced challenges hiring and retaining qualified staff and that, as a  result, existing staff can feel overworked, stressed, or exhausted,  which can lead to abusive behaviors. Staffing issues are not just risk  factors for staff as perpetrators of abuse, but they can also limit a staff  member’s ability to identify and report abuse. For example, insufficient  staffing may mean that there are not enough available staff to notice  signs of abuse in a timely fashion, such as noticing a resident’s  bruises before they heal.

Nursing homes with inadequate staff training on abuse.

Inadequate staff training on abuse was noted by stakeholders we  interviewed in four of the five states as a risk factor for abuse  because; for example, staff may not know how to diffuse challenging  situations with residents and identify and report abuse. As  previously noted, recognizing abuse can be challenging and, even  when abuse is identified, it is often not reported. Officials from all of  the nursing homes that we visited said that they provide training to  their staff on abuse, including on defining abuse, identifying or  detecting different types of abuse, and reporting abuse. Staff  members we spoke with at one nursing home said that, not only are  they trained to look for physical signs of abuse, such as bruising, but  they are also trained to observe changes in behavior that may be  warning signs for abuse, such as a resident suddenly withdrawing  from group activities. Staff at another nursing home said that they are  also taught to ask another staff member for assistance when they are  feeling frustrated or stressed by caring for a particular resident. In  contrast, staff at another nursing home noted the challenges of not  having these types of resources and said they are needed at their  facility.

Nursing homes with inadequate staff screening. Stakeholders in  three of our five states said that inadequate staff screening can be a  risk factor for abuse. Some stakeholders said that a thorough  background screening can be time consuming. Further, because staff  screening through background checks and the nurse aide registry is  not coordinated across the country, there are gaps that could enable  individuals who committed crimes in one state to obtain employment  at a nursing home in another state, a concern that we previously  reported. Staff from a nursing home we visited said the prevention of  abuse “starts with hiring the right staff” and noted the importance of  conducting background checks and checking references for  prospective employees.

Underreporting of Abuse, Cognitive Impairment of Victims, Lack of Nursing Home Cooperation, and Lack of Agency Coordination Pose Challenges for Abuse Investigations

The key challenges for abuse investigations most frequently identified by  stakeholder groups in the five states we reviewed were underreporting of  abuse, cognitive impairment of victims, lack of cooperation from nursing  homes, and lack of agency coordination. (See table 5 for a description  of these challenges.) Officials we interviewed from national organizations  with knowledge of abuse in nursing homes also noted some of these  same challenges.

Underreporting of abuse. Stakeholders in each of the five states in our  review noted that abuse in nursing homes may be underreported because  residents or their families feel uncomfortable or fear retaliation from  nursing home staff. For example, residents who were sexually abused  may feel ashamed or embarrassed to report these incidents. In addition,  residents may fear retaliation by the nursing home staff on whom they  depend, which might include substandard care, exclusion from activities,  or even eviction from the home. A fear of retaliation can also extend to  nursing home staff, who may witness abuse by another staff member, but  may be afraid to report it out of fear that they will lose their jobs or that  they will face retaliation from co-workers. This underreporting creates  challenges for investigators, who are unable to investigate if they do not  know that abuse has occurred.

Cognitive impairment of victims. Stakeholders in each of the five states  in our review said that victims with cognitive impairment may not be able  to give statements regarding the abuse or may not be considered reliable  witnesses. For example, residents with dementia may not be able to  remember the details of an abusive incident, and their memory of the  details may deteriorate over the course of an investigation. Or, residents  with dementia may report abuse that stems from traumatic memories  from an incident that occurred earlier in their lives. One stakeholder said  this can be a challenge for investigations because they do not know how  much they can rely on a cognitively impaired resident’s statement, making  it difficult for them to corroborate an abuse allegation. However, one  stakeholder noted that, while it can be difficult to interview abuse victims  with cognitive impairment, it is important to treat their allegations seriously  and with credibility. One law enforcement stakeholder noted that  interviews with these victims require special training.

