When District of Columbia inspectors visited the Wisconsin Avenue Nursing Home in December 1983, they found there weren't enough nurses at the Northwest Washington facility. Patients were not properly dressed, left unattended and were not receiving special liquids and diets that their doctors had ordered, according to inspection records. But the city took no action beyond issuing citations.
Two months later, city inspectors cited similar problems, but again no sanctions were imposed.
On June 11, 1984, Mildred Baker, 77, a resident of the home, was taken to the George Washington University Medical Center emergency room, where she was found to be suffering from dehydration. Seventeen hours later, she died. A subsequent investigation by the D.C. Commission on the Healing Arts concluded that extra fluids ordered by Baker's doctor were never given during her 46-day stay at the home.
A spokeswoman for Beverly Enterprises, which owns the home, disputed the conclusion, saying, "The actual care rendered to the patient was proper and adequate." But Alice Fastenrath, the women's social worker at George Washington University Medical Center, thought otherwise.
"Mildred Baker starved to death," she told an investigator from the healing arts commission, which concluded it had no authority to act because it only regulates the conduct of doctors.
To critics of the District government, the Wisconsin Avenue case illustrates the consequences of having a regulatory system so lax that violations of health and safety standards are tolerated for months and even years, resulting in discomfort and sometimes danger for thousands of residents of nursing homes, boarding houses and group homes.
The city's own inspection reports are a depressing litany of instances in which poor and elderly residents have been subjected to cockroaches crawling in their bedclothes, scaldings from excessively hot water, mental abuse and serious bedsores. But an examination of those records by The Washington Post found that what action the city has taken against violators in recent years has been prompted largely by the federal government, which has put increasing pressure on the city to step up its enforcement efforts.
"We are very, very concerned over the situation in the District," said Claudette Campbell, chief of the review branch of the U.S. Health Care Financing Administration's regional office. In audits over the last four years, the office has criticized the city for failing to follow up on serious deficiencies in health and safety standards and for not cutting off payments to facilities with serious violations.
Frances Bowie, who since 1981 has run the Service Facility Regulation Administration, the agency responsible for inspections, said reorganization problems have plagued the agency. But, she said, it is fulfilling its role in "educating" facility owners about their legal responsibilities.
"We are not the police," Bowie said. "We are offering consultation." 1,255 Centers to Be Monitored
The agency's 29 inspectors are charged with monitoring health and safety standards at 1,255 facilities in the District, including 17 nursing homes, 14 dialysis centers, 350 boarding homes, 535 children's day-care centers, 14 hospitals and 7 surgical centers, as well as 32 group homes for the mentally retarded, 14 child placement agencies, 12 home health agencies, 65 medical laboratories and 195 pharmacies.
In the last three years, the agency has proposed 15 disciplinary actions, five of which were initiated by the federal government, according to agency officials. Five of the facilities ultimately were relicensed, seven were closed and action on three is pending. The agency keeps no records of the number of citations it issues each year.
Although technically under its jurisdiction as well, the quality of hospital care in the city is the primary responsibility of a private accreditation agency. But there are no backup regulatory agencies for most of the other health-related facilities in the District, and there is widespread agreement on the result.
"If left to the District inspections, care was horrible," said Dr. Irving Burka, medical director from 1981 to 1984 of the National Capitol Medical Foundation, a federal review group that monitored patient care in the District. "You had to ride herd constantly."
An examination of records of hundreds of agency inspections and interviews with city officials and health care experts found that the Service Facility Regulatory Administration:
* Routinely gives operators advance notice of inspections. At Hope Village, a collection of residences in Southeast Washington for former prisoners, drug addicts and the mentally ill, the advance notice gave the staff time to remove beds from overcrowded rooms before inspectors arrived, according to city records and interviews with staff members. Staff and residents at other homes report frantic clean-ups the day before city inspectors arrive and say that temporary nurses are hired to boost staff-to-patient ratios.
* Waives mandatory rules, including federal safety standards, for some operators and allows facilities with chronic violations to remain open, often for years.
The Laurel Clinic, an abortion clinic cited for improperly using anesthesia and unsanitary conditions, was allowed to operate without a license for two years until Mayor Marion Barry bypassed the licensing agency and ordered it closed last November. At least three other unlicensed facilities were allowed to operate for more than a decade.
Delays or fails to investigate complaints of poor care brought by the public and other city agencies.
* Has few enforcement powers compared to similar agencies in other states and fails to use some of the powers it does have. Other states use fines, put facilities into receivership, issue limited licenses and reinspect until corrections are made.
One problem is that it is the District's policy not to take action until a violation has been cited by inspectors three times. "The third time, they get a warning notice," said Bowie.
In theory, the agency could take the drastic step of stopping the flow of government dollars by dropping homes, clinics and centers from the Medicare and Medicaid programs. But this threat is not used and the District has none of the lesser fines and penalties that have been adopted by 26 states, including Maryland and Virginia.
A bill to permit fines was introduced in the City Council in 1983. But David Rivers, head of the Department of Human Resources, opposed fines for city-run facilities, and the entire measure died. A similar measure was introduced this year and is awaiting action.
A 1983 law, initiated by the D.C. Hospital Association, gave the licensing agency the power to ask for restricted licenses, but it has never been used.
The agency, which has a $1.1 million budget, 44 employes and elaborate regulations designed to protect those using D.C. health, residence and day-care centers, is one of six divisions of the Department of Consumer and Regulatory Affairs. But according to Carol Thompson, the department's director, the Service Facility Regulation Administration's role and powers are weaker than some of the other five divisions.
