The Tennessee Department of Health has suspended admissions at 22 nursing homes this year — including the three in Middle Tennessee that lost their CMS funding — after the most serious type of violations were found there.
According to the Health Department, the commissioner "may suspend admissions to a nursing home when conditions are determined to be, or are likely to be, detrimental to the health, safety or welfare of the residents."
Cornelia House had 25 of these "immediate jeopardy" violations in 2007, McKendree had 19, and Mitchell Manor had 14, state officials said. While lots of facilities have been cited with these serious violations, the facilities that lost their funding were unable to fix the problems within the 23 days given by the Centers for Medicare and Medicaid or were unable to stay in compliance.
Five Tennessee nursing homes with a total of 750 beds have lost CMS funding this year, up from one in 2006 and one in 2007.

"These facilities were afforded the same number of days as others across the country to develop and implement a plan to correct the violations, maintaining an appropriate standard of care for residents," said Christy Allen, assistant commissioner of the Tennessee Department of Health, Bureau of Health Licensure and Regulation.

Ron Taylor, executive director of the Tennessee Health Care Association, has maintained that the nursing homes aren't getting worse but that inspectors are getting stricter.

"The overwhelming majority of these nursing homes that have had admissions suspended haven't had past compliance history issues of a serious nature," Taylor said, adding that the problems could be resolved without such harsh punishments.

Documentation stressed

The Cornelia House has had a history of problems.

For four consecutive years, the nursing home was cited with immediate jeopardy violations. According to inspection reports, residents had wallets and clothes stolen; patients were observed smoking crack; residents were told to go to the bathroom in their pants; and their health-care needs weren't attended to, among other problems.

"Nurse was asked by this resident to reapply tape but didn't return for several hours," the report states. "The nurse was asked again when the nurse stated she/he was going to lunch and it would be another 35 minutes. Resident stated (he/she) become insistent and nurse proceeded to slam his/her lunch down on the cart and rewrapped resident's leg so tight it cut off the circulation."

On the other hand, McKendree Village and Mitchell Manor don't have a history of these serious immediate jeopardy violations, state officials said.
Officials with McKendree Village declined to be interviewed for this story through their public relations spokeswoman. However, they maintain that none of the issues identified by the state have resulted in any actual harm.

They say that many of the state's findings are related to documentation. For example, the inspectors found that the facility failed to investigate the cause of injuries for 11 of 42 residents to ensure that abuse or negligence had not occurred. However, that doesn't mean that abuse or negligence did occur.

Dr. Joseph Ouslander, an Emory University professor of adult and elder health, who has worked with the Centers for Medicare and Medicaid Services to improve the quality of care in nursing homes, said part of the problem with the inspection process is that there is a heavy emphasis on relying on documentation, which may not adequately reflect care.

"There's a lot of missing documentation, sometimes just because staff is too busy to get to it," Ouslander said. "There's also a lot of false documentation. Boxes are checked off when care has never been given."

Ouslander said that documentation is important. But he thinks that inspectors rely too much on documentation and not enough on observation of care.

Taylor, with the Tennessee Health Care Association, said that another problem is that the inspection process is subjective and open to bias.

"We see inconsistencies in the inspection process," Taylor said. "We see where one facility will be cited at a higher level than another facility for what appears to be the same deficiency."

The Health Department's Allen said immediate jeopardy is determined through a multi-tiered process of checks and balances that includes state and federal officials.

"These decisions are not made in isolation," she said.

Reviews mixed for home

Scott Anderson said his mother received excellent care at McKendree and loves it there, even though she got scabies, a skin infestation caused by mites that burrow into the skin.

"I was impressed with how it was handled. And, stuff like that happens," Anderson said. "My daughter got scabies in the seventh grade from school, 
but the state didn't close the school or cut funding to it. I am just shocked that McKendree has been dealt such a harsh blow."

But according to the state inspection report, others weren't so happy with the care they received.

The documents show the facility was short-staffed and that contract employees in particular didn't receive proper training and sometimes neglected patients.
"They are abusive by the tone of their voice and what they say,'' a resident told inspectors.

Another said staffers respond like snails to call lights, but "break their necks" when state inspectors are on the prowl.

"We need TLC, not being stomped on," one resident said.

McKendree also had a few problem patients who endangered other residents.
One patient attempted to stab a nurse with scissors, pushed staff and residents, and was sexually inappropriate with a resident. Another patient was so violent to others — cursing, slapping, throwing coffee on them and running over one patient's foot with a scooter — that nursing home officials transferred her to another facility. That drew a violation because the facility officials didn't tell the resident's doctor or family she was being moved, the documents show.
Despite the state's findings, many McKendree residents and their family members have said they are happy with the care they have received at the facility and don't want to leave.

In Ouslander's opinion, it all comes down to this: "You have to balance the risks to health and safety the facility poses to the risk of moving this very frail population," he said.