Lack of cooperation from some nursing homes. Stakeholders in each  of the five states in our review said that some nursing homes may  withhold, alter, or make it difficult for investigatory agencies to gain  access to necessary, timely, or accurate information about alleged abuse.  This may be, for example, because they may fear adverse publicity,  litigation, or penalties from the state or CMS. In addition, as noted  previously, nursing home staff may be fearful of losing their jobs.  Stakeholders said that nursing home staff who witnessed abuse may be  intentionally vague when interviewed by investigators; for example, by  saying they cannot recall an incident. Some stakeholders also noted that  nursing homes may delay investigators’ access to patient records, or they  may even alter patient records in order to fill in information that should  have been documented but was not at the time of the incident. One  stakeholder we interviewed noted that the problem is not necessarily  widespread—that some nursing homes are open about sharing  information while others can be more difficult. Another stakeholder noted  that a nursing home’s cooperation can sometimes depend on the  seriousness of the allegation.

Lack of agency coordination. Stakeholders in three of the five states in  our review said that having multiple agencies involved in investigations,  such as the state survey agency, law enforcement, the ombudsman, and,  in some states, Adult Protective Services, can create challenges,  including coordinating investigations and notifying one another about  investigation outcomes. One stakeholder said they sometimes begin an  investigation without realizing another investigatory agency has already  started its own investigation. Further, stakeholders in two of the five  states in our review said that CMS does not allow state survey agencies  to share important investigatory information with law enforcement. (We  discuss this issue in more detail later in this report.)

CMS’s Ability to Ensure Nursing Home Residents Are Free from Abuse May Be Limited by Gaps in Oversight

We found that CMS: (1) cannot readily access data on the type of abuse  or type of perpetrator, (2) has not provided guidance on what information  nursing homes should include in facility-reported incidents, and (3) has  numerous gaps in its referral process that can result in delayed and  missed referrals to other entities. Together, these gaps affect critical  points in CMS’s oversight of abuse in nursing homes including the  prevention, identification, and timely investigation of abuse.

Information on Abuse and Perpetrator Types Is Not Readily Available

CMS cannot readily access information on abuse or perpetrator type in its  datasets and, as a result, lacks key information critical to understanding  and appropriately addressing nursing home abuse with its oversight.  Specifically, in two of CMS’s datasets—complaints/facility-reported  incidents and deficiencies—agency officials told us they do not require  the state survey agencies to record abuse and perpetrator type. As a  result, we found that CMS’s data do not readily support CMS’s  understanding of the types of abuse and perpetrators that are most  prevalent in nursing homes. CMS officials told us they believe that the  majority of abuse is committed by nursing home residents, and that  physical and sexual abuse were the most common types; officials said  they based this current understanding of abuse and perpetrator types on  professional experience, literature, and ad hoc analyses of deficiency  narrative descriptions. However, our review of a representative sample of  abuse deficiency narratives from 2016 and 2017 found that staff were  more often the perpetrators of deficiencies cited as abuse than residents  or others, and that physical and mental/verbal abuse occurred most often  in nursing homes, followed by sexual abuse. CMS officials noted that  some incidents resulting from resident altercations—particularly those  that do not show a willful intent to harm—may not have been cited as an  abuse deficiency by some state survey agencies and may have been  cited as other deficiencies not specified as abuse. This may have  contributed to the difference between CMS’s understanding of the  prevalence of resident to resident abuse and what their abuse deficiency  data show.

If CMS required information on abuse and perpetrator type to be  recorded, the agency would have a better understanding of abuse in  nursing homes. However, CMS officials told us they do not currently  require the state survey agencies to specify abuse and perpetrator type  because they consider the surveyor’s job to be identification and  documentation of noncompliance. Additionally, CMS officials told us they  have not conducted a systematic review to gather information on abuse  and perpetrator type. This is inconsistent with federal internal control  standards directing management to use quality information to achieve  program objectives. Without the systematic collection and monitoring of  specific abuse and perpetrator data, CMS lacks key information and,  therefore, cannot take actions—such as tailoring prevention and  investigation activities—to address the most prevalent types of abuse or  perpetrators.

Facility-Reported Incidents Lack Key Information

All of the state survey agencies we spoke to told us that facility-reported  incidents can lack key information that can cause potential delays in  abuse investigations. Specifically, officials from each of the five state  survey agencies told us that the facility-reported incidents they receive  from nursing homes can lack key information that affects their ability to  effectively triage incidents and determine whether an investigation should  occur and how soon. Two state survey agencies we spoke with said  they sometimes have to conduct significant follow-up with the nursing  homes to obtain the information they need to prioritize the incident for  investigation—follow-up that delays and potentially negatively affects  investigations. For example, one state survey agency told us that a  facility reported abuse involving two residents but did not initially report  that the residents were injured, and that the facility did not file an  addendum to the facility-reported incident to indicate resident injury. As a  result of this incomplete information, the state survey agency did not  properly prioritize this incident response.

