We were down to 92 patients at the conclusion of this outbreak. We now have 118. So, we feel that our position in the community is well known and people have a regard for the home. Senator Moss. Do you operate other homes besides this one? Mr. GOULD. I have an interest in one other, yes. This was a home that we started through the FHA in 1962 before this Convalesarium was originated and through various procedures it took 8 years for the papers to clear. So, it was not until last year that this home was built. It was opened in April of this year. It is a 100-bed nursing home also built under the auspices of the Federal Housing Administration. These are the only two homes that I have any connection with. Senator Moss. Have you had any similar outbreaks or problems like this at the homes that you operated earlier, the one on Eutaw Street? Mr. GOULD. No, sir. I have been in the business for 18 years and have never had any such incident before. Senator Moss. We do appreciate having this. Of course, the terrible disaster of losing so many lives has caused us to look rather deeply into this nursing home problem. And the State is now instituting a number of changes that will improve the operation, we hope. We need to look, I am sure, still deeper. We have here a problem of older people who are very defenseless, of course, and we must make sure they are not imperiled in any way besides the other factors that we have talked about today of giving them care and attention and visitation. Mr. HALAMANDARIS. As a staff member who did the investigation for these hearings, I want to confirm what Mr. Gould said, in that when I went to his establishment I was very well treated, treated with kindness and courtesy and every effort was made to give me all the facts. The question of what kind of nursing home the Gould institution was has received much attention. I just wanted to say that after having gone over all of the information available I can confirm the conclusion of the Sellinger report that the Gould home was a better-thanaverage home. Mr. GOULD. Thank you very much. Senator Moss. Thank you, Mr. Gould. We are glad you came to testify. We, at no time, intended to focus exclusively on your home. Still our investigation did reveal to us many deficiencies in the operation of nursing homes generally and brought to our attention the inadequacies of State inspection, the problem of physicians' attendance on patients and signing of death certificates and other matters, which have broadened our view in this field. Therefore, the study has been helpful to us. I would perhaps like to prolong this, but unfortunately, I am due down in the city in 10 minutes. We have to terminate at this point. Thank you very much. Mr. GOULD. I appreciate your efforts, sir, and I am available at any time. Senator Moss. We will recess this hearing to reconvene Thursday, December 17, 1970. (Whereupon, at 11:50 a.m., the subcommittee was recessed to reconvene Thursday, December 17, 1970.) APPENDIXES Appendix A REPORTS: BALTIMORE NURSING HOMES ITEM. 1. REPORT OF AN INVESTIGATION INTO THE SALMONELLA EPIDEMIC AT GOULD CONVALESARIUM IN BALTIMORE IN JULY 1970 BY A BOARD OF INQUIRY APPOINTED BY THE SECRETARY OF HEALTH AND MENTAL HYGIENE OF MARYLAND, OCTOBER 27, 1970 FINDINGS RESULTING FROM AN INVESTIGATION OF AN OUTBREAK OF SALMONELLOSIS AT THE GOULD CONVALESARIUM What you are about to read is the story of a human tragedy. This document reports our findings stemming from an investigation into the deaths of 36 men and women in the summer of 1970 at the Gould Convalesarium, a nursing home in Baltimore, Md. The investigation indicates individual failures by physicians. by those who run nursing homes, by State and city health officials, by State and national government. Collectively they add up to the failure of our society to properly concern itself with the fate of its sick old people. The fact that such a tragedy could occur in a nursing home in Maryland that is considered above average clearly indicates the generally serious and unacceptable situation which exists in nursing homes. The evidence presented clearly shows that we have allowed these homes to operate in a bewildering tangle of bureaucratic regulations and inadequate laws where State agency overlaps city agency, where ambiguous lines of authority and the absence of clearly delineated responsibilities create confusion and carelessness, and where lack of adequate supervision potentially endangers the life of every patient in every nursing home. It is clear to the members of this board of inquiry that recent events at the Gould nursing home could be repeated tomorrow at any nursing home in this state unless multiple corrective measures are undertaken. This board of inquiry was appointed by the Secretary of Health and Mental Hygiene of the State of Maryland, Dr. Neil Solomon, to discover the facts surrounding the outbreak of salmonellosis at the Gould Convalesarium. We