Donovan Slack, USA TODAY, and Andrea Estes, The Boston Globe

At the Veterans Affairs nursing home in Brockton, Massachusetts, 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.

Veterans moaned in pain without adequate medication at VA nursing homes in Dayton, Ohio, and Augusta, Maine. A unit at the VA nursing home in Lyons, New Jersey, had no functional call system for residents to summon caregivers.

Nine months after USA TODAY and The Boston Globe reported veterans received substandard care at many Department of Veterans Affairs nursing homes, newly released inspection reports paint a discouraging picture of the care that veterans have received.

From April through December 2018, inspectors from a private contractor cited 52 out of 99 VA nursing homes for deficiencies that caused “actual harm” to veterans. In three facilities, they found veterans’ health and safety in “immediate jeopardy,” and in eight, inspectors found both veteran "harm" and "jeopardy."

The facilities cited for shortfalls that caused harm are in 25 states, the District of Columbia and Puerto Rico. Harm and jeopardy are standard categories of severity in the industry, but non-VA nursing homes are rarely cited for them.

“That is really bad. It’s really bad,” said Richard Mollot, executive director of the Long Term Care Community Coalition, a New York City-based nonprofit advocate of nursing home care improvement.

“It should be very rare when there is harm (or) when someone is ... in immediate jeopardy,” he said in an interview, adding it’s difficult to compare VA findings with inspections of non-VA nursing homes because those inspections may not be as rigorous.

Inspectors found that staff at more than two dozen VA nursing homes failed to take steps to ensure bedsores healed or new ones didn’t develop. They can occur when frail people are left in the same position for too long. In Cincinnati, one resident had five bedsores in six months, yet when inspectors visited, they found no one moved the man or put cushions under him for hours.

“It’s heartbreaking, and you think these are our vets, how can we not be taking care of them?” Mollot said.

Bedsores are “almost always preventable and quickly treatable,” he said. “So there’s just no excuse.”

In a statement issued with the inspection reports 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 that have left them 50 percent or more 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 posting the VA reports for the first time, "we hope to drive improvements throughout the system."

The inspection results – made public nearly a year after USA TODAY and the Globe disclosed the existence of the reports – reveal for the first time the deficiencies identified during surprise visits by the outside inspectors.

Data reveal:VA homes have more residents with bedsores, pain, than private facilities

Inspections can provide veterans and their families important background information on the homes. More than 40,000 elderly and infirm veterans stay in the agency's nursing homes each year.

Widespread deficiencies

Many VA nursing homes failed in one of the most fundamental responsibilities – taking steps to prevent and control infection.

At two out of three VA nursing homes, inspectors found the staffs often didn’t follow simple protocols, such as wearing sterile gowns and gloves when treating residents.

In Des Moines, Iowa, they found managers didn’t make sure staff adequately cleaned a veteran, who contracted six urinary tract infections in seven months – the last three from E. coli bacteria.

Residents weren’t properly monitored or were exposed to hazardous conditions at more than 50 VA nursing homes, inspectors concluded.

Water used for washing hands and bathing was so dangerously hot at nursing homes in Carrollton, Georgia; Martinsburg, West Virginia; and St Cloud, Minnesota, that it could scald residents, particularly those with dementia or other conditions that make them less sensitive to pain or heat.

Temperatures at the facilities – up to 128 degrees in two cases – were intended to kill Legionella bacteria but were too high to be safe, inspectors said.

In Bedford, Massachusetts, 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 – he previously had returned with burn holes in his clothing and on the seat cushion of his wheelchair.

In Chillicothe, Ohio, the VA allowed a family to hire a private aide to take care of a resident and didn't provide adequate supervision. Inspectors said the aide nearly allowed the man with Parkinson's disease to fall. The aide was lying on the man's bed looking at a cellphone as the man 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. In one instance, the veteran was found eating Styrofoam from fast-food packaging.

When confronted by inspectors, facility management agreed to immediately stop allowing untrained aides to feed residents.

Inspectors cited a handful of VA nursing homes, including in Washington, for failing to meet standards of care in as many as 10 key categories, such as treating residents with dignity.

The VA nursing home in Jackson, Mississippi, performed the worst of all the facilities on that count, 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, Kansas; Orlando; Houston; Miles City, Montana; Fargo, North Dakota; and New Orleans.

Uneven record on transparency

When veterans need nursing home care, the VA can place them in agency nursing homes or in other facilities at VA expense.

Taxpayers pay $1,125 each night to house a veteran in VA nursing homes. That's far higher than the average $296 each night in private facilities or $174 in state-run nursing homes where the VA pays a portion of the cost, according to agency budget documents.

VA officials said the rates are not directly comparable because VA nursing home costs include hospital care and "more expensive medical services that just aren't available in most non-VA facilities."

The agency told the Government Accountability Office in 2013 that about 40 percent of VA nursing home costs account for "core" services and would be comparable. At that percentage, the current VA core cost would be $450 a night, still 52 percent more than the agency's cost for private placement.

Despite the sizable public spending on VA nursing homes – more than $3.6 billion in 2018 – the agency until recently had kept the findings of inspections of its nursing homes confidential.

USA TODAY and the Globe revealed in June that the VA had long tracked the quality of care at its nursing homes through inspections as well as quality indicators and star ratings.

Under pressure from the news outlets, the VA pledged to release the inspection reports. That did not happen until this month, when the agency posted the reports for 99 of its nursing homes on its website. The VA said it planned to post the remaining 35 reports by October.

USA TODAY and the Globe obtained previously confidential quality data and reported in June that more than 100 VA nursing homes scored worse than other nursing homes in 2017 on a majority of key quality indicators. At more than two-thirds of VA nursing homes, residents were more likely to have serious bedsores, as well as suffer serious pain.

VA nursing homes:Secret ratings hide poor quality care from the public

The newly released inspection results add depth to those findings and chronicle cases in which individual veterans suffered from poor care.

'The resident moaned throughout’

One severely impaired veteran with Parkinson’s disease went without adequate pain medication day after day at the VA nursing home in Augusta, Maine, as nursing staff treated a sore at the base of his spine that had penetrated to the bone.

“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.

Inspectors cited the Augusta facility and 28 other VA nursing homes for failing to ensure veterans didn’t suffer from serious pain.

The issue has been a long-standing problem at VA nursing homes – flagged more than seven years ago by the GAO, which found a high percentage of veterans were in pain.

Specialists said caregivers should assess and adjust medications or try other methods to make sure residents get 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. “Veterans have gone through so much, the last thing that they should be facing is relentless pain, especially if it could be mitigated.”

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