Despite federal law requiring nursing homes to self-report allegations of  abuse, and covered individuals to report reasonable suspicions of crimes  against residents, CMS has not provided guidance on what information  should be included in these reports. Our review of CMS’s State  Operations Manual found that CMS does not have guidance related to the  information that nursing homes or covered individuals should report to the  state survey agencies or local law enforcement; in contrast, it does  contain guidance on the type of information members of the public should  include in a complaint about nursing home quality to the state survey  agency—and CMS makes a standardized complaint template form  available on its website.

The lack of guidance on the information that state survey agencies should  collect on facility-reported incidents is inconsistent with federal internal  control standards directing management to use quality information to  achieve program objectives. CMS could outline basic information  requirements that states must include on incident forms used by nursing  homes and covered individuals to ensure the state survey agency is  receiving the information it needs to accurately and quickly triage these  incidents. CMS officials told us in November 2018 that they have efforts  underway to examine guidance related to the information state survey  agencies need to appropriately triage these facility-reported incidents and  are developing a facility-reported incident template. Until the guidance  and template are in place, these facility-reported incidents may lack key  information that can cause potential delays in abuse investigations.

Gaps Exist in CMS Process for State Survey Agency Referrals to Law Enforcement and MFCUs

CMS requires state survey agencies to make referrals to law enforcement  and, if appropriate, to MFCUs when abuse is substantiated; however, we  found numerous gaps in CMS’s referral process that can result in delayed  and missed referrals. (See table 6.)

Timing of abuse referrals. We found CMS’s requirements for when state  survey agencies should report abuse to law enforcement and MFCUs lag  behind the federal requirements for when covered individuals should  make such referrals, and, as a result, referrals may be significantly  delayed. Specifically, federal law requires covered individuals to  immediately report reasonable suspicions of a crime against a resident  that results in serious bodily injury to law enforcement and the state  survey agency. Conversely, state survey agencies do not have to report  suspicions of crime identified on complaints submitted to, and surveys  conducted by, the state survey agency until the abuse has been  substantiated—a process that can often take weeks or months. Officials from one law enforcement agency and two MFCUs that we interviewed  told us the delay in receiving referrals limits their ability to collect evidence  and prosecute cases—for example, bedding associated with potential  sexual abuse may have been washed and wounds may have healed.  This is consistent with the findings of our 2002 report, where we  recommended that CMS should ensure that state survey agencies  immediately notify law enforcement or MFCUs when nursing homes  report allegations of physical or sexual abuse. One state survey agency  in our review established more stringent guidelines than CMS by requiring  the surveyors to notify law enforcement and the MFCU promptly upon  receiving a complaint of abuse. CMS officials told us their state survey  agency reporting requirements are based on a March 2002 policy. This is  inconsistent with standards for internal control, which state that  management should communicate quality information externally so that  external parties can help the entity achieve its objectives.

Tracking of abuse referrals. In addition to delays in referring cases to  law enforcement and MFCUs, CMS officials also told us that CMS does  not conduct oversight to ensure that state survey agency referrals to law  enforcement and the MFCUs are occurring as required for substantiated  abuse, and, as a result, CMS cannot ensure that state survey agencies  are complying with reporting obligations. For example, an official from one  of the five state survey agencies we interviewed said they had never  made a referral to law enforcement or the MFCU, despite having  substantiated allegations of abuse. The state survey agency official told  us that they do not refer cases to law enforcement, and that law  enforcement referrals are the responsibility of the nursing home. This is  incompatible with CMS guidelines requiring that substantiated abuse be  referred to law enforcement; however, CMS officials told us that they do  not track whether state survey agencies make referrals to law enforcement and the MFCUs. This is inconsistent with federal standards  for internal control, which state that management should establish and  operate monitoring activities to monitor the internal control system and  evaluate the results.

