John and Terri Hale own The Hale Group, an Ankeny-based advocacy firm working for better lives for all Iowans. Contact them at terriandjohnhale@gmail.com. An earlier version of this commentary appeared in the Des Moines Register and Cedar Rapids Gazette.

Twenty-seven years ago, the Quad-City Times published a six-part series on neglect and abuse in nursing homes. The articles told the stories of residents whose physical and mental health needs were not met, who were subjected to verbal or physical abuse by staff or other residents, and had been injured or had died.

The stories were tragedies. And sadly, tragic stories still regularly appear in Iowa Capital Dispatch and other Iowa media written by Clark Kauffman—the same journalist who authored the stories in 1996.

For more than 27 years, horrific stories of neglect and abuse have stemmed from far too many nursing facilities that have employed too few workers; failed to adequately compensate, train, and respect workers; routinely accepted exceptionally high levels of employee turnover; lobbied elected officials to increase annual appropriations of tax dollars but to also minimize oversight of their efforts; avoided criminal prosecution for their misdeeds; and have put the desire for profit ahead of the needs of the Iowans they exist to serve.

In 27 years, little has changed. At too many facilities, neglect, abuse and dehumanization of older Iowans continue.

And we ask, “Where is the outrage?”

Where is the outrage among state and federal legislators, from Governor Kim Reynolds, from local, state, and federal prosecutors, from leaders of state government departments, from the higher quality nursing homes who are tarred by the bad apples amongst them, and from the public?

CASUAL ACCEPTANCE OF NEGLECT AND ABUSE

Shame on all for the casual acceptance of neglect and abuse, the willingness to ignore what’s going on, and the choice to view older Iowans as invisible and expendable.

Consider the reaction when stories are told of neglect, abuse, or death of children in daycare or foster care, of horses on farms, or dogs in kennels.

When it’s abuse or neglect of other than older human beings, outrage is common. Charges are filed. Owners and operators are taken to court. Licenses to operate are revoked. Tax dollars that might have been a revenue stream are stopped.

But with nursing homes? If charges are filed (which is rare), they are typically against the lowest person on the totem pole—the front line nursing aide; not a supervisor or administrator, not the management company, and not the owner or investors who are ultimately responsible.

And for these nursing homes that disserve older Iowans on either a frequent or regular basis, tax dollars—yours and ours—that pay the bulk of the cost of care just keep flowing to them year after year. This is not a small amount of money; millions of dollars annually go to individual facilities that enable them to keep providing more unsatisfactory care.

To us, this acceptance of what should be unacceptable is appalling.

GOP REJECTS REQUEST FOR OVERSIGHT HEARING

We’re pleased a small number of elected officials are beginning to express concern and ask questions.

Unfortunately, they are in the Democratic minority at the Iowa state capitol. They currently have little power. But they have a voice, and they are starting to use it.

On December 14, Democratic State Senator Claire Celsi and Senate Minority Leader Pam Jochum held a press conference at the capitol to draw attention to the quality-of-care crisis in Iowa nursing homes, and request a meeting of the Iowa Senate Government Oversight committee to ask questions of state agencies, hear from the public, sort out what is happening, why, and what needs to be done about it. We were pleased to speak at the event.

State Senator Amy Sinclair, the second-ranking Iowa Senate Republican and the chair of the oversight committee, immediately shot down the request for oversight, as did a spokesperson for Governor Reynolds.

Their rationale: there is no need for oversight. Iowa is dealing with the crisis effectively, as evidenced by the thousands of nursing home deficiency citations written by the Department of Inspections, Appeals and Licensing; the regular increases in appropriations going to nursing homes, and the significant efforts being made to deal with chronic workforce shortages.

Their rationale had more holes in it than Swiss cheese.

Here are the realities:

STANDARD OPERATING PROCEDURE HASN’T WORKED

Writing citations and levying fines against nursing homes for poor quality care has been standard operating procedure for decades. It hasn’t improved the quality of care. Facilities budget for fines imposed by state agencies—it’s just another cost of doing business.

The Department of Inspections, Appeals, and Licensing is understaffed. It’s failing to timely inspect nursing homes and contracts out much of its inspection work to private sources at a higher cost to taxpayers. It is failing, but legislators aren’t interested in determining why, or how to improve its performance.

Sinclair said Senate oversight would be a “distraction” to the Department and impede their work. Really?

Consider this: on the same day Sinclair said state government couldn’t be bothered to take time to look into deficiencies in care quality at nursing homes, Iowa Public Radio reported that the Iowa Department of Agriculture and Land Stewardship had recently held a town hall meeting to discuss standards of care in puppy mills. So the quality of care for puppies warrants some time and oversight, but the quality of care for vulnerable older adults doesn’t?

Failing at oversight is one thing. Refusing to conduct oversight is something else (the Iowa Senate’s oversight committee last held a hearing in 2019). Refusing to do one’s job in the typical workplace results in the employee being fired. Continued refusals by those elected to serve the public—not the governor, not their party, not the nursing home industry—should lead to their dismissal in the next election cycle.

