Some states have found innovative ways to protect the elderly in nursing homes.
After former Pulaski County, Ark., coroner Mark Malcolm exhumed the bodies of six nursing home residents over four years because of suspicions of foul play, the state passed a law in 1999 requiring nursing homes to report all deaths to the county coroner.
Malcolm, now retired, said he thinks that nursing home care has improved and that the number of suspicious deaths has declined since the law was passed.
"We saw the person where they died ... and the conditions in which they died," Malcolm said. "If there were injuries, if there was blood, if the patient had choked on food, we were able to see that. Prior to the law going into effect, the coroner was never called."
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During Malcolm's tenure, he said, the number of prosecutions of nursing home crimes did not increase, but the number of homes being fined or shut down did.
In the first six months after the law was passed, Malcolm's office investigated 489 nursing home deaths. Of those, 21 were referred to regulators. In 2005, Malcolm's office investigated 1,235 nursing home deaths. Only two cases were referred.
"Nursing homes had to step up and do the right thing," he said.
In Kentucky, there is no protocol for calling a coroner when a nursing home resident dies. A Herald-Leader review of serious violations by nursing homes also found that it's impossible to tell how often autopsies were performed in 18 deaths in which the state issued citations to the nursing homes.
Dr. Barbara Weakley-Jones, now Jefferson County coroner and a former state medical examiner, said funeral home directors or nursing home employees sometimes tip off investigators to deaths caused by abuse or neglect.
Fayette County Coroner Gary Ginn said the vast majority of his calls about unnatural deaths in nursing homes are from hospitals. In many cases, a resident who falls or is injured at a nursing home is transferred to a hospital, where they later die.
The law is clear
The state law is clear, said Ginn: If it's a suspicious death, the local coroner should be called. That's true in any death, not just a nursing home death.
Weakley-Jones and Ginn said it would be difficult for coroners in the state's most populated areas to be called to every nursing home death. But in less-populated counties, it's not uncommon for coroners to go to nearly every death, even those in nursing homes, Ginn said.
Weakley-Jones, who examined the issue in 1991, recommended in a recent interview that nursing homes' directors of nursing or administrators sign off on all deaths.
Arkansas is the only state to require that coroners be called for all such deaths, Malcolm said. Similar laws in other states have been blocked by the nursing home industry.
Mitchel T. Denham, executive director of the Office of Medicaid Fraud and Abuse Control in Kentucky, said his office increased awareness of questionable deaths by speaking at statewide coroners' conferences, and has educated other law enforcement agencies about nursing home deaths and elder abuse.
Attorney General Jack Conway said his office has tried to increase training and prosecutions concerning elder abuse. However, there is no dedicated federal funding for tracking elder abuse or training investigators.
Currently, the federal Elder Abuse Victims Act, which could provide millions of dollars for training prosecutors, has been pending before Congress for years.
Conway, who is running for U.S. Senate in November, said he would support the legislation.
Prevent versus punish
In Maine, an advocacy group meets quarterly to review elder fatalities.
Using a grant from the American Bar Association, the state established a panel in 2003 to review questionable deaths. The team, made up of prosecutors, law enforcement, medical examiners and adult protection workers, reviews nursing home deaths to determine patterns or problems.
The mission is not to punish but to prevent, said Ricker Hamilton, administrator of Maine's adult protection unit.
For example, the panel found that a nursing home resident had died after getting caught in a particular type of bed rail. The group sent out an alert, cautioning the state's nursing home administrators about the problem.
"We will look at systematic things," Hamilton said. "But we don't point fingers."