Definition of substantiated abuse. We found confusion among some  state survey agencies about CMS’s definition of what it means to  substantiate an allegation of abuse—a challenge because substantiation  is a trigger in the investigation process, and CMS requires state survey  agencies to make referrals to law enforcement and staff registries when  abuse is substantiated by evidence. As a result, there is a potential for  substantiated abuse to not be reported and, subsequently, not referred to  law enforcement or MFCUs for criminal investigation. Two of the five state  survey agencies in our review told us they believed they could not  substantiate an allegation unless they could also cite a federal deficiency.  This is inconsistent with CMS’s guidance, which says that state survey  agencies can substantiate that an allegation occurred without citing a  federal deficiency and that, subsequently, these substantiated allegations  must be referred to law enforcement and staff registries. For example,  according to CMS guidance, if the state survey agency investigated and  found evidence that a resident was abused, but the nursing home had  taken preventive actions against the deficient practice, the state survey  agency would then substantiate that the abuse occurred, but not cite a  deficiency. However, state survey agencies may decide not to  substantiate an abuse allegation verified by evidence if they believe no  deficiency should be cited, such as if the nursing home had taken  preventive action against the deficient practice, which could result in that  abuse going unreported and not referred to law enforcement, MFCUs, or  staff registries. Because substantiation of abuse is a critical trigger in  abuse investigations, confusion around its interpretation could prevent  these important next steps. CMS officials told us they are aware that the  state survey agencies have varying interpretations of what it means to  substantiate abuse. According to federal standards for internal control, management should internally communicate quality information to  achieve the entity’s objectives.

Information sharing. We also found that CMS’s guidance on state  survey agency referrals contained in its State Operations Manual does  not specify what incident information can be shared with local law  enforcement, either in response to local law enforcement’s request for  information or when the state survey agency refers substantiated findings  of abuse to local law enforcement. As a result, both state survey and  law enforcement agencies expressed confusion and frustration about  what information can be shared and said delays have occurred that can  impede law enforcement investigations. Officials from two state survey  agencies told us that CMS does not allow them to share any information  with law enforcement without a written request. For example, officials  from one state survey agency said that they cannot share the name of the  resident abused or the time when the incident occurred. One state survey  agency said that information sharing can be uneven, and told us that law  enforcement is required to share information with the state survey  agencies, but the state survey agencies do not share their investigatory  information with law enforcement. Officials from another state survey  agency wrote to CMS notifying CMS of a change in their state survey  agency protocol that would make the referral process timelier by providing  un-redacted survey records of substantiated abuse to local law  enforcement. However, in CMS’s 2017 written response to the survey  agency, CMS told them that all written requests for these records must  continue to be forwarded to CMS for processing in accordance with the  federal Privacy Act.

When we asked CMS officials what information state survey agencies can  share with law enforcement in a referral, CMS explained that scenarios  for requesting information can vary, and that CMS does not prescribe a  specific method as it depends on the needs of the investigation. This lack  of guidance is inconsistent with federal standards for internal control,  which state that management should internally communicate quality  information to achieve the entity’s objectives.

While nursing home abuse is relatively rare, our review shows that abuse  deficiencies cited in nursing homes are becoming more frequent, with the  largest increase in severe cases. As such, it is imperative that CMS have  key information critical to understanding abuse and that the agency’s  oversight of nursing homes is strong. We found weaknesses in both  CMS’s understanding of abuse and in its oversight that need to be  addressed. Specifically, because CMS cannot readily access information  on abuse or perpetrator types in its data, it lacks key information critical to  taking appropriate actions to address the most prevalent types of abuse  and perpetrators. In addition, CMS has not provided guidance on what  information should be included in facility-reported incidents, contributing  to a lack of information for state survey agencies and, subsequently,  delays in their investigations. This lack of guidance related to facility- reported incidents is important in light of our findings that abuse  deficiencies are identified most commonly through facility-reported  incidents. We also found other gaps in CMS’s process related to ensuring  timely referrals of abuse to law enforcement, tracking abuse referrals,  defining abuse substantiation, and sharing information with law  enforcement. These gaps affect CMS’s oversight of abuse in nursing  homes—including the prevention, identification and timely investigation of  abuse—and may limit CMS’s ability to ensure that nursing homes meet  federal requirements for residents to be free from abuse.

