The memory of the suffering Letasha Mims endured at the Alden Wentworth nursing home on Chicago's South Side still makes her mother Mary weep.
In less than two years she developed a decubitus ulcer on her buttock.
She lost close to 60 pounds.
Her feet developed gangrene and her legs contracted upward toward her torso.
A majority-black facility, Alden Wentworth in 2012 listed registered nurse staffing levels on a government website that were among the lowest 17 percent of more than 15,000 skilled nursing facilities nationwide.
That website, Nursing Home Compare, is promoted by the government and widely used by the public in making nursing home choices. The staffing figures are based on self-reported data for the period two weeks before annual nursing home quality surveys.
But a Center for Public Integrity investigation has raised questions about the accuracy of the oft-used Nursing Home Compare information. Critics say it may reflect staffing levels that are briefly inflated for the sake of the annual quality survey. The Center’s probe found that hard-to-locate Medicare cost reports filed by nursing homes show lower daily staffing levels, especially among registered nurses, than those reflected in Nursing Home Compare. In 2005 the federal Centers for Medicare and Medicaid Services cited Medicaid cost reports that contain much of the same information as the Medicare documents as being a more accurate source than the data collected by state surveyors for the quality survey.
Although homes with residents of all racial groups had lower registered nurse staffing levels listed in the cost reports, the discrepancy was particularly pronounced in nursing homes where the majority of residents were either black or Latino. And the overall gap in this type of care for minorities was even more dramatic.
Hundreds of majority-black homes throughout the country were listed in Nursing Home Compare as providing a little more than a half-hour of registered nurse care per day. But the average daily level of registered nurse care at those facilities calculated through the Medicare cost reports was just about 20 minutes a day. Medicare cost data was not available for Alden Wentworth. The amount of registered nurse care is widely considered an important measure of quality care.
This staffing gap was even more stark in nursing homes where Latinos composed more than half of the residents.
“Majority-white” facilities (i.e., where a majority of residents were non-Latino whites) had daily average registered nurse staffing levels that were about 60 percent higher than majority-Latino nursing homes and about 34 percent higher than black facilities, the Center found in its analysis of the Medicare cost reports.
The disparities for majority-black nursing homes existed nationwide, but were particularly high in several Midwestern states, including Illinois, Michigan and Wisconsin. Among metropolitan areas with at least five facilities where black people made up the majority of patients, Chicago and Houston had notably low registered nurse staffing levels relative to majority-white homes, the Center found.
For Latinos, cities in Texas, among them El Paso and Brownsville, had daily registered nurse care levels of about 10 minutes per resident.
The Center analyzed a series of variables, including how rural or urban the area was where the home was located, the residents’ average physical ability when they entered the nursing home, and the percentage of days paid for by Medicaid, the state-federal health care assistance program.
But none of these variables accounted for all of the disparities between majority-white homes and majority-minority homes. Residents in black and Latino homes got far less registered nurse care than those in white facilities, even when the residents were equally sick and poor.
Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color and national origin by health care providers that receive federal dollars from programs like Medicare and Medicaid, said Rachel Seeger, a spokeswoman for the U.S. Department of Health and Human Services’ Office of Civil Rights.
Seeger said that anti-discrimination laws do cover discrimination in the levels and quality of staffing in federally funded nursing care homes, but added that the office could not say whether the Center’s analysis revealed civil rights violations. The Centers for Medicare and Medicaid Services declined to comment.
But the findings disturbed Richard Mollot, executive director of New York advocacy group Long Term Care Community Coalition (LTCCC).
“It is… troubling that these disparities exist even when Medicaid days and needs of residents are factored in,” Mollot wrote in an email. “My feeling has long been that some providers take advantage of situations in which there are lower expectations — such as in poorer and minority communities — to provide lower levels of services.”
Registered nurse staffing critical
Numerous academic studies published since 1990 have shown a connection between registered nurse staffing levels and residents’ quality of care and health outcomes.
Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, the nation’s largest nursing homes advocacy group, explained that the importance of registered nurses has grown during the past decade as residents have come into nursing homes from hospitals sicker than in previous years due in part to shorter hospital stays.
