For decades, state and federal officials have monitored the quality of care in nursing homes by conducting annual inspections, and ordering changes and sometimes fines when they found problems. But far too often, officials agree, poor-quality homes have continued to operate by temporarily fixing the worst problems, only to have them recur a few months later. This was among the reasons the Bush administration created new quality measures.
A Government Accountability Office report last year found that the number of poor-quality nursing homes remained ''unacceptably high," and a report commissioned by the federal office that oversees nursing homes found in April that the enforcement system is not ''ridding the industry of chronically poor-performing" homes. Among problems cited: lack of a ''death penalty" for managers who close a substandard home, only to open another; not enough inspectors to unearth problems; and fines that are not large enough to be a deterrent.
Asked what the US government is doing on the issue, a top enforcement official noted a pilot program begun in 1999 that sends inspectors to bird-dog troubled homes. The two homes in Massachusetts subjected to additional inspections improved slightly, yet the state ranks them among the bottom 30 percent in quality because of continuing infractions.
Meanwhile, other homes have gotten worse. For example, inspectors have cited East Longmeadow Skilled Nursing Center repeatedly in the past three years for failing to prevent residents from assaulting one another, for failing to prevent falls and bedsores, and for leaving a resident crying out in pain.
''I'm not sure anyone is convinced that this particular approach is that helpful," said Paul Dreyer, who oversees nursing home enforcement in the state.
State and federal officials say they think the worst homes have been shut by authorities or closed voluntarily. But inspectors nationwide last year identified 1,464 cases in which nursing homes put the lives of residents in jeopardy and 8,000 more in which they harmed residents. Federal officials shut down only two.
Meanwhile, complaints from the public and reports from facilities about abuse and injuries are overwhelming the number of investigators, according to federal and state officials. In Massachusetts, for example, investigators were not able to get to about 30 percent of the complaints and reports that appeared to warrant on-site visits, Dreyer said.
Despite an increasing number of investigations nationally, citations against nursing homes for harming residents have dropped 42 percent since 2000 and sanctions on homes have dropped 22 percent, federal reports indicate.
''It's troubling," said Alice Hedt, executive director of the National Citizens' Coalition for Nursing Home Reform. ''We need to have strong enforcement and a strong [inspection] system."
The government is investigating why enforcement seems to be lagging and it plans to make some changes in enforcement techniques by next October, officials said. Quicker investigations are one goal. Another is possibly linking the size of payments to nursing homes to quality, they said.