We are making the following six recommendations to the administrator of  CMS:  Require that abuse and perpetrator type be submitted by state survey  agencies in CMS’s databases for deficiency, complaint, and facility- reported incident data, and that CMS systematically assess trends in  these data. (Recommendation 1)

Develop and disseminate guidance—including a standardized form—to  all state survey agencies on the information nursing homes and covered  individuals should include on facility-reported incidents.  (Recommendation 2)

Require state survey agencies to immediately refer complaints and  surveys to law enforcement (and, when applicable, to MFCUs) if they  have a reasonable suspicion that a crime against a resident has occurred  when the complaint is received. (Recommendation 3)

Conduct oversight of state survey agencies to ensure referrals of  complaints, surveys, and substantiated incidents with reasonable  suspicion of a crime are referred to law enforcement (and, when  applicable, to MFCUs) in a timely fashion. (Recommendation 4)

Develop guidance for state survey agencies clarifying that allegations  verified by evidence should be substantiated and reported to law  enforcement and state registries in cases where citing a federal  deficiency may not be appropriate. (Recommendation 5)

Provide guidance on what information should be contained in the referral  of abuse allegations to law enforcement. (Recommendation 6)

We provided a draft of this product to HHS for review and comment. In its  comments, reproduced in appendix IV, HHS concurred with our six  recommendations and identified actions it is taking to implement them.  Specifically, HHS said that it will: (1) look into options for requiring state  survey agencies to record data on abuse and perpetrator type so that  HHS may assess trends in these data; (2) develop guidance that includes  a list of standardized data elements to be included when nursing homes  report facility-reported incidents and guidance specific to the reporting  and tracking of facility-reported incidents involving abuse; (3) require state  survey agencies to immediately refer complaints to law enforcement if a  reasonable suspicion of a crime against a resident has occurred and  share relevant survey information; (4) consider how to implement  mechanisms for tracking law enforcement referrals; (5) identify  opportunities to clarify in guidance situations where citing a federal  deficiency may not be appropriate, but reporting the abuse is still  required; and (6) develop a list of standardized elements that should be  included when reporting an abuse allegation to law enforcement. HHS  also provided technical comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Secretary of HHS and  other interested parties. In addition, the report will be available at no  charge on the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or at dickenj@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made key contributions to this  report are listed in appendix V.

Appendix I: Additional Detail on Analysis of Centers for Medicare & Medicaid Services’ (CMS) Data

This appendix describes our scope and methodology for determining the  trends and types of abuse occurring in nursing homes in recent years. For  this examination, we reviewed CMS guidance and analyzed data from  2013 through 2017, which represented the most recent data for a 5-year  period at the time of our review. Specifically, we first reviewed the CMS  State Operations Manual’s Appendix PP that was in effect during our  period of review to determine which federal standards and deficiency  codes were relevant to resident abuse. We focused our analysis on the  deficiency code to be used by state surveyors when a nursing home fails  to keep a resident free from abuse, which encompasses mental/verbal,  sexual, or physical abuse. Surveyors can also use other deficiency  codes for abuse-related issues, such as a failure by the nursing home to  train staff on issues related to abuse, either in conjunction with an abuse  deficiency or without an abuse deficiency. Since these abuse-related  deficiency codes do not necessarily represent incidents of abuse, but do  represent situations where a nursing home’s inadequate policies could  leave residents vulnerable to abuse, we conducted a limited analysis on  the trends of these deficiencies, which is described in appendix II.

For our analysis, we identified abuse deficiencies cited by surveyors in all  50 states and Washington, D.C., between 2013 and 2017, using data  provided by CMS from its Certification and Survey Provider Enhanced  Reports system. Specifically, we calculated the number of abuse  deficiencies cited each year and determined how many of these abuse  deficiencies were at each level of severity—no actual harm with a  potential for minimal harm, no actual harm with a potential for more than  minimal harm, actual harm, and immediate jeopardy—for each year. We  compared the results for abuse deficiencies with the results for all types  of deficiencies in each year. To avoid over-counting deficiencies,  deficiencies that were for the same violation on the same day for the  same facility were counted as a single deficiency. We then tracked (1)  the origin of these abuse deficiencies and (2) enforcement actions  implemented against nursing homes with these abuse deficiencies.

Origin of abuse deficiencies. To identify trends in the origin of those  abuse deficiencies—that is, whether the deficiency originated from a  standard survey, complaint investigation, or a facility-reported incident  investigation—we analyzed data provided by CMS from its Automated  Survey Processing Environment Complaint/Incident Tracking System.  Specifically, we matched the deficiencies with the complaint/incident  data using provider number, survey date, and deficiency code. We  found that some deficiencies were the result of a combination of  complaints, facility-reported incidents, surveys, or all three. We  counted those deficiencies as originating from each relevant category.

