Report: Arizona health officials not protecting nursing home patients

By Howard Fischer
Capitol Media Services
PHOENIX -- Arizona state health officials are doing a poor job of ensuring that people in nursing homes are properly protected, a new report concludes.
And what's worse, said Auditor General Lindsey Perry, is that the situation hasn't changed since her agency pointed out the problems 30 months ago.
In fact, she noted that auditors made five recommendations in September 2019 of things the Department of Health Services should implement to ensure that all complaints are prioritized, investigated and resolved in a timely manner. To date, Perry said, none have been implemented.
Perry said her staffers, conducting a follow-up investigation, found multiple cases where the health department inappropriately closed most high-priority complaints without the required on-site investigation. She said that includes complaints about lack of precautions to keep residents from getting pressure sores, patients being left soiled for extended periods, and incidents of abuse and neglect.
And Perry said she found the agency inappropriately changed virtually all of its open high-priority complaints to lower priorities. What that did, she said, is artificially extended the time to respond to those complaints from 10 days to a full year.
Even then, Perry said, some cases still ended up being closed without any inquiry at all.
But what really got Perry's attention is was the failure of the health department to implement those 2019 recommendations.
"We identified additional significant complaint-prioritization and investigation failures that have continued to put long-term care facility residents' health, safety, and welfare at risk,'' she wrote of the follow-up investigation.
In a prepared statement, state Health Director Don Harrington said there were mitigating circumstances.
"Amid the COVID-19 outbreak, and on instruction from the Centers for Medicare and Medicaid Services, the agency's main focus shifted to infection control survey for long-term care facilities,'' he said. The goal there, according to Harrington, was to reduce the chances of outbreaks that could endanger residents.
He said the agency exceeded the federal requirements for those infection control surveys which staff conducted at all facilities and "handled rapidly when outbreaks were reported.''
Perry, however, was not impressed.
"While we understand that the state's COVID-19 pandemic response has required significant department time and resources and the department experienced executive and licensing changes during this time period, neither mitigate its failure to appropriately prioritize and investigate complaints (and) self-reports alleging abuse or neglect of long-term care facility residents,'' she wrote in her report.
Self reports are incidents that a nursing home must report on its own to the health department. These range from resident injuries of unknown origin and allegations of abuse or neglect to misappropriation of a resident's property.
"It also does not justify changing high-priority complaints and self-reports to lower priorities that do not need to be investigated as urgently,'' Perry said.
And she said the numbers bear out the scope of the problem.
It starts with the requirement to investigate high-priority complaints within 10 days.
These are one step below those classified as "immediate jeopardy,'' meaning there is an immediate and serious threat to health and safety. They have to be checked out within two days.
High priority, by contrast, is defined to include actual harm that impairs a resident's mental, physical or psycho-social status. It also includes hazards to health and safety that may exist and are likely to cause a significant problem in care and treatment.
Perry said the follow-up audit to the 2019 report found that 73% of the high-priority complaints the agency received still were not investigated within the 10-day window as required.
"Failing to timely investigate high-priority complaints can have severe, adverse effects including compromised investigations impacting the department's ability to substantiate allegations such as sexual abuse where time is of the essence,'' she said. Perry said it also ensures that actions can be taken to protect not only that resident but others at the facility.
She cited several actual examples.
One was a January 2020 complaint from the wife of a resident of a long-term care facility who reported her husband had developed unexplained bruises on his arm. The wife also said that he had not been receiving doctor-ordered respiratory treatments and had developed a pressure sore on his tailbone due to being left soiled for extended periods of time.
The complaint noted that the man had severe cognitive impairment which would limit his ability to complain about the level or care or report instances of physical abuse or unreported accidents.
Perry said the health department listed seven separate allegations and designated it a high-priority complaint.
Only thing is, she said, the agency did not act on it until 15 months later when it downgraded it to a medium-priority complaint.
"Approximately two weeks later, the department closed the complaint without investigating any of the allegations,'' Perry wrote.
In a similar situation, the department got a complaint from a daughter of a resident at a long-term care facility who had been hospitalized with a pressure ulcer resulting in dead skin and a bone infection.
The complaint record said the man did not have that problem when he entered the facility. And because he was nonverbal, he could not complain about pain or other symptoms.
He eventually was placed in hospice care to to the pressure ulcer and bone infection and died at the end of the month.
But Perry said while the health department classified it as alleged neglect and assigned it a high-priority level, it simply closed the complaint 18 months later without an investigation and took no further action against the facility.
It is not just that high-priority complaints were not promptly investigated.
Perry said the health department "inappropriately'' changed 98% of its open high-priority complaints to lower priorities, "artificially'' extending the time to respond from 10 days to a full year.
She said her interviews her investigators did found that the health department staff sometimes made decisions about whether to downgrade complaints based on factors ranging from whether staff was available within the required time frame and whether the resident already had died.
Perry also said the person who was responsible for assigning priority levels also told her investigators that it considers complaints that come from the Adult Protective Services program at the Department of Economic Security to be not credible, saying that agency "often sensationalizes its reports'' to the health department.
And she said that complaints from family members also are not considered as credible by the health department, with the staffer saying that "the family is simply upset about the passing of the resident.''
Harrington, in his prepared response, said Perry's office has provided the data about complaints that were closed without an investigation or simply downgrade.
"We have begin a thorough review to see what improvements are needed,'' he said. "The department takes very seriously any concerns about our oversight of long-term care facilities.''
Harrington did acknowledge the agency has not met the recommendations from the 2019 report. He said, though, that there have been more than 1,000 visits to long-term care facilities since July 1, 2019, with an average of seven visits to each.
And Harrington said all the immediate jeopardy and high-priority complaints received since the beginning of 2021 have been investigated within the required timeframes.
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