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Bed sores, smeared faces, helplessness: New reports paint dismal picture of care at VA nursing homes

A hall at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford. Craig F. Walker/Globe Staff/Globe Staff

At the Veterans Affairs nursing home in Brockton, a severely impaired veteran with dementia sat trapped in his wheelchair for hours, his right foot stuck between the foot rests. Inspectors watched as staff walked past the struggling man without helping.

In the Cincinnati VA nursing home, one resident in six months developed five bedsores, tissue injuries that happen when frail people are left in the same position for too long. During their visit, inspectors said no one moved the man or put cushions under him for hours.

At the Bedford VA, meanwhile, inspectors watched elderly veterans smear their faces with food or drop much of their meals on the floor because they couldn’t feed themselves and staff didn’t help.


Nine months after USA Today and The Boston Globe reported that veterans received substandard care at many Department of Veterans Affairs nursing homes, newly released inspection reports paint a discouraging picture of the care that sick and frail veterans continued to receive at these federal nursing homes.

From April through December 2018, outside inspectors found deficiencies that caused “actual harm” to veterans at 52 out of the 99 VA nursing homes they reviewed. In three facilities, they found veterans’ health or safety in “immediate jeopardy.” In eight, inspectors found veterans both harmed and in jeopardy.

Non-VA nursing homes are rarely cited for causing actual harm to residents.

“That is really bad. It’s really bad,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a New York-based nonprofit advocate of nursing home care improvement. He added that it’s difficult to compare VA findings with non-VA findings because those inspections may not be as rigorous.

Inspectors found that staff at more than two dozen VA nursing homes, including in Brockton, Bedford, and Cincinnati, failed to take steps to ensure existing bedsores healed or new ones didn’t develop.
Bedsores are “almost always preventable, and quickly treatable,” Mollot said. “So there’s just no excuse.”


In a statement issued when they released the inspection reports earlier this month, VA officials said residents in their nursing homes are more difficult to care for than residents in private facilities. They said 42 percent of residents last year had conditions related to military service, leaving them severely disabled.

“Overall, VA’s nursing home system compares closely with private sector nursing homes, though the department on average cares for sicker and more complex patients in its nursing homes than do private facilities,” VA Secretary Robert Wilkie said.

VA spokesman Curt Cashour said Wednesday that non-VA nursing homes also have problems. He said that, by publicly posting the VA reports for the first time, “we hope to drive improvements throughout the system.”

But Mollot said VA officials have no excuse for poor care.

“You don’t accept somebody in unless you have the ability to provide care for them, period,” he said. “It’s incredible to me that one has to even say that.”

The inspection results were made public nearly a year after the Globe and USA Today disclosed that the VA possessed the reports as well as the results of a star-based rating system for VA nursing homes. The reports’ release provides valuable information for the 41,000 elderly and infirm veterans who stay in the homes each year, as well as for their families.

“The results of these independent inspections show that serious deficiencies in care remain at VA nursing homes in Brockton and Bedford, among others,” said Senator Elizabeth Warren of Massachusetts. “We must keep conducting rigorous oversight until performance and quality of care issues are fully addressed and our veterans are receiving excellent care across the board.”


Widespread deficiencies

Across the country, inspectors found that VA nursing homes failed in one of their most fundamental duties: taking steps to prevent and control infection.

At two-thirds of VA nursing homes, they found staff often didn’t follow simple protocols, such as wearing sterile gowns and gloves when treating residents.

In Des Moines, inspectors found that managers didn’t ensure staff adequately cleaned a veteran, who contracted six urinary tract infections in seven months.

Reviewers found residents weren’t properly monitored or were subjected to hazardous conditions at more than 50 VA nursing homes.

Water used for washing hands and bathing was so dangerously hot at nursing homes in Carrollton, Ga., Martinsburg, W.Va., and St Cloud, Minn., that it could scald residents — particularly those with dementia or other conditions that make them less sensitive to pain or heat. The high temperatures — up to 128 degrees — were designed to kill legionella bacteria, but were too high to be safe, inspectors said.

In Bedford, inspectors concluded veterans were in “immediate jeopardy” because a resident with dementia who was physically unable to hold, light, or extinguish a cigarette was allowed to go outside to smoke by himself. And it wasn’t the first time. Previously, he had returned with burn holes in his clothing and on the seat cushion of his wheelchair.


In an e-mail to congressional aides earlier this month, Bedford VA director Joan Clifford said that the new findings were better than the last inspection in 2017 because inspectors identified only six problem areas compared to nine the previous year. However, the six remaining deficiencies were serious, including three that caused actual harm or immediate danger to residents.

In Chillicothe, Ohio, the VA allowed a family to hire a private aide to care for a patient with Parkinson’s disease. As the aide lay on the man’s bed looking at a cellphone, the veteran leaned dangerously forward. He had fallen four times in less than two months, once sustaining a head injury that the aide said required stitches.

The same aide was supposed to feed the man a semi-liquid diet because he had trouble swallowing, but the aide often fed him fast food. When confronted by inspectors, facility leaders agreed to immediately stop allowing untrained aides to feed residents.

The nursing home in Jackson, Miss., performed the worst of all the facilities, with failures cited in 12 areas. Residents suffered in serious pain. A veteran didn’t have a bowel movement for days, but staff didn’t tell doctors until his temperature spiked to more than 100 degrees. Veterans languished without staff-assisted exercise to help them gain or maintain muscle tone.

In just seven cases, VA nursing homes passed inspections with no identified problems. Those facilities are in Topeka and Wichita, Kan.; Orlando; Houston; Miles City, Mont.; Fargo, N.D.; and New Orleans.


Uneven transparency record

Despite the vast public investment in VA nursing homes — more than $3.6 billion in 2018 — the agency until recently had kept the findings of its annual inspections of its nursing homes confidential. The Globe and USA Today revealed last June that the VA had quietly tracked the quality of care at its nursing homes through inspection reports as well as star ratings.

Under pressure from the Globe and USA Today, the VA pledged to release the inspection reports. But that did not happen until this month, when the VA posted the reports for 99 of its nursing homes. The agency said in a release that it planned to post the remainder — 35 more reports — by October.

The news organizations reported that more than 100 VA nursing homes scored worse than private nursing homes in 2017 in quality ratings. At more than two-thirds of the homes, residents were more likely to have serious bedsores, as well as suffer serious pain.

The newly released inspection results add more depth to those findings and chronicle the misery of some veterans such as the Augusta, Maine, patient whose back wound had penetrated to the bone and who did not receive adequate medication.

“The resident moaned throughout the wound care and the moaning increased during wound cleansing and measuring,” noted an inspector who witnessed the episodes in July.

Experts say caregivers should be assessing and adjusting medications or trying other methods to make sure residents get pain relief.

“There’s very little quality of life” when you’re in constant pain, said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care. “And veterans have gone through so much, the last thing that they should be facing is relentless pain, especially if it could be mitigated.”

Andrea Estes can be reached at