Enforcement actions. To identify trends in the enforcement actions  imposed and implemented against nursing homes with abuse  deficiencies, we analyzed data provided by CMS from its Automated  Survey Processing Environment Enforcement Manager. Specifically,  we matched the deficiencies with the enforcement data using provider  number, survey date, case identification number, and deficiency code.  To avoid over-counting, deficiencies that share the same code and  case identification number were counted as a single deficiency. For  each year, we determined how many of the abuse deficiencies  resulted in enforcement actions imposed or implemented, the severity  of the abuse deficiencies with enforcement actions, and the types of  enforcement actions implemented.

We then examined these abuse deficiencies to determine the number of  nursing homes that had abuse deficiencies, as well as the number of  homes with repeated abuse deficiencies cited across the 5 years and the  characteristics of those homes. We also determined the proportion of  surveyed nursing homes in a given year that had an abuse deficiency.

Nursing homes that had repeated abuse deficiencies. Since a  nursing home can have more than one abuse deficiency cited in a  given year, we determined the number of surveyed nursing homes  each year that had at least one abuse deficiency, both nationally and  by state. For each of those nursing homes, we determined if the home  had an abuse deficiency repeated in multiple years and in two or more  consecutive years.

Nursing home characteristics. We attempted to identify  commonalities among homes with multiple years of abuse  deficiencies, homes with only a single year with an abuse deficiency,  and surveyed homes without any abuse deficiencies throughout the 5- year period. Specifically, we matched deficiency data to CMS’s  publicly available Provider of Services files and the Nursing Home  Compare Provider Information files for each nursing home; and we  examined bed size, non-profit or for-profit status, Five-Star Quality  Rating System overall rating, Special Focus Facility designation, and  urban or rural location.

Finally, because abuse and perpetrator type are not readily identifiable in  CMS’s data, we identified this information by reviewing the narratives  written by surveyors that describe the substantiated abuse. Specifically,  we obtained 1,557 narrative descriptions written by state surveyors for  abuse deficiencies cited in 2016 and 2017 provided by CMS from its  Automated Survey Processing Environment database. From that  universe of abuse deficiency narratives, we selected a randomly selected  representative sample of 400 narratives, and each narrative was  reviewed by two separate reviewers who independently analyzed the text  of each narrative to determine the abuse and perpetrator type according  to the definitions that CMS implemented on November 28, 2017, in its  State Operations Manual. Any disagreements between the two reviewers  were resolved by a third independent reviewer. (See table 7.) For those  narratives where the abuse type could not reasonably be categorized  under an existing CMS definition, reviewers had the option to mark  narratives as “other.” Furthermore, we analyzed the scope and severity  for each narrative within our sample.

CMS’s abuse deficiency code also included involuntary seclusion in the  time period we examined and is defined in its November 22, 2017,  guidance as “separation of a resident from other residents or from her/his  room or confinement to her/his room (with or without roommates) against  the resident’s will, or the will of the resident representative.” Our analysis  of the narrative descriptions found that 3 percent of the abuse deficiency  narratives in our sample were attributable to involuntary seclusion. We  were unable to categorize the abuse and perpetrator type for about 11  percent of the deficiency narratives in our sample, because we  determined the narrative description did not meet CMS’s abuse definition.

We assessed the reliability of each of the datasets by checking for  missing values and obvious errors and discussed them with CMS officials  who were knowledgeable about the data. In the course of this  assessment, we found some data limitations. Specifically, CMS officials  told us that some state survey agencies may not have entered all facility- reported incidents into the Automated Survey Processing Environment  Complaint/Incident Tracking System, while other state survey agencies  did. We also found underreporting, as noted in our 2019 report, where  the Oregon state survey agency was not entering all abuse-related  complaints or facility-reported incidents into this same database—a  problem that could exist in other states. In addition, CMS officials told us  that it is possible there are additional incidents that may not have been  represented in the abuse deficiency data during the period of our review.  Specifically, CMS officials noted that some incidents resulting from  resident altercations—particularly those that do not show a willful intent to  harm—may not be cited as an abuse deficiency by some state survey  agencies. We therefore consider the number of abuse deficiencies that  resulted from complaints or facility-reported incidents to be a conservative  estimate. After reviewing the possible limitations of these data, we  determined the data were sufficiently reliable for the purposes of this  reporting objective.

