About 1.5 million individuals are currently residents in approximately 16,000 nursing homes nationwide. For many, it’s the best place to receive care and housing; for some, it’s the only real option. But for too many, there is a documented dark side behind closed doors: abuse and neglect. Periodic reports of the wrongs committed have resulted in some legislative changes. But the most recent Senate hearing highlighted a new cause for concern: In the past two years, the Trump Administration has put several “deregulatory” measures into effect. Those moves included an 18-month moratorium on enforcing many protective standards of care, substantially decreasing fines for violations, and watering down regulations recently revised to address longstanding problems of abuse and neglect.

The hearing, with the hopeful title “Not Forgotten: Protecting Older Americans from Abuse and Neglect in Nursing Homes,” was held on March 6, 2019 before the Senate Finance Committee, which has jurisdiction over Medicaid programs.

The Politicians

It began in the usual way hearings do — with politicians offering platitudes and self-congratulatory back-patting about strides made, reports they released, legislation they pushed. Then Sen. Chuck Grassley (R-Iowa) eventually noted the elephant still remaining in the room: “Hardly a week goes by without seeing something about nursing home abuse or neglect in the national news,” he said.

And Senator Ron Wyden (D-Oregon) lamented the likelihood the upcoming federal budget would include another attack on Medicaid, sure to lead to more nursing home closures, noting: “At a time when the federal government ought to be raising standards and rooting out harmful, substandard care and those who provide it, the Trump administration and CMS is going in the wrong direction.”

The Family Members

The wrongheadedness of that direction was underscored most poignantly by the testimony of two women, both of them daughters of nursing home residents.

Patricia Blank delivered her testimony a year and a day after her mother’s funeral. Her mother, Virginia Olthoff, diagnosed with dementia, had been a resident at Timely Mission Nursing Home in Iowa for 15 years. During that time, Blank had nothing but accolades for the Timely Mission, which held a five-star rating — CMS’s highest possible ranking for quality of resident care. She recalled her mother was always dressed when she visited, that staffers contacted her when her mother had personal needs such as new glasses and whenever her medications were changed.

Then last year she got a call summoning her to the hospital,where her mother had been taken in the early morning hours. There, the Emergency Room doctor said Olthoff was extremely dehydrated with sodium levels so elevated that she likely had suffered a stroke. “He also said, ‘This did not just happen. I believe she has been without water or any type of fluid for at least 4 or 5 days,’” Blank recalled. Her mother died shortly after.

The doctor reported the abuse to state authorities, who eventually issued a report about the matter. “The report read like a horror story,” Blank testified. “According to numerous staff members, my mother had been eating very little and drinking almost nothing for almost two weeks. Where was my call? The report also said she had been crying out in pain often. Where was my phone call?”

Maya Fischer also testified about her mother, Sonja Fischer, who was suffering from advanced Alzheimer’s while a resident at Walker Methodist Health Center in Minneapolis. A few days before Christmas in 2014, a nurse walked into her room at 4 a.m. and witnessed a male caregiver raping her.

In online reviews of Walker Methodist, family members gave the staff five stars — the highest rating possible. CMS ranked both staffing and quality of care there as above average (4 stars).

“My mother had suffered from Alzheimer’s for 12 years. She was totally immobile, unable to speak and was fully dependent on others for her care,” Fischer testified. “My final memories of my mother’s life now include watching her bang uncontrollably on her private parts for days after the rape, with tears rolling down her eyes, apparently trying to tell me what had been done to her, but unable to speak.”

The Bureaucrats

David Gifford, representing the American Health Care Association, the trade association for nursing facilities, had some tough acts to follow and had to tiptoe — giving shout-outs to staff at a Florida nursing home who stayed with residents during a hurricane and others at a Colorado nursing home who weaned a resident off antipsychotic meds. And he testified that over the past seven years, there have been some improvements in 18 of the 24 measures of care tracked by the government — basing that boast on the CMS data. Kate Goodrich, Director of the Center for Clinical Standards at CMS, focused only a small portion of her testimony on the topic at hand: nursing home abuse and neglect.

“CMS requires nursing homes to report allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, immediately to their state survey agency,” she defended. “When we learn a nursing home failed to report or investigate incidents of abuse, CMS takes immediate action against the nursing home.”

The Enforcers

Antoinette T. Bacon, an associate deputy general at the Department of Justice who identified herself as “a career prosecutor” for 18 years, also testified.

After toeing the company line by reciting the Justice Department’s commitment to cracking down on “grossly substandard care,” she found hope in a recent order requiring the 94 U.S. Attorneys’ offices to appoint an Elder Justice Coordinator to serve as the legal counsel on elder abuse investigations, “particularly focusing on nursing home quality matters.”

Finally, Keesha R. Mitchell, director of the Ohio Medicaid Fraud Control Unit, pointed to a number of reasons enforcement efforts are often hampered — zeroing in on the periodic surveys in which inspectors allegedly visit and evaluate facilities. “As we have confirmed in numerous investigations, facility staff are often not truthful with surveyors, the administration encourages falsification of information, and facility administrator’s ramp up staffing during the survey to give the appearance of readily available staff,” she said.

Mitchell also noted that while the law requires care facility operators to promptly report any reasonable suspicion of a crime committed against residents, they routinely fail to do this, or they soft-pedal the facts. One facility, for example, reported an injury of unknown origin resulting from an incident that occurred outside of building. “Our investigation revealed that the facility resident had escaped and drowned in a pond on the facility grounds,” she said.

And she took on the issue of money, criticizing both the quantity and quality of staff and the fact that facilities have the incentive to increase the alleged complexity of care their residents require, which in turn increases their reimbursement. “Let us be plain: If we want adequate staffing and quality of care, we are going to have to pay for it,” she said.