Nursing home inspector shortage may be jeopardizing care for patients

In July, a licensed practical nurse was hired to provide care for residents at Cross Timbers Nursing and Senior Mental Health in Midwest City. Less than two weeks later, a resident died while under care at the facility.

The resident, who is not identified by name in documents reviewed by The Oklahoman, began choking on food during a meal. Several certified nursing assistants who were later interviewed by the Oklahoma State Department of Health said the Cross Timbers Licensed Practical Nurse (LPN) was slow to respond, did not attempt to clear the resident's airway and left the room while she was still struggling to breathe.

The woman died within 12 minutes. A certified nursing assistant (CNA) in the room called it a painful death.

During a state Health Department investigation, the agency discovered that Cross Timbers did not have the LPN's certification on file and could not prove that the CNAs at the woman's bedside had the training and competency required to treat a choking patient. The state Health Department surveyor also learned that Cross Timbers hired at least one CNA without formally training them or checking their skill level.

This incident and the deficiencies uncovered during the state Health Department investigation highlighted the important need for state-employed surveyors to ensure nursing homes and assisted living facilities are safe and follow the rules.

But Oklahoma is seriously short of staff to conduct those inspections.

Inspection staff decimated by retirements, private-sector competition

The state Health Department team responsible for inspecting nursing homes was at nearly half-strength and struggled to meet its goals, a department chief told Congress this year.

States are required by federal regulators to inspect nursing homes and assisted living facilities about once each year. The inspectors, who are also licensed nurses, conduct visits as needed to investigate complaints. One component of these inspections is a sample review of personnel records to make sure staff have the right training and certifications.

In February, the state Health Department reported a 45% vacancy rate in its 60 budgeted surveyor positions.

Oklahoma's data was added to a report by the U.S. Senate Special Committee on Aging, which found that nearly a third of the nation’s 15,000 nursing homes are behind on comprehensive annual inspections. The main culprit is a lack of staff and money.

Already facing high demand in the health care industry, many states like Oklahoma have complained about the difficulty hiring and keeping enough surveyors to comply with Medicare and Medicaid regulations.

Attrition is a major cause of Oklahoma's vacancy problem. Between 2019 and 2022, three of every four nursing home surveyors retired. Others left for the private sector, for another career, or for a job with less travel and odd hours.

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"The departure of qualified surveyors affected (the agency's) availability of experienced surveyor staff, resulting in lengthier times for survey completion," Janene Stewart, state Health Department long term care director, wrote to Congress.

The state continued to struggle to refill vacant positions despite raising salaries by 10%. Late in the year, the state Health Department had to contract with two additional surveyors to help with the workload.

Nursing home surveyors are funded by both federal and state sources. The state Health Department reported that federal funds have remained mostly stable, approximately $4.5 million each year. Oklahoma's Legislature, however, has reduced spending for surveyors 57% over the past five years.

State Rep. Marcus McEntire, chair of the health budget subcommittee at the Oklahoma House of Representatives, calls the surveyor shortage a "sticky problem." The U.S. as a whole is experiencing a shortage of nurses, and Oklahoma ranks 46th in the per-capita number of nurses working in the state in all positions.

"Salaries for surveyors have been increased in Oklahoma, but the state is still competing with hospitals for them," said McEntire, R-Duncan. "Until the federal government and Legislature prioritizes funding for these surveyors’ salaries where the states can compete with private companies, inspections will continue to lag. We simply need more nurses."

Inspecting nursing homes

For every state Health Department surveyor in Oklahoma, there are nearly seven nursing homes that need to be regularly inspected. Only three other states have a higher surveyor-to-nursing home ratio. In contrast, California has fewer than two nursing homes for each surveyor.

The state Health Department told the Senate committee that its ability to perform routine surveys as scheduled is being hindered by the high number of "immediate jeopardy" complaints it is called upon to investigate. The department received 134 such complaints last year, compared to just 45 the year before. The state Health Department said it was unable to speculate why the number of complaints suddenly spiked.

As a result of the investigation at Cross Timbers Nursing and Senior Mental Health, the state Health Department recommended denial of payment for new Medicare/Medicaid admissions at the facility for nearly three weeks and levied civil monetary penalties of over $70,000. By September, the nursing home was back in substantial compliance after refresher training for staff and ensuring the company has access to information about its employees' qualifications and competency.

The nurse's name was not mentioned in the survey report. The nursing home did not return a phone call requesting comment for this story.

This article originally appeared on Oklahoman: Oklahoma has a shortage of nursing home inspectors