NO ACCOUNTABILITY FOR HOW NURSING HOMES USE TAXPAYER DOLLARS

The governor and legislature have regularly given millions more dollars to the nursing home industry, with no expectations for how the dollars are used or the results they produce. It’s been a routine gift to the industry. No one in the legislature knows how the tax dollars have been used, and no one seems to care.

What is known: millions of additional tax dollars have not improved care or reduced the number of complaints regarding abuse, neglect or inhumane treatment of residents.  Legislators and the governor dance to the tune played by the nursing home industry. Their voice, their economic impact on communities throughout Iowa, and their campaign contributions drown out the voice of consumers, workers, and their advocates.

Several years ago, a lobbyist for the nursing home industry told ustheir annual request to the legislature and to the governor consists of eight words: “Give us more money and leave us alone.” In other words, write the check and don’t ask any questions, don’t ask for results, and don’t peer behind the curtain. The legislature and Reynolds do as requested.  That’s a sweet deal for the nursing home industry, a horrible deal for nursing home residents and taxpayers.

QUALITY OF CARE CRISIS STEMS FROM WORKFORCE SHORTAGE

The nursing home quality-of-care crisis stems from a workforce crisis. Sinclair and the governor’s staff want the public to believe they’ve got it under control, and that actions to create a health care apprenticeship program (along with giving the industry more money) indicates that there’s no reason to be concerned.

We’ve been in the thick of discussions at the capitol for more than fifteen years. If we know anything at all, it’s this: state government has failed to address the perpetual workforce crisis in nursing homes. They seem to believe talking about the problem or tinkering around the edges actually solves it. It hasn’t.

An apprenticeship program is a good idea. But how much impact will it have? Think about this for a minute. Anyone interested in an apprenticeship wants it to lead to a good job. That is, a job that offers good pay and benefits, trains them well initially and on an ongoing basis, allows them career growth and continuing increases in both responsibilities and compensation, is in a profession respected by society, and that offers assurances that they will work in an environment that is safe and prevents on- the-job injury. 

Jobs on the front lines of a nursing home offer none of those things. Until the fundamentals of the jobs—wages, benefits, training, and so on—are addressed to make them more attractive, not nearly enough people will take these jobs or stay in them.

LACK OF CARING IS ALSO A CRISIS

We have been sickened by the reports of continued abuse and neglect in nursing homes, the stories Clark Kauffman and other journalists continue to write, as well as those that show up in our email, phone calls, and texts from Iowans outraged by the treatment of loved ones in an Iowa nursing home.

We, and the countless members of the public that advocates like us are hearing from, are just as sickened by the quick and outright rejection by Sinclair, her Republican colleagues, and the governor’s office to discuss, in a bipartisan way, what’s happening in nursing homes. On December 14, Iowa Senate Democrats called for lawmakers to “ensure accountability for bad actors (in the nursing home industry) while ensuring success for high-quality facilities.” What’s objectionable about that?

As we said in our brief presentation at the recent news conference, in the upcoming legislative session,

It’s time to end business as usual. Meaningful oversight is needed. We’re pleased that Senate Democrats are seeking to provide that. We ask their Republican colleagues to join them. Frankly, we expect their Republican colleagues to join them.

Why do we expect that? Because a resident of a nursing home doesn’t look at their quality-of-care concerns as a Republican or Democrat. They look at them through the eyes of an Iowan who’s asking for help and who needs results.

All who are elected to serve Iowans – Republicans and Democrats – should make sure that residents in nursing homes get what they’re asking for, and what they deserve – help and results.

We have a crisis in the quality of care provided in Iowa nursing homes. We have a crisis in the lack of caring at the Iowa statehouse.

But we haven’t given up hope.

WHAT CAN BE DONE?

It’s the holiday season; a time for joy, kindness, and love; for a little more reflection, a little more gratitude, and a little more concern about the lives of those who aren’t blessed with good heath and the ability to live independently.

Those nursing home residents who can’t get a call light answered, who lie in bed in their own urine or feces, who make valiant attempts to get to the restroom unassisted and fall, who are lonely, depressed and afraid, who feel neglected or abused, invisible and expendable – they deserve the most important holiday gift we can give.

Let’s give them the gift of attention. Seeing and hearing them. Addressing their needs.

Attention translates to oversight; an awfully small thing to ask. It’s something that can be easily done by people of good will, when the better angels of our nature are displayed.

If the Senate’s oversight committee continues to refuse to discuss the needs of vulnerable older Iowans in nursing homes, then what does that say about the Republican majority that controls the statehouse? Do they really want to be known as the heartless majority, the too-busy-to-be-bothered majority, or the ostrich majority, that keeps their heads stuck in the sand?

We don’t think they do. But what they decide and what they do is what they are. We hope they’ll shift gears.

Readers who agree with the need for oversight can take action. Write a letter to the editor of your local paper expressing your concerns, contact your Republican legislator or the governor’s office asking for oversight, share thoughts on social media, and urge like-minded friends and neighbors to do the same.

Like most change, it doesn’t just happen—it comes from public pressure. If Iowans remain quiet, the chance for action is slight.

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The Hale Group’s “12 Steps to Fix the Quality-of-Care Crisis in Iowa’s Nursing Homes“