Two deaths, wildly different penalties: The big disparities in nursing home oversight

To see the federal government's inconsistent oversight of nursing homes, one needs only to look at what happened after two residents died – one in Texas, one in South Carolina.

At a nursing home in the East Texas town of Hughes Springs earlier this year, a resident approached the nurses' station gagging on a cookie. Attempts to clear his airway failed, and he died. Government inspectors determined that staff at the home were not trained for emergencies and did not immediately call 911.

Months earlier, in North Augusta, S.C., a resident pulled out her breathing tube and died. Inspectors faulted the home for failing to take appropriate steps to keep the resident from harming herself, even though she had pulled out the tube multiple times in the two months before she died.

In each state, inspectors working on behalf of the U.S. Centers for Medicare and Medicaid Services cited the homes for their failure to operate "in an acceptable way that maintains the well-being of each resident." Both homes posed an "immediate jeopardy" to residents' health and safety, inspectors determined.

But the consequences were starkly different.

In the Texas case, at the recommendation of state officials, CMS imposed a fine against The Springs nursing home of $9,500. In the other, acting at the suggestion of South Carolina officials, CMS required Unihealth Post-Acute Care-North Augusta to pay a fine of $305,370.

These disparities aren't unusual, it turns out. But they are now much easier to spot using ProPublica's expanded Nursing Home Inspect tool. We've mapped the differences among states in finding serious violations and parceling out fines. Here's more on how to use our updated tool.

The results support what auditors and researchers have maintained for years: Federal fines vary widely by state. Homes in some states pay a steep price for misconduct while those in neighboring states don't. See our state-by-state breakdown here.

The average fine paid by a South Carolina nursing home in the past three years was $40,507. The average fine in Texas: $6,933.

A Balkanized System

CMS pays states to inspect nursing homes on its behalf. It gives states guidelines on when and how to impose penalties, and states recommend actions to CMS regional offices.

Those regional offices must approve sanctions before they are imposed, but CMS almost always accepts the states' recommendations. The federal government and states share the fine money.

Despite its authority, some experts say, the federal government has not done enough to standardize punishments.

"The enforcement system is broken," said Charlene Harrington, a nursing home expert and emeritus professor of nursing at the University of California, San Francisco. "If you don't go after these really bad violations and try to force these nursing homes to improve quality, they're going to continue to cause harm and jeopardy."

Harrington was the lead author of a 2008 study that found enforcement disparities and encouraged the government to "re-examine" the system of imposing fines, called civil monetary penalties (CMPs) in bureaucratic parlance.

Federal officials acknowledged inconsistencies identified by ProPublica and said they are working to reduce them. Years ago, CMS came up with guidelines to advise states and its own regional offices on when and how much to fine homes.

But the guidelines give them wide latitude. States can choose penalties either by incident, capped at $10,000, or on a per-day basis, which can quickly add up to a much higher number.

Beginning next year, CMS will test a new program that provides more specific guidance.  "Our new tool reduces that latitude by a fair degree," said Alice Bonner, director of CMS' division of nursing homes.

Bonner said some flexibility is warranted because not every situation is the same. Factors affecting the size of a fine could include a home's past record of deficiencies, the speed with which it corrects problems and whether too large a penalty could force a facility to close, a hardship on residents, she said.

Some states also have the authority to impose fines against homes under state law, but CMS does not centrally collect and report them.

Tim Thornton, administrator at The Springs in Texas, said his nursing home has retrained staff since the resident choked on a cookie and died.

"With this specific case, the nurse on duty showed a lack of leadership ... There was kind of a breakdown and maybe a little panic in the situation, and the nurse took it all upon herself and didn't ask for assistance from the others."

The $9,500 fine against the home is not yet listed on the CMS website because it has not been paid, officials said.

Calls to Unihealth-North Augusta were referred to the home's parent company, UHS-Pruitt Corp. in Norcross, Ga. Spokesman Nick Williams declined to comment.

Unihealth-North Augusta has received more federal fines than any other home in the nation, $736,580, in the past three years, according to government data. Another of the chain's homes, in North Carolina, was fined $372,970 during the same period.