accepted appointments to this panel with the clear understanding that we would act as public servants on the behalf of the citizens of Maryland and the patients who occupied not only the particular nursing home under consideration, but all patients in nursing homes throughout the state. Thus, we do not, and have publicly so stated, regard ourselves as responsible to any agency or group with direct or indirect responsibilities for the operation, management or regulation of nursing homes. At the opening of the public hearings, the panel stated that from our incomplete and fragmentary knowledge of the complex problems posed by the longterm care of the helpless and aging, we felt it quite possible that this tragedy in one nursing home might be but the tip of an iceberg-an alarm signal indicating that as a society we had failed to deal responsibly with the problems of our elderly citizens who require care not given in their homes or by their families. Our investigation confirms this suspicion and points up the crying need for an in-depth study of nursing homes in Maryland. This panel's report, which should not be mistaken for the exhaustive study that is demanded, is offered at this time because of this panel's profound obligation to make known to the families of those persons who died during the salmonella epidemic at the Gould Convalesarium, and the public, its general findings. Thus, the report of this board of inquiry will raise more questions than it answers. Our short investigation strongly suggests that nursing homes in general are not doing the job they should be doing for our elderly citizens, that they may be managed by poorly trained administrators, that their standards of cleanliness may not meet either the letter or the spirit of legal standards, that their personnel are often insufficiently trained and sometimes insensitive to their patients. Further, there is much to suggest that medical practices of physicians and other personnel in the nursing homes are at times not good, that the public health agencies which monitor the practices and the conditions in nursing homes are not doing their jobs, and that the legislation that controls nursing homes needs dramatic overhauling. In the course of its investigation, this panel held public hearings, at which it heard from the top public health officials in Maryland and Baltimore, the owner of the Gould Convalesarium and one of his administrators, city and state health officials directly responsible for inspecting and licensing the Gould Convalesarium and other Maryland nursing homes, and from several persons with relatives in the Gould Convalesarium. We have also utilized additional information made available to us. This included information from officials of the Medical Services Administraton of the U.S. Department of Health, Education and Welfare, from concerned persons in Maryland who are knowledgeable about nursing homes in this state and the country as a whole, and data received from the American Nursing Home Association in Washington, D.C. and its Maryland affiliate, the Health Facilities Association of Maryland. In addition, this panel also reviewed testimony of various State Health Department officials before a United States Senate Investigating Committee, and other documents and reports from public and private sources. Documents considered important have been attached to this report as exhibits. Our objectives at the outset of our hearings and throughout our subsequent study included the following: To determine the events surrounding the particular tragedy occurring at the Gould home. a. How did it happen? b. Where did the infection come from? c. Was the epidemic adequately investigated by proper authorities? d. Did problems and delays in reporting influence the number of deaths arising from the outbreak? e. Was treatment of individual cases appropriate? During our investigation it became increasingly apparent that a much more important and broader series of questions also faced the panel. These included: 1. How does the Gould home compare with other nursing homes throughout the state and the nation? 2. How are standards for nursing homes set? 3. What are the procedures for licensing? 4. How are the standards and practices in nursing homes monitored? 6. Were responsibilities for medical practices within the home clearly fixed and delineated? 7. Where do ultimate responsibilities for a catastrophe such as that occurring in the Gould home reside? 8. How are nursing homes actually developed? How are they financed? Who owns them? Is it a profitable business? Are there possibilities for undue political influence or other potential hazards stemming from the way nursing homes are established? Our report is divided into two sections. 1. Findings about the Gould nursing home and the events surrounding the epidemic. 