"We can only deny, suspend or revoke" following a series of written procedures, said Thompson. "Unlike what we do for restaurants, we cannot go in a facility and take immediate action."
In some states, inspectors are seen by state officials as adversaries of those they regulate. In the District, the relationship is more collegial, and agency officials and inspectors say they see their role as educating home owners and operators.
"We're a consumer and a regulatory agency," said Lucenia Dunn, a department aide. "The facility owners are consumers, too."
The "consultation" approach favored by the District has drawn repeated criticism from several state task forces that have studied health inspections elsewhere.
"Under the consultation model, the only way that patients can contribute to good enforcement is by dying spectacularly," said Catherine Hawes, a research consultant for the Center for Social Research and Policy Analysis in Research Triangle, N.C., who helped prepare state reports in Ohio and Texas on nursing home licensure.
Thompson said that one sign of the close relationship between regulator and regulated -- the advance warning on inspections -- does not affect the city's enforcement efforts.
"We don't give them a long period of time to know we're coming, just a matter of days," said Thompson. "We think we're getting a realistic picture of what's going on." She said the purpose of advance notice is to make sure all residents are on hand and records are available.
According to staff members and residents of some of the facilities, the warnings can prompt last-minute clean-ups and staff hirings.
"They make sure we're clean-shaven, clean the wheelchairs, make everything right," said Bernard Urby, 44, a former economist who has lived in the Washington Nursing Facility since he was partly paralyzed by a stroke two years ago. "The food is completely different than usual. It's a big front: they race around bringing on extra staff just for a few days." Problems Defy Solution
A license granted by the Service Facilities Regulation Administration represents the city's stamp of approval. It allows a facility to operate and enables it to receive patient referrals and obtain city and federal payments.
Bowie and her deputy, Judy McPherson, blame most of the health and safety deficiencies in the facilities they regulate on problems that defy solution.
"Facilities have the most problem with staff who call in sick or contract personnel who don't pan out," said Bowie. Added McPherson, "There are only two nursing homes in the city that don't have roaches. It's almost impossible to keep homes clean."
Even when there are repeated violations, the city is slow in taking action. Nothing better illustrates this than the recent history of the Wisconsin Avenue Nursing Home. Those involved in monitoring the 355-bed home, including its owners, admit it has had continuing problems meeting the government's minimum requirements for care. Nonetheless, violations persist.
District inspectors over the last four years have found the Northwest Washington home has not hired sufficient staff, given proper medical care or clothed or fed its patients properly. The home has led the city in citizen complaints, with 84 last year, and most of them were substantiated by the same inspectors who describe the home's repeated deficiencies.
In 1981, 1982 and 1983, for example, the city found the home failed to meet at least one of every seven conditions checked. In 1983, inspectors found the home was seriously understaffed, medicines were not being given in 12 cases it checked, doctor's treatments were missing in more than 50 cases and patients were "improperly positioned, unattended and idle for long periods in sun rooms and halls."
In addition, according to one report, "there was disregard for the comfort and dignity of patients left to sit and eat in rooms where beds were soiled with feces for several hours."
A year later, many of the same deficiencies were cited again.
The home has experienced "very, very poor medical practice, no doubt about that," Tom Clark, executive vice president of Beverly Enterprise's Heritage Division, conceded at a recent hearing. But he said the home has worked hard to improve conditions. Beverly Enterprises is the largest nursing home chain in the United States, operating 965 homes.
Andrew McBride, D.C commissioner of health, said there was a "pattern" at the home of doctors not attending to patients.
But the city's licensing agency has not imposed sanctions. Instead, another agency, the District of Columbia State Health Planning and Development Agency, gave Wisconsin Avenue in 1981 the distinction of becoming the first city facility to lose its "certificate of need," or operating permit. The action was taken because of inspection reports citing poor conditions, improper medical and nursing care, insufficient staff and a lack of equipment. The planners issued a modified certificate the day the initial certificate was revoked, with provisions that the home report more often to health planners.
But recent city inspections found several of the problems remain. Health planners, upset at the lack of progress, again have asked that the home's certificate of need be revoked. That request is pending.
The frequency of city inspections has also been criticized. Unlike Maryland health officials, who regularly visit homes up to four times a year, inspectors in the District visit most facilities only once a year.
Besides inspections, the strongest protection that D.C. residents have in ensuring good care is the complaint system. Several city agencies receive complaints about poor conditions, and all are sent to the Service Facilities Regulation Administration for investigation.
The agency's own records, however, show that it takes weeks, months and even years to investigate complaints of poor care, if it investigates them at all. After The Post asked to examine complaint files, Barbara Blount, director of the division that inspects social service facilities, said she hastily created files to give the impression that complaint records were kept up to date for the city's boarding homes, child-care centers, adoption agencies and other social service facilities.
In fact the files did not exist, Blount said, because of a lack of secretarial help.The reports she found included complaints that apparently took five years to investigate. Most were unsigned and incomplete. "We know everybody's writing," Blount said. "If I had a good staff assistant I wouldn't be in the mess we're in."
Cleaning up problem homes "is a very weak link in our system," said Geraldine Britton, director of Columbia Senior House, which monitors District nursing homes under a federal contract.
Because the city's licensing authorities have failed to act in many cases, other agencies, such as the health planning board and the D.C. Commission on Healing Arts have tried to help. But according to Bowie, the other agencies do not understand her agency's unique role.
"We have to persuade and educate," she said. "It's a long, long process and you must be patient."