Basic steps to prevent infections -- such as washing hands, isolating contagious patients and keeping ill nurses and aides from coming to work -- are routinely ignored in the nation's nursing homes, endangering residents and spreading hazardous germs.
A Kaiser Health News analysis of four years of federal inspection records shows 74 percent of nursing homes have been cited for lapses in infection control -- more than for any other type of health violation. In California, health inspectors have cited all but 133 of the state's 1,251 homes.
Although repeat citations are common, disciplinary action such as fines is rare: Nationwide, only one of 75 homes found deficient in those four years has received a high-level citation that can result in a financial penalty, the analysis found.
"The facilities are getting the message that they don't have to do anything," said Michael Connors of California Advocates for Nursing Home Reform, a nonprofit in San Francisco. "They're giving them low-level warnings year after year after year and the facilities have learned to ignore them."
Infections, many avoidable, cause a quarter of the medical injuries Medicare beneficiaries experience in nursing homes, according to a federal report. They are among the most frequent reasons residents are sent back to the hospital. By one government estimate, health care-associated infections may result in as many as 380,000 deaths each year.
The spread of methicillin-resistant Staphylococcus aureus (MRSA) and other antibiotic-resistant germs has become a major public health issue. While Medicare has begun penalizing hospitals for high rates of certain infections, there has been no similar crackdown on nursing homes.
As average hospital stays have shortened from 7.3 days in 1980 to 4.5 days in 2012, patients who a generation ago would have fully recuperated in hospitals now frequently conclude their recoveries in nursing homes. Weaker and thus more susceptible to infections, some need ventilators to help them breathe and have surgical wounds that are still healing, two conditions in which infections are more likely.
"You've got this influx of vulnerable patients but the staffing models are still geared more to the traditional long-stay resident," said Dr. Nimalie Stone, the CDC's medical epidemiologist for long-term care. "The kind of care is so much more complicated that facilities need to consider higher staffing."
The Centers for Medicare & Medicaid Services (CMS), which oversees inspections, has recognized that many nursing homes need to do more to combat contagious bugs. CMS last year required long-term care facilities to put in place better systems to prevent infections, detect outbreaks early on and limit unnecessary use of antibiotics through a stewardship program.
But the agency does not believe it has skimped on penalties. CMS said in a statement that most infection-control violations have not justified fines because they did not put residents in certain danger. For instance, if an inspector observed a nurse not washing his or her hands while caring for a resident, the agency said that would warrant a lower-level citation "unless there was an actual negative resident outcome, or there was likelihood of a serious resident outcome."
In November, CMS waived penalties for 18 months against facilities that violate the new stewardship rule. The industry had said nursing homes needed more time to prepare. (The moratorium does not affect California's antibiotic stewardship requirement, which took effect last January.)
Holly Harmon, the senior director of clinical services at the American Health Care Association, a nursing home trade group, said the industry has made strides in combating infections through better training and encouragement for staff members to look for gaps in infection control and to speak up about them. The percentage of nursing home residents with urinary tract infections -- the only type of infection all nursing homes must report to Medicare -- has dropped by more than half since 2011.
"Infection prevention control is a priority," Harmon said. "The path really is focused on continuous improvement."
A Sick Patient, A Family Complaint, Little Action
James Morris said he did not see such dedication when his mother, Georgina, entered Astoria Nursing & Rehabilitation Center in Sylmar, Calif., in October 2015. "Workers were coming in and out without washing their hands," he said.
While there, Georgina Morris, 86, fell ill to a particularly virulent strain of Clostridium difficile, known as C-diff. Morris said he insisted his 86-year-old mother, who was severely dehydrated, be sent to the hospital, where she stayed for 10 days. She has had subsequent flare-ups of the infection that required rehospitalization and, later, a fecal transplant, in which doctors transferred stool from a healthy patient into her bowels, a procedure that can treat the infection by introducing bacteria that counter the C-diff germs.
James Morris complained about Astoria to health authorities shortly after his mother left. Records show inspectors waited 18 months, until a regularly scheduled review in May 2017, before investigating her case. Such delays are common: California Department of Public Health cases remain open, on average, for nearly 20 months.
Although inspectors faulted Astoria workers for not cleaning their hands while treating Georgina Morris, they could not definitively determine whether she contracted the infection there or before she arrived. But the inspection found other infection-control lapses throughout the home. A housekeeper cleaned the wall with the same cloth used to wipe the toilet. A patient had a dirty intravenous line left in longer than necessary. The inspector watched as a worker failed to wash her hands after delivering a breakfast tray to a contagious resident in isolation.
It was the second consecutive year inspectors cited the home for substandard infection control that had the potential to harm residents. Both citations were below the level that could trigger fines.
Astoria did not respond to requests for comment.
Homes Cited Repeatedly But Few Punishments
Elsewhere, health regulators are similarly reluctant to assert that nursing home errors led to patient infections or put patients in imminent danger. Only 161 homes among the 12,056 that violated infection-control rules were cited at those higher levels since 2014, according to KHN's analysis.
The value of lower-level citations as deterrents is questionable: Authorities have cited 7,045 homes more than once over infection-control lapses, including 942 that racked up four or more violations, the analysis found.
"Perhaps a bigger stick might be more helpful," said Joseph Rodrigues, California's long-term-care ombudsman.
In January, an inspection of Decatur Nursing and Rehabilitation in Decatur, Texas, found that one nurse didn't wash her hands after picking up a bottle of medication that fell on the floor and another nurse didn't properly clean a syringe.
Two months after citing the home, inspectors were back to issue another violation. This time, a resident died from the flu after a contagious resident who lived across the hall was let out of isolation earlier than the CDC recommends. Only then did inspectors issue a citation at the most serious level.
Decatur did not respond to requests for comment.
Inspection records show nurses and aides are often not familiar with basic protocols, such as wearing protective clothing when coming into contact with contagious residents and isolating them from others in the home and visitors. Others are not trained properly on how to clean patients. Still others, in a rush and understaffed, take shortcuts that compromise sanitary precautions.
"We've always been shocked at how often we've personally witnessed people providing care in facilities and not washing their hands, which has got to be the most basic thing in infection control and prevention," said Sherry Culp, who as Kentucky's long-term-care ombudsman advocates for aggrieved nursing home residents.
This year in New Mexico, 25 residents of the Rehabilitation Center of Albuquerque, part of the Genesis Healthcare chain, developed urinary tract infections because nurses and aides cleaned residents' genitals and catheters in unsanitary ways, according to an inspection report.
Another recurring problem stems from nurses and aides infecting residents because they come to work ill knowing they would not get paid for the sick time, said Dr. David Nace, an associate professor at the University of Pittsburgh School of Medicine.
During a norovirus outbreak in January at Fir Lane Health & Rehabilitation Center in Shelton, Wash., at least six infected employees returned to work without waiting the minimum 48 hours after their symptoms abated. Inspectors discovered the virus ultimately spread to 32 employees and 43 residents -- more than 40 percent of those living in the home.
Fir Lane and the Albuquerque home did not respond to requests for comment.
"They have these draconian policies for taking off," Nace said, speaking broadly about the nursing home industry. "And if you don't have the draconian policies, then everyone takes off. That plagues the entire health care industry."
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.