When a beloved, elderly relative suffering from a degenerative brain disease had to move into a nursing home a few years ago, we were grateful she was able to secure a room in one of the best facilities in her town. It’s a lovely place, clean and comfortable, with kind and attentive staff.

Even so, her husband was determined never to leave her alone. Day after day, he sat with her for hours at a time, except for occasional breaks when he’d line up a close friend or family member to take over. It was admirable but it must have been incredibly challenging at the same time.

She passed away before the pandemic caused lockdowns and bans on visitors at nursing homes all over the state. Perhaps that was another blessing, although we still miss her terribly.

Their story came to mind this week when a report by Iowa Capital Dispatch Deputy Editor Clark Kauffman brought to light the nightmarish conditions in another Iowa nursing home. Among the findings of a state inspection: an infestation of toxic mold that caused immediate risk to residents’ safety but had been allowed to persist for a year or more; staff routinely sleeping on duty; a resident who had to call 911 for help and was hospitalized after staff dismissed her complaints; another resident hospitalized with sepsis and acute kidney failure after an inspector alerted an aide to the resident’s apparent high fever.

A key point of the story was the lack of any real enforcement action by the state against the home, QHC-Mitchellville. The Iowa Department of Inspections and Appeals regularly proposes fines for serious violations but then suspends them to allow Centers for Medicare and Medicaid Services to consider the imposition of federal fines. In this case, the state proposed, but did not impose, more than $36,000 in fines.

The federal agency only reports fines publicly once the money is collected, leaving families and the public with a glaring gap in information they might otherwise use to evaluate a nursing home. If the home refuses to pay, the feds don’t report the fine at all, which seems like a strong incentive for a home to stall or refuse payment.

Iowans who read this story, including health care professionals, wrote to Iowa Capital Dispatch to express their outrage. One reader, who described herself as a longtime health care worker, said the story left her in tears. “It is, by definition, abuse (not to mention inhumane and criminal)!! That facility should be SHUT DOWN and residents and (their) families should SUE! Obviously the state doesn’t care, in fact the state is enabling that disgusting behavior and treatment.”

Several others wondered why family members haven’t intervened. But the sad fact is that too many vulnerable, elderly people in Iowa and around the country do not have family living near enough to monitor their care. Certainly, most can’t make a commitment to round-the-clock monitoring, like my relatives did. It’s the state’s responsibility to protect and advocate for these people and it is not doing its job.

State laws and policies leave consumers in the dark

In many cases, state laws and policies work against consumers in favor of the interests of the political active nursing home industry.

Here are just a few examples that Kauffman has documented for Iowa Capital Dispatch:

• Long-term care ombudsman: This state agency, which is tasked with advocating for Iowans in long-term care facilities, has been gutted by legislative budget cuts and further curtailed by the pandemic. The office’s most recent annual report, for the 2019 fiscal year, documented a dramatic decrease in nursing home visits and a reduction in participation in inspections and training. Iowans need more people watching over elderly nursing home residents, not fewer. This should be a budget priority.

• Arbitration agreements: Many nursing home companies get new residents or their families to sign away their right to sue the company in cases of injury or wrongful death caused by abuse or negligence. The agreements instead force families into arbitration, which nearly eliminates the chance of winning any money. Such agreements were banned under the Obama administration, but the rule was blocked by a court. The Trump administration specifically allowed the agreements. Doing away with lawsuits is yet another way nursing homes are relieved of accountability for endangering elderly residents.

• Reporting of COVID-19 outbreaks, staff vaccination: Iowa Department of Public Health recently stopped listing the names of nursing homes experiencing COVID-19 outbreaks on its website. While Iowa Capital Dispatch periodically requests the names through the state public records law and reports them, it’s an extra hurdle for the public. Throughout the pandemic, the agency has refused to report deaths of nursing home staff due to COVID-19. The state also reported it was not keeping track of staff vaccinations in long-term care facilities, even though federal data showed a significant number of staff were refusing a vaccine.

There are many quality facilities in Iowa with caring staff, just like the one my relatives were fortunate enough to find. But the bad actors put the responsible ones at a disadvantage.

The bigger issue: Paying for quality care

Beefing up enforcement, including state fines for violations, doing away with arbitration agreements and expanding public access to records related to compliance are all just interim steps. The larger issue, which needs state and national attention, is how to pay for higher quality long-term care.

Low-skilled, low-paid staff and high turnover in nursing homes devastates patient care, as we’ve seen over and over in Iowa. The case in Mitchellville of staff sleeping on the job relates directly to workforce problems. But Americans already have trouble paying for even the substandard care that is allowed to proliferate in Iowa.

Iowans who think our vulnerable elderly deserve better need to make it a campaign issue. Candidates for governor, the Legislature, and Congress all should face pointed questions about how they will ensure the safety of the 44 residents of QHC-Mitchellville and of nursing home residents across our state.

Iowa is failing our vulnerable elderly. Who will keep them safe?