Patient safety at risk because of state oversight failures in NC nursing homes, audit finds
An audit of North Carolina’s health and human services department cited problems in its oversight of nursing homes, including delays in inspections, complaint investigations and verifying corrective actions, which the audit said put residents at risk of unsafe conditions.
One safety issue cited: a complaint about a resident injury for which the investigation was completed 145 days after the incident.
In a letter responding to the problems uncovered, Mark Benton, chief deputy secretary for health services at the state’s health and human services department (DHHS), said the team responsible for nursing home inspections and investigations has been understaffed and under-resourced for years, resulting in ongoing struggles to keep up.
Despite “repeated requests” for additional staff, higher salaries and better benefits for his team, the General Assembly has not made the necessary investments, apart from some partial funding, he said.
Benton also cited COVID-19 as impacting work and said the auditor’s findings “differ vastly” from federal-level reports.
The audit notes that the period from March 4, 2020, to March 1, 2021, was excluded from all its findings because the federal Centers for Medicare and Medicaid Services (CMS) had suspended certain state reporting requirements during that time.
Charlotte Observer reporter Ames Alexander’s 2022 Left Alone investigation revealed that severe staffing shortages inside North Carolina nursing homes were putting thousands of patients at risk.
Nursing homes are defined by DHHS as centers that provide ongoing medical supervision, health monitoring and rehabilitation for people who do not necessarily require general hospital care.
DHHS deferred a request for comment, pointing to its response in the audit.
The Health Service Regulation Division within DHHS oversees adult care facilities.
Here’s a deeper look at the audit’s findings.
Did not conduct timely inspections
The audit found that the Health Service Regulation Division did not conduct timely inspections of nursing homes as required by federal regulations between March 1, 2021 and Dec. 31, 2023.
Of 425 nursing homes, 289 (68%) were inspected late. The audit also found that 10% of nursing homes went more than 20 months without an inspection.
Medicare and Medicaid provide coverage for nursing home care for eligible beneficiaries, and federal regulations require inspections at least once every 15 months. Inspections cover areas such as resident rights, protection from abuse, neglect and exploitation, and rights related to admission, transfer and discharge.
The report noted that these 425 nursing homes account for 44,128 beds and received $9.36 billion in Medicaid funds.
As a result of these late inspections, “nursing home residents were at risk of conditions that could have threatened their health and safety,” says the audit, published under the leadership of state Auditor Jessica Holmes, a Democrat.
Holmes was appointed as state auditor by Democratic Gov. Roy Cooper to complete former Auditor Beth Wood’s term. She lost her bid for reelection to Republican Dave Boliek. State Health and Human Services Secretary Kody Kinsley Kinsley was also appointed by Cooper.
Problems cited included a case of abuse and neglect in which a resident suffered foot wounds after staff ignored her request to stop the wheelchair transport, leading to a monthlong recovery. Division management attributed the delays in annual inspections to COVID-19-related challenges, including staff health concerns, high vacancy rates and turnover, says the report.
Did not complete timely investigations of complaints
The division failed to complete investigations of nursing home complaints within the time-frames set by state law between Jan. 1, 2019, and Dec. 31, 2023. The division received 35,564 complaints, of which 17,152 required investigations. Of these, 6,756 (39%) were completed late, and 6,543 (38%) did not have investigations initiated within 60 days, according to the report.
State law requires complaints to be investigated and resolved within 60 days. Delays in meeting this timeline put nursing home residents at greater risk, says the report. In one instance, a resident was injured after slipping from a lift during a transfer from bed to a wheelchair, resulting in hospitalization and surgery. The division took 145 days to complete the investigation.
The division said it had struggled to meet state timelines due to high complaint volumes and lack of resources, the report says. It also said, according to the report, that although an initial analysis showed a need for more investigators to comply with state law, it has not formalized its analysis to request additional resources from the General Assembly.
Did not always verify the correction of deficiencies
Auditors reviewed a list of deficiencies cited by the division for 425 North Carolina nursing homes from Jan. 1, 2019, to June 30, 2022.
Of the 6,004 deficiencies requiring a correction plan, auditors selected 612 to assess whether the division verified corrections.
The analysis found that the division did not verify the correction of 224 (37%) of these deficiencies.
When a nursing home is cited for a deficiency during an inspection or investigation, the report says, the division is federally required to ensure — via obtaining evidence or conducting an on-site revisit — that each deficiency is corrected.
Division management said that while employees held weekly meetings to prioritize inspections, investigations and verifications based on staffing and due dates, there were no formal procedures to track deficiencies or ensure verifications were documented. Instead, management relied on informal, undocumented reviews, says the report.
The auditor’s office recommended, among various other things, that the division conduct a formal analysis to determine the resources needed to meet these requirements and request enough money from the General Assembly to ensure compliance. Alternatively, the division should ask for clarification from the General Assembly regarding its responsibilities, according to the audit.
This story was originally published December 18, 2024 at 3:41 PM with the headline "Patient safety at risk because of state oversight failures in NC nursing homes, audit finds."
CORRECTION: An earlier version of this article incorrectly identified the main author of the letter responding to the audit findings.