Appendix II: Trends in Abuse-Related Deficiencies

This appendix describes trends in abuse-related deficiencies over the 5- year period from 2013 through 2017. We reviewed Centers for Medicare  & Medicaid Services (CMS) guidance that was in effect during this period  of review to determine which federal standards and deficiency codes  were relevant to resident abuse. For the report, we focused our analysis  on the deficiency code cited when state surveyors substantiate incidents  of abuse, but there are also deficiencies that surveyors can cite for  abuse-related issues, such as a failure by the nursing home to train staff  on issues related to abuse, either in conjunction with an abuse deficiency  or without an abuse deficiency. Since these abuse-related deficiencies do  not necessarily represent incidents of abuse, but do represent situations  where a nursing home’s inadequate policies could leave residents  vulnerable to abuse, we also conducted a limited analysis on the trends of  these deficiencies. Specifically, we analyzed CMS data to identify the  number of abuse-related deficiencies cited in each year in all 50 states  and Washington, D.C., and determined how many were cited at each  level of severity—no actual harm with a potential for minimal harm, no  actual harm with a potential for more than minimal harm, actual harm, and  immediate jeopardy. We also tracked the source of these abuse-related  deficiencies—that is, whether the deficiency originated from a standard  survey, complaint investigation, or a facility-reported incident  investigation. Finally, we compared the results for abuse-related  deficiencies with the results for all types of deficiencies cited by surveyors  in each year.

From 2013 to 2017, we found that abuse-related deficiencies became  slightly more common with a resulting increase in severity. Specifically,  abuse-related deficiencies increased by about 9.9 percent over the 5-year  period, from 4,899 deficiencies cited in 2013 to 5,383 deficiencies cited in  2017, but peaked in 2016 with 5,687 deficiencies. This increasing trend  for abuse-related deficiencies is in contrast to the slight decrease in all  deficiencies cited over the same period, but not nearly as high as the  103.5 percent increase in abuse deficiencies. In addition, the proportion  of abuse-related deficiencies cited at the highest levels of severity— deficiencies causing actual harm to residents or putting residents in  immediate jeopardy—fluctuated throughout the 5-year period.  Specifically, about 6.1 percent of the 4,899 abuse-related deficiencies in  2013, about 5.6 percent of the 5,278 abuse-related deficiencies in 2015,  and about 7.8 percent of the 5,383 abuse-related deficiencies in 2017  caused actual harm or immediate jeopardy. (See fig. 7.)

We also found that over half of the abuse-related deficiencies each year  were cited by surveyors as a result of standard surveys, and the rest were  cited by surveyors as a result of either complaint or facility-reported  incident investigations. This falls between what we found for abuse  deficiencies—the majority were a result of either complaint or facility- reported incident investigations—and all types of deficiencies—the vast  majority were a result of standard surveys. Over the 5 years, similar to  abuse deficiencies and all types of deficiencies, the percentage of abuse- related deficiencies that resulted from standard surveys decreased while  the percentage that resulted from both complaint and facility-reported  incident investigations increased. Specifically, over the 5-year period, the  percentage of abuse-related deficiencies resulting from standard surveys  decreased by about 8.8 percentage points, complaint investigations  increased by about 3.6 percentage points, and facility-reported incident  investigations increased by about 5.3 percentage points. (See fig. 8.)

Appendix III: State Information on Abuse Deficiencies

Tables 8 and 9 provide state-level data on abuse deficiencies and the  nursing homes that had abuse deficiencies cited in consecutive years.

Appendix IV: Comments from the Department of Health and Human Services

Appendix V: GAO Contact and Staff Acknowledgments

John E. Dicken, (202) 512-7114 or dickenj@gao.gov.

In addition to the contact named above, Karin Wallestad (Assistant  Director); Sarah-Lynn McGrath and Kathryn Richter (Analysts-in-Charge);  Luke Baron; Summar Corley; Zosha Kandel; and Julianne Flowers made  key contributions to this report. Also contributing were Laurie Pachter,  Jennifer Whitworth, and Vikki Porter.

To protect vulnerable nursing home residents from abuse, the Centers for Medicare & Medicaid Services (CMS) contracts with state agencies—known as survey agencies—that can cite nursing homes for incidents of abuse.

Abuse citations doubled from 2013-2017. We reviewed a 2016-2017 sample of narratives substantiating abuse citations and determined that physical and mental/verbal abuse were more common than sexual abuse, and that perpetrators were often staff.

CMS can't readily access this information, which it could use to improve its oversight by focusing on the most prevalent problems. Our recommendations address this and other issues we found.