Ombudsmen
often feel powerless in efforts to
BLOW
THE WHISTLE
Articles Courtesy of
the STL.TODAY.com |
By Phillip O'Connor
Copyright 2002
A special report by the
ST. LOUIS POST-DISPATCH
Posted 10/16/2002
In 1972, Congress passed a law that legislators
believed would help end deadly care in America's nursing homes. It mandated
that each state set up an ombudsman program to identify and investigate
complaints in hopes of preventing the neglect and abuse that were harming
the elderly in the facilities paid to care for them.
Thirty years later, the deaths continue
throughout the country, and ombudsmen frequently find themselves powerless
to protect the elderly.
More than two dozen ombudsmen interviewed
by the Post-Dispatch from coast to coast say their attempts to blow the
whistle on bad care are often dismissed by state regulators and demeaned
by the nursing home industry. Their efforts, mandated by Congress, to push
for legislative improvements are often ignored by lawmakers in their own
states.
"Our goal is to prevent harm to residents,"
said Esther Houser, Oklahoma's state ombudsman. "It's a mandate, but it's
been terribly, weakly enforced, and it's been either ignored or abused
in many states."
A report in 1995 by the Institutes of Medicine,
which does research for the federal government, backs her assertion, declaring
that any success by ombudsmen occurred "despite considerable barriers in
most, if not all, states."
While Congress created the program with
high hopes, it didn't provide ombudsmen with much power. Instead, their
role is to advise residents and their families of their rights and to resolve
resident complaints. In cases of poor care, they often must rely on regulators
to intervene. Their only power is the power of persuasion.
"They can't make a facility do anything,"
said Alice Hedt of the Washington-based Long Term Care Ombudsman Resource
Center.
Still, Hedt and others laud the work of
ombudsmen. Hedt says she would hate to see the condition of nursing homes
if the program did not exist.
In 2000, ombudsmen responded to more than
232,000 complaints, the most frequent being lack of resident care because
of inadequate staffing.
The federal legislation that created the
ombudsmen initiative left it to each state to choose its own type of program.
States, in turn, often left it to cities or regions to develop their own
programs. The result is a patchwork of uneven approaches.
State programs operate with little federal
oversight; no regulations exist that might provide better continuity among
the states. With no established performance measures, there's no way to
determine whether state programs are doing a good job.
Most state efforts to launch programs have
been piecemeal and fragmented. For example, only now, 30 years after the
program began, is Missouri finally developing written regulations.
Today, fewer than 9,000 ombudsmen, the
vast majority of whom are poorly trained, unpaid volunteers, are responsible
for helping to ensure the safety and care of the nation's 1.8 million nursing
home residents. The federal government allocates about $13 million annually
for the program.
Only 20 states meet a standard recommended
by the Institutes of Medicine of one paid ombudsman for every 2,000 nursing
home residents. Even those who meet the standard say it is a struggle to
keep up with all of the demands.
Not enough time
Nancy Flowers, a paid staff member, operates
the local ombudsman program in Evanston, Ill., which monitors 2,000 beds
in the city's 13 nursing homes. Flowers recently walked into her office
at 7:30 a.m. after a long weekend and found 73 voice and e-mail messages
waiting.
"They're all asking for help, and I desperately
need to return those," she said.
Flowers spent much of the morning with
a phone pressed to her ear, a cup of coffee in close reach. On a nearby
bookshelf sat a book titled "The 36-Hour Day."
By noon, Flowers was driving toward Chicago
for a 1 p.m. court hearing on behalf of a resident. After court, she grabbed
a sandwich before the hourlong drive back to Evanston. Back in the office,
more messages had piled up, and she stayed on the phone until nearly 6
p.m., when she called it a day. The next morning she met with her boss
to plead for hiring another staff person.
Volunteers: Tired of being muzzled
This year at a senior service center in
Washington, Bush administration officials said the ombudsman program embodies
the spirit of volunteerism that the president has highlighted in his national
call to community service.
But according to many involved in the program,
the volunteers are poorly trained, face overwhelming workloads and are
often inaccessible on evenings and weekends.
In the St. Louis region, a paid staff of
two and 40 volunteers are responsible for nearly 200 nursing homes. Statewide,
about 20 percent of nursing homes are not visited by an ombudsman in any
given year.
Many volunteers quit out of frustration.
Rose Hilger finished as a finalist for
volunteer ombudsman of the year in Illinois just a few years ago but no
longer works in the program. Hilger said she grew tired of being muzzled
by her bosses from talking to lawmakers about needed changes, being told
to curb her criticism of bad homes and at times being asked to turn a blind
eye to poor care.
"They have no power, no enforcement, and
people ignore them, basically," Hilger said. "I thought we were supposed
to seek the truth, but basically they don't want that all the time."
Paid staff: At odds with the bosses
By federal law, the ombudsman is required
to speak out against government laws, regulations, policies and actions
when justified. But that often puts ombudsmen at odds with their bosses
and their bosses' bosses. Only 13 of 50 state programs operate independently
of state aging offices.
"It's not your typical state job," said
Carol Scott, Missouri's state ombudsman, who also serves as president of
the National Association of State Long-Term Care Ombudsman Programs. "We're
asked to be an advocate, and yet most of us are placed in an atmosphere
where you don't buck the tide of what the governor's agenda is."
Since 1998, 40 people have left their jobs
as heads of state ombudsman programs, many over political differences with
a government administration.
The turnover took place in 28 states.
In 1998, Robyn Grant quit as head of the
ombudsman program in Indiana after being forbidden by her bosses in the
state's Bureau of Aging to talk to lawmakers, speak at public hearings
or even send copies of proposed legislation to local ombudsmen.
"Every move I made was scrutinized," she
said. "I banged my head against the wall for eight years and got incredibly
frustrated."
In Colorado, the state ombudsman resigned
last year, citing state interference with access to the legislature and
the media.
In Alaska, three state ombudsmen resigned
within two years.
Going undercover in New Mexico
Despite the program's widespread shortcomings,
a handful of success stories have emerged.
In Georgia, ombudsmen recognized that malnutrition
was a problem. As a result, the ombudsman program evaluated feeding practices
in all the state's homes and then worked with the industry to make improvements.
In Louisiana, the ombudsman program is
noted for the extensive training volunteers get, including 26 hours of
classroom work followed by an exam and an internship alongside a more experienced
ombudsman.
In New Mexico, an escalating war of words
with the nursing home industry prompted officials on aging there to send
some ombudsmen undercover to pose as residents.
"Their (the nursing home staff's) ability
to bathe and toilet me was inappropriate," said Michelle Grisham, director
of the state agency on aging. "They left me completely naked with only
a robe that was open and let me sit for three and a half hours watching
a Ninja Turtle movie with the rest of the residents. I was the most popular
girl in the facility."
Other investigations found even worse problems,
including verbal and emotional abuse, thefts, residents left sitting for
hours in urine and feces, and records being falsified.
"We witnessed a resident fall . . . and
the nurse's aide was screaming, 'Get up, get up. I'll get into trouble,'
" Grisham said. "She left the 90-year-old laying on the floor for several
hours before taking him to the hospital."
One undercover ombudsman received a steady
diet of Spam.
When the industry complained about the
visits, the governor backed Grisham.
Since then, Grisham got the authority to
conduct the undercover visits written into the state law.
But even the undercover visits aren't enough
to bring meaningful change, said Tim Covell, former New Mexico state ombudsman.
"My feeling is that bad care is endemic
and marginal care is probably what they aspire to in the nursing home industry,"
Covell said. "I would not live in a nursing home, period. I would choose
to die in my home. And that's on the basis of what I saw."
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