Marvin Mandel, Governor                        1821

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." (Pg. 1) * * *

"At the opening of the public hearings, the panel stated that from
our incomplete and fragmentary knowledge of the complex problems
posed by the long-term 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 nurs-
ing homes in general are not doing the job they should be for our
elderly citizens, that they may be managed by poorly trained admin-
istrators, 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."
(pg. 2)

"The panel must state * * * 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 nurs-
ing 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." (pg. 5)

And Whereas, the Board of Inquiry considered the general prob-
lem of nursing homes in Maryland and concluded:

"We now turn to the broader problems which we believe underlie
the Gould Convalesarium tragedy and, indeed, almost inevitably
assure its recurrence in other nursing homes in Maryland. The prob-
lem surrounding nursing homes is a problem for all of American
society today. The shamefully low priority our society places on the
care and comfort of its aging and infirm is obvious throughout all
of the testimony and the material we have reviewed.