The Center analyzed 10 years of health data from Vincent Mor, professor of community health at Brown University, finding that the average sickness levels for residents moving into nursing homes rose 9 percent from 2001 to 2010.
Registered nurses are the only workers with the credentials, education and training to conduct assessments, Grant said. Not having a nurse in the facility at all times means there is no one there who can evaluate a medical situation and respond.
“As a result, residents may not be sent to the hospital when it is critically necessary or be sent unnecessarily, leading to devastating and even fatal consequences,” she said.
Nearly all of the majority-black and Latino facilities were operated on a for-profit basis and on average had larger patient populations than the majority-white nursing homes. Mor said this is in part a reflection of black and Latino seniors having fewer nursing home options in their neighborhoods than white seniors.
“Nursing homes are even more segregated than cities, and cities are very segregated,” said Mor, who has published several articles about the racial distribution of residents in nursing homes.
“The best predictor of which nursing home somebody will choose is proximity to their zip code of origin,” Mor said.
The issue of race compounds the effect of residential segregation, according to Ruqaiijah Yearby, law professor at Case Western Reserve University in Cleveland.
Charlene Harrington, a retired nursing professor from the University of California San Francisco, said that the absence of any federal regulations establishing minimum staffing levels means that large homes, like those that are often the only choices for residents in black and Latino neighborhoods, are not required to have any more staff than smaller facilities.
“So large homes have been historically understaffed, and they have consistently had more deficiencies than small homes,” Harrington wrote in an email.
Registered nurses are also the most expensive workers in nursing homes. As a result, they can be the focus of cost-cutting efforts by for-profit and nonprofit nursing home owners alike, according to Mollot of LTCCC.
In 2012, registered nurses earned an average of almost $68,000, according to data from the Bureau of Labor Statistics.
Certified nursing assistants and orderlies earned less than half that amount.
David Gifford, senior vice president of quality and regulatory affairs at nursing home organization the American Health Care Association, did not address the disparity issue directly, but said improved staffing ratios in nursing homes across the country are one of several factors that are contributing to a “continually improving” quality of care.
But Mor pointed out that poorer quality nursing homes are in less affluent areas with higher concentrations of minorities and often have trouble attracting skilled staff.
“They don’t want to go there, and they have alternatives,” Mor said. “They can go to a hospital and make more money.”
Agonizing choices
In early 2014 Letasha Mims went to the hospital after her stay at Alden Wentworth.
Mary Mims said she had tried to move her daughter, but other nursing homes would not take her.
The low staffing levels remained the same throughout her daughter’s time at the Alden home, she said.
Alden Network founder and owner Floyd Schlossberg declined repeated requests for comment.
In February, Mims uttered words to her youngest daughter that she never imagined she would have to say.
“I do not want you to suffer,” she said. “If your desire is to live I’m going to fight for you until the very end, girl. But if your desire is to go, I’m going to get over it.
“And I’m going to be OK,” the mother said.
Letasha Mims died in August 2014.
Mary Mims said she is determined to fight to improve the care other nursing home residents receive.
Change may come from civil rights groups demanding equal treatment for minority residents, said Dr. Martha Daviglus, professor of medicine at the University of Illinois at Chicago.
In July 2010 a jury returned a $677 million verdict in a class-action lawsuit against nursing home chain Skilled Healthcare Group Inc. for failing to comply with California’s minimum nurse staffing requirements and misleading its residents and the public about its actual staffing levels. Rather than pursue an appeal, two months later the company settled the case for $62.8 million, including $12.8 million to add staff and comply with a continuing injunction. The firm did not admit to any wrongdoing.
Yearby of Case Western said she didn’t know of any examples of nursing home class-action suits based on race or ethnicity.
“This shouldn’t happen,” said Daviglus, principal investigator of a landmark longitudinal study of Latino health. “If we don’t address this, we’ll never be able to narrow the gaps on health disparities.”
The story was written with support from the Fund for Investigative Journalism.