2. Findings relating to problems which plague nursing homes in general. We have initiated this report with an assessment of the Gould home and the specific events surrounding the salmonella outbreak. This has been done to develop the necessary data on which to base more general conclusions. The panel must state at the outset, however, that it firmly believes that specific failures evident in the current tragedy are but symptomatic of the serious problems of nursing homes in general. All of the evidence suggests that the Gould home was and is a better-than-average nursing home. Thus, we feel that the recent events at the Gould home could be repeated at virtually any nursing home in the state, unless the broader, general problems are faced and corrected. THE GOULD CONVALESARIUM The Gould Convalesarium is a three-story, brick nursing home in Northeast Baltimore that was built at a cost of $1 million. It opened in the latter part of 1964. Its principal owner, Mr. Mitchell Gould, advertises it as a "new concept in nursing and convalescent home care . . . built to provide, not a 'last stop' for our senior citizens, but a home-like yet ultra-modern establishment with the ultimate in efficiency, comfort and service." In the same advertisement, Mr. Gould notes that his nursing home has been approved by Medicare, the Joint Commission on Accreditation of Hospitals, the Maryland State Department of Health, the Maryland Blue Cross plan, and the United Auto Workers Health Plan. The home has had its state license renewed with little difficulty each year since it opened. It is also worth noting that two of the registered nurses that work in the Gould Convalesarium have their mothers in the home, and the mother-in-law of Dr. Harold Harbold, the principal physician of the Gould home, was in the home at one time for 18 months. The nursing home is organized so that the first floor houses approximately 40 patients, most of whom are ambulatory and able to care for themselves. On the second floor are some 50 patients, who require occasional nursing care, and on the third floor are 56 patients, all of whom require regular nursing attention. The Gould Convalesarium has a very liberal admissions policy-which many homes do not-and accepts both incontinent patients and patients who are terminally ill. At the time of the epidemic there were 60 incontinent patients in the nursing home. The home, which is licensed for a maximum of 146 patients, appears to exceed slightly state staffing requirements. There is an administrator on duty 12 hours each day. There are four full-time registered nurses and one part-time, as well as three licensed practical nurses; in addition, there are 45 to 50 nurses aides and other ancillary help. The kitchen staff ranges between 7 and 11 persons, to give the home an overall ratio of approximately one employee for every two patients. The maintenance and heavy cleaning inside and outside the nursing home are done by an outside cleaning firm. Like other homes, the Gould Convalesarium is regularly visited by state and city health inspectors. Between July 1, 1968, and July 1, 1970, 22 inspection visits were made. The nursing home, which was consistently termed average or above average by public health officials in their testimony before this panel, has had a continuing problem in the all-important areas of food handling and kitchen sanitation. Particularly important were violations noted by a consultant dietician for the State Health Department. On August 19, 1969, the dietician reported finding tapioca pudding standing at room temperature, and on May 4, 1970, the consultant dietician reported pudding was again found standing unrefrigerated in the kitchen. Mr. Robert Williar, principal sanitarian for the Baltimore, City Health Department's Bureau of Food Control, put the critical nature of food handling into perspective in his testimony: "Any defect in handling of food can lead to disaster," he said. The importance of the error can seem petty to the uninitiated, such as leaving food standing at room temperature for long periods of time before meals, in a kitchen that might otherwise be clean. If the food happens to be contaminated with salmonella bacteria, for example, leaving it unrefrigerated sets up an ideal breeding ground in which the salmonella will multiply. The kind of explosive outbreak of salmonellosis that occurred at the Gould home can be the unfortunate result. Still, it must be reiterated that the quality of the Gould Convalesarium equals or is better than most nursing homes in Maryland or the U.S. In response to a request from this panel, Mr. John W. DeBiak, director of nursing home licensing and certification for the State of Iowa and a recognized expert, conducted a survey of the inspection records of the Gould nursing home, talked with a number of public health officials and inspected the nursing home itself. Mr. DeBiak, whose services were arranged through the Medical Services Administration of the U.S. Department of Health, Education and Welfare, provides in his report |