Infection control lapses rampant in nursing homes but penalties are rare

Basic steps to prevent infections — such as washing hands, isolating contagious patients and keeping ill nurses and aides from coming to work — are routinely ignored in the nation’s nursing homes, endangering residents and spreading hazardous germs.

A Kaiser Health News analysis of four years of federal inspection records shows 74 percent of nursing homes have been cited for lapses in infection control — more than for any other type of health violation. In California, health inspectors have cited all but 133 of the state’s 1,251 homes.

Although repeat citations are common, disciplinary action such as fines is rare: Nationwide, only one of 75 homes found deficient in those four years has received a high-level citation that can result in a financial penalty, the analysis found.

“The facilities are getting the message that they don’t have to do anything,” said Michael Connors of California Advocates for Nursing Home Reform, a nonprofit in San Francisco. “They’re giving them low-level warnings year after year after year and the facilities have learned to ignore them.”

Infections, many avoidable, cause a quarter of the medical injuries Medicare beneficiaries experience in nursing homes, according to a federal report. They are among the most frequent reasons residents are sent back to the hospital. By one government estimate, health care-associated infections may result in as many as 380,000 deaths each year.

The spread of methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant germs has become a major public health issue. While Medicare has begun penalizing hospitals for high rates of certain infections, there has been no similar crackdown on nursing homes.

As average hospital stays have shortened from 7.3 days in 1980 to 4.5 days in 2012, patients who a generation ago would have fully recuperated in hospitals now frequently conclude their recoveries in nursing homes. Weaker and thus more susceptible to infections, some need ventilators to help them breathe and have surgical wounds that are still healing, two conditions in which infections are more likely.

“You’ve got this influx of vulnerable patients but the staffing models are still geared more to the traditional long-stay resident,” said Dr. Nimalie Stone, the CDC’s medical epidemiologist for long-term care. “The kind of care is so much more complicated that facilities need to consider higher staffing.”

The Centers for Medicare & Medicaid Services (CMS), which oversees inspections, has recognized that many nursing homes need to do more to combat contagious bugs. CMS last year required long-term care facilities to put in place better systems to prevent infections, detect outbreaks early on and limit unnecessary use of antibiotics through a stewardship program.

But the agency does not believe it has skimped on penalties. CMS said in a statement that most infection-control violations have not justified fines because they did not put residents in certain danger. For instance, if an inspector observed a nurse not washing his or her hands while caring for a resident, the agency said that would warrant a lower-level citation “unless there was an actual negative resident outcome, or there was likelihood of a serious resident outcome.”

Last November, CMS waived penalties for 18 months against facilities that violate the new stewardship rule. The industry had said nursing homes needed more time to prepare.

Holly Harmon, the senior director of clinical services at the American Health Care Association, a nursing home trade group, said the industry has made strides in combating infections through better training and encouragement for staff members to look for gaps in infection control and to speak up about them. The percentage of nursing home residents with urinary tract infections — the only type of infection all nursing homes must report to Medicare — has dropped by more than half since 2011.

“Infection prevention control is a priority,” Harmon said. “The path really is focused on continuous improvement.”

Elsewhere, health regulators are similarly reluctant to assert that nursing home errors led to patient infections or put patients in imminent danger. Only 161 homes among the 12,056 that violated infection-control rules were cited at those higher levels since 2014, according to KHN’s analysis.

The value of lower-level citations as deterrents is questionable: Authorities have cited 7,045 homes more than once over infection-control lapses, including 942 that racked up four or more violations, the analysis found.

“Perhaps a bigger stick might be more helpful,” said Joseph Rodrigues, California’s long-term-care ombudsman.

Inspection records show nurses and aides are often not familiar with basic protocols, such as wearing protective clothing when coming into contact with contagious residents and isolating them from others in the home and visitors. Others are not trained properly on how to clean patients. Still others, in a rush and understaffed, take shortcuts that compromise sanitary precautions.

“We’ve always been shocked at how often we’ve personally witnessed people providing care in facilities and not washing their hands, which has got to be the most basic thing in infection control and prevention,” said Sherry Culp, who as Kentucky’s long-term-care ombudsman advocates for aggrieved nursing home residents.

Another recurring problem stems from nurses and aides infecting residents because they come to work ill knowing they would not get paid for the sick time, said Dr. David Nace, an associate professor at the University of Pittsburgh School of Medicine.

Jordan Rau, Kaiser Health News