Slowly the public is coming to realize that health care institutions are not always safe places. Since the Institute of Medicine published its landmark study on unsafe medical care more than a decade ago, a grassroots patient safety movement has blossomed and media interest along with it. This is the fourth in a series of posts that will examine what the media are doing to report on patient safety in their communities. The series is archived here.
By now we’re accustomed to nursing homes delivering bad care, and the ensuing news stories that detail what that has meant for patients. But we’re not used to hearing that nursing homes falsify patient records. So two stories published this week written by Sacramento Bee reporter Marjie Lundstrom deserve a shout-out for revealing yet another dark chapter in the sorry saga of America’s nursing homes. As the paper described its series: “It is the untold story of nursing home care: falsification of patient records.” This wasn’t simply another piece examining government data about nursing home quality—in reality, data that may not be that great. This story was built on Lundstrom’s review of nearly 150 cases of alleged chart falsification in California. “We see (this) with regularity,” said the chief of prosecutions for the state attorney general’s Bureau of Elder Abuse.
Lundstrom reported that nursing homes fear costly lawsuits, which causes them to “re-create medical records to hide neglectful care.” She noted such practices as covering up bad outcomes, fill-in-the-blank charting, indicating that medicines were given when they weren’t, and falsifying consent forms to sedate patients. In one case, a seventy-seven-year-old woman died after suffering a pulmonary embolism related to fecal impaction “so severe her rectum had dilated to ten centimeters, or about four inches.” The woman’s chart at the nursing home indicated that she had had bowel movements in the days before her death, which professionals said would have been “extremely unlikely given the severity of her condition.” The Bee reported the ugly detalis of what happened to this woman in a second-day story.
Another case showed readers the journey of a ninety-two-year old man who went to a facility after a hospital stay for shortness of breath. He died several days later from pressure ulcers on his heels that led to leg amputations and a raging bone infection. Apparently nursing home staff had not repositioned him often enough. Lundstrom combed through court depositions and learned that the nursing home administrator and a representative of the facility’s corporate offices had ordered a nurse to alter the medical records to show that the resident had arrived at the facility with “softened heels.” But the nurse admitted she had not seen the patient when he was admitted and had “no memory of him ever having softened heels.” The nurse said a corporate representative had told her “to falsify the medical records because the current records did not ‘look good’ and he was worried about a lawsuit.”
I wish the paper had told us which of those 150 cases of falsified records involved for-profit nursing homes and not-for-profit facilities. Most of the nation’s facilities operate on a for-profit model, and it would have been good to know whether the problem was more prevalent when the bottom line was at stake. The Bee did point out that fraudulent charting is often the result of understaffing: “public documents reveal tales of chaotic shifts on which certified nurse assistants are scrambling to provide care.” Since nursing staff is a facility’s biggest cost, it’s easy to see how fewer nurses makes good business sense, especially when doctoring the records appears so easy.
A few paragraphs on the historical context of nursing home abuse would have helped readers understand why this problem never disappears. Over the last four decades, there have been numerous news stories about horrific deaths in nursing homes and the problems with a regulatory system that never seems to improve. Comments from the industry and regulators are the same ones that I’ve heard many times before and reported in my own work on nursing homes for Consumer Reports. Lundstrom reported that between 1990 and 1999, the state issued 180 citations against long-term-care facilities for falsifying records; between 2000 and 2011, it issued only twenty-nine citations.
That’s consistent with what I found in 2006, when a federal regulator told Consumer Reports that enforcement was easing off largely because shrinking state budgets couldn’t handle the increasing legal challenges from the facilities. Lundstrom’s kicker also meshed with my own investigation, which showed that fines—called civil monetary penalties in government jargon—are hardly a deterrent to bad care. In March, she wrote, the state imposed a fine for willful material falsification in a case involving a forged consent form to administer a drug and an eighty-six-year-old man who died from severe dehydration. The amount—$350—is the smallest fine for falsifying records the state has levied in the past decade.
There’s a larger takeaway from the Bee’s story. Falsifying medical records to hide poor care and neglect speaks to what our society values, a legitimate topic for the media to explore in the context of poor nursing home or hospital care for that matter. “The thing that’s so insidious about it (falsifying records) is that it’s become a part of the culture,” said Sacramento attorney Ed Dudensing, a former prosecutor who won a $29 million jury verdict against one of the state’s nursing homes. In 1963, President Kennedy, quoting the historian Arnold Toynbee, said in a special message to Congress “a society’s quality and durability can best be measured ‘by the respect and care given its elderly citizens.’”
The next crop of nursing home stories must inquire into the deeper questions posed by Lundstrom’s reporting. Why is the best consumer protection law on the books so poorly enforced? Why must nursing home operators profit from the misery of the nation’s oldest citizens? Lundstrom interviewed Patricia McGinnis, who has spent most of her career advocating for nursing home residents through her organization California Advocates for Nursing Home Reform. I, too, have interviewed McGinnis. During one of our conversations, tears came to her eyes as she asked: Why does such maltreatment have to continue?