The biggest issue was apparently that many nursing facilities failed to create appropriate, individual care plans for every patient as required by law. These care plans are necessary because they ensure that every member of the health care team knows the patient's current treatment plan, goals and progress.
Unfortunately, all too often DHHS found that there was no care plan, an inadequate plan, or a plan that wasn't being followed.
Around 20 percent of the time, patient health problems weren't addressed in the care plan at all. For example, one patient studied was on an anti-depressant and two anti-psychotic drugs that could have serious side-effects, but nothing was in the plan about monitoring those medications.
In nearly a third of cases, nursing homes failed to make adequate plans for patient discharge or transfer. They failed to provide enough information for follow-up treatment when patients were transferred to another facility or to for successful home care.
In many cases, patients' care plans weren't followed, perhaps due to greed. The report specifically called attention to the fact that it was in the nursing homes' financial interest to provide or continue treatment patients didn't need. For example, one patient continued to receive occupational and physical therapy even though the care plan stated that all the health goals were already met.
The report did not list the nursing homes studied or the number of patients harmed by neglect. All of the offending facilities, however, were forwarded to the Centers for Medicare & Medicaid Services for action.