Margaret Morganroth Gullette’s books include “American Eldercide: How It Happened, How to Prevent It” and “Ending Ageism, or How Not to Shoot Old People.”
In Nikolai Gogol’s 1836 play “The Inspector-General,” a provincial governor tells local leaders that “an inspector is coming! … So you had better see to it that everything is in order, that the nightgowns are clean, and the patients don’t go about as they usually do, looking as grimy as blacksmiths.”
Gogol’s play is a farce, but a deadly serious version of this phenomenon seems to be playing out in nursing homes. A recent study from the National Bureau of Economic Research finds that American nursing homes tend to increase staffing levels and expend more effort on patient care as a government inspection looms and cut back afterward.
When the health cops are on the way, suddenly there are mold-free bathrooms, fresh supplies, rodent control, and most important, new staff hires. Staffing levels are life-and-death variables. Adequate staffing means medications are delivered on time, call bells are answered, wounds are treated, medical and medication errors are caught faster, hospitalizations are avoided. With less turnover, residents get to know their caregivers, and caregivers can become more responsible and responsive.
To avoid risks to helpless people, inspectors from states’ departments of health are required to make unscheduled visits to every facility, usually every nine to 15 months. State surveyors do not warn facilities, but once nine months have passed since the last visit, nursing home owners know another inspection is coming soon. The predictability of inspections influences the homes’ timing: They’ll do what they need to do to clean up and then go back to business as usual. More than 70 percent of nursing homes are owned by for-profit companies.
Sending out inspectors randomly would be a simple fix. The authors of the new study estimate that hundreds of lives are saved every year because of nursing home inspections and calculate that the figure would be 12 percent higher if inspections were unpredictable. And, they add, randomizing visits would not force states to hire any more inspectors.
Another sensible and no-cost solution could be to focus the surprise inspections on the homes with the most complaints from residents, their families, and their advocates. An even better reform would be to require each facility to always post prominently on its website its current ratio of aides and nurses to residents. That would be a way to consistently enforce the state standards for minimum staffing.
By 2030, one-quarter of us in Massachusetts, and one-fifth of all Americans, will be over 65. If we are serious about keeping our vulnerable elders in basic comfort and dignity, we need more than bureaucracy’s checkboxes and aspirations to be an “age-friendly” place.