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Duty of care: the trouble with America’s nursing homes

We will sacrifice so much to save lives. So why are we indifferent to the quality of those lives?

October 9, 2020

11:51 AM

9 October 2020

11:51 AM

We can debate the value of sacrificing normal life to COVID-19. Personally I think the measures are increasingly destructive — but nobody can deny their scale. Social and economic activity has been tightly limited. Jobs have been lost. Businesses have collapsed, and boredom and anger set in.

Yet Western politicians have done a bad job of protecting the most vulnerable. In Europe and the US, COVID has torn through nursing homes. Sometimes, as in New York under Gov. Andrew Cuomo, infected elderly patients were knowingly returned to them.

The failure to anticipate this crisis — by politicians, public health authorities and, yes, the media — reflects a broader indifference towards the state of nursing homes. ‘I get a steady trickle of psychiatric patients who are perfectly happy to be in the psychiatric hospital,’ the psychiatrist Scott Alexander writes, ‘but who freak out when I tell them that they seem all better now and it’s time to send them back to their nursing home, saying it’s terrible and they’re abused and neglected and they refuse to go.’

There is data to back up this anecdote. In 2014, an OIG report suggested that at least one allegation of abuse or neglect had been made in 85 percent of nursing homes. Of course an allegation can be unsubstantiated, but there are grounds to believe that elderly people are often too slow rather than too quick to report mistreatment. As Professor Catherine Hawes has written, ‘many are either unable to report abuse or neglect or fearful that such reporting may lead to retaliation or otherwise negatively affect their lives’.


Abuse perpetrated by staff includes physical violence, financial exploitation and rape. A CNN investigation found that the federal government has cited over 1,000 nursing homes for ‘mishandling or failing to prevent alleged cases of rape, sexual assault and sexual abuse at their facilities during this period’.

Abuse can also be perpetrated by other residents. Sometimes this is unavoidable; other times it is the result of clear negligence. This year, a video went viral of a young man beating his bedridden 75-year-old roommate in a care home. The old man suffered four broken fingers, broken ribs and a broken jaw. Why was an unstable young man sharing a room with a septuagenarian in the first place? It defies belief.

Of course, nursing homes can be inadequate without there being actual abuse. Local reporters in Colorado investigated nursing homes where patients had been dying from COVID-19 and found that two had been previously cited for ‘dirty facilities’ and ‘improper hand-washing while providing wound care’. Loneliness is also acute in long-term care institutions, where 22 to 42 percent of residents report feelings of loneliness compared to 10 percent of the community population.

None of this means there are not admirable nursing homes, and good men and women working with harder jobs than most of us will ever have. But that does not excuse dysfunction and abuse. We could easily blame some of these failures on owners trying to minimize expenditure to maximize profits, and on weak and inefficient governmental regulations. That would not be unfair, but it would be too easy. There has been no urgency behind calls for reform. As Scott Alexander wrote, ‘Bedridden old people are very bad at complaining in ways anyone else can notice, and if we don’t want to think about them we don’t have to.’ You won’t see them on the streets, or on the TV, or even on social media. You don’t have to think about them.’

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If we are prepared to sacrifice so much in order to save lives, why are we so indifferent to the quality of lives? Our year has been spent agonizing over case rates, hospitalizations and deaths — but rarely do think about the wellbeing of the people most at risk. This seems peculiar. Protecting life is valuable, of course, but protecting lives without expending time, energy and resources to ensure they are free of abuse, neglect and isolation is absurd. Perhaps we have been too absorbed with COVID in the abstract and not interested enough in the communities it threatens. Certainly, that would explain why Andrew Cuomo is treated as one of 2020’s success stories rather than a failure.

This has to change. In March, Bill Barr announced that the Department of Justice had found ‘facilities unfit for living, plagued by filth, mold, insects, and rodents,’ and pledged to ‘pursue nursing homes that provide grossly-substandard care to their residents.’ This would be a very positive step, though it will demand the Trump administration reversing its rolling back of regulations intended to prevent mistreatment, such as, for example, the ability to fine homes which unnecessarily prescribe antipsychotic drugs. Greater investment in social interventions could ease loneliness and, perhaps, make it easier for residents to report their problems.

Overall, far greater investment will be needed in residential care over the coming decades. Perhaps the answer is to appeal to selfishness and rather than just compassion. According to the National Research Council, the ‘occurrence and severity of elder mistreatment are likely to increase markedly over the coming decades, as the population ages, caregiving responsibilities and relationships change, and increasing numbers of older persons require long-term care’ All of us will be ‘older persons’ one day.


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