Michael Clark was shocked by how quickly his elderly mother deteriorated in May when he put her in a Philadelphia nursing home because caring for her had become overwhelming.
After 10 days, Clark found her "in the cafeteria slumped over the table in distress, not able to lift her head, complaining of neck pain," Clark said.
The next day, May 12, Rebecca Clark, 96, was admitted to Pennsylvania Hospital, where she spent two weeks, followed by 10 days of therapy at a different home.
When Michael Clark complained to the Pennsylvania Department of Health, which regulates nursing homes, he was stunned by how easily the facility was cleared.
"No interview with me. No interview with the client," Clark said, pointing to his mother, who is back in his home.
"No 'Can we see any pictures?' So what kind of investigation did they do? Really, it was a one-sided investigation where they said they went to the facility and spoke to the staff. The staff is going to give you a one-sided story," Clark said.
Advocates for nursing-home residents and their families said Clark's experience is common.
"It's like calling 911 and the police going to the suspect's house, listening to his side of the story," and then clearing the suspect, said Samuel Brooks, a senior attorney at Community Legal Services Inc., of Philadelphia.
The state Department of Health countered that it takes nursing-home complaints seriously, follows up on every inquiry, and, in the last year, has improved oversight.
"Some people being displeased with the results of our investigations doesn't mean that the investigatory process was not followed," said agency spokesman Wes Culp.
In June of last year, Community Legal Services published a report by Brooks that criticized the Health Department for dismissing 92 percent of the complaints against Philadelphia nursing homes and minimizing the severity and breadth of harm when it finds deficiencies.
The following month, Secretary of Health Karen Murphy asked Pennsylvania Auditor General Eugene A. Pasquale for an audit of how the agency ensured adequate nursing care, how it responded to complaints, and how consistently it imposed fines.
That 81-page report appeared late last month. It highlighted problems in all three areas.
As for the agency's investigations, the audit said that "it is difficult to determine if a complaint was sufficiently investigated - even for [agency] management" because "surveyors typically only document the deficiencies that are found," as opposed to making a full record of all investigations, whether or not a deficiency is found.
Still, even agency critics such as Brooks praised Murphy for a sharp rise in fines and for issuing more provisional licenses, which allow a home to keep operating while the agency monitors areas that need improvement.
"We applaud her on that," Brooks said. "We still see, especially on a day-to-day basis, problems with the investigation process itself, and that's my biggest concern."
New Jersey's process is similar to Pennsylvania's, with a big difference: New Jersey has always accepted anonymous complaints. Pennsylvania did not from July 2012 to July 2015, likely dampening reports from employees, which accounted for half of New Jersey complaints in fiscal 2015.
The complaint process in Pennsylvania typically starts with a call to Harrisburg by the resident, a relative, or other advocate. The agency counts that initial interview as part of the investigation. Officials send a report from that call to one of nine field offices, where another employee takes over.
The investigator should talk to the person who made the complaint, said Mark Davis, an ombudsman at the Center for Advocacy for the Rights & Interests of the Elderly, in Center City.
Things can go awry.
Two years ago, Patricia Montana called with a complaint that St. Monica Manor in South Philadelphia, when it was still owned by the Archdiocese of Philadelphia, was threatening to improperly discharge her father.
The letter from the agency showed that the investigation - which cleared the facility of wrongdoing - centered on his care, not on the attempt to discharge him.
"They completely ignored what my complaint was about," Montana said.
The federal Centers for Medicare and Medicaid Services have guidelines for investigators. They say to interview the person the complaint involves, without mentioning that some residents might not be able to communicate. That may have been the case with Rebecca Clark. She has Alzheimer's disease, Michael Clark said.
"While we expect our protocols to be followed, we recognize that, depending on the situation, not every aspect of the protocol can be conducted on every survey," a spokeswoman for the federal agency said.
Davis, who for 13 years has helped residents and families with nursing-home problems, said that bypassing the resident is not always a bad sign.
The key is finding the right person, whether it's the resident, a family member, or a social worker at the hospital, "who could verify what's reported to us. In my experience, they don't reach out to them," Davis said.
Investigators rely heavily on talking to the home's administrators and looking at the home's medical records, advocates said.
That infuriates Martin S. Kardon, a Center City lawyer who sues nursing homes for malpractice.
"There's nothing in the records because the records aren't kept honestly," Kardon said. What's more, he said, the Health Department does not check hospital records for information about what happened.
At home in North Philadelphia, Michael Clark has a two-inch stack of paper containing his mother's records from her stay at Pennsylvania Hospital.
Germantown Home, which cared for Rebecca Clark, says it gives excellent care. She was quick to smile and laugh during a visit this month.
"This is the person I know. When she came back, I could not believe it," said home health aide Ana Escalante, who was also with Clark before the ordeal in May and June.
A June 21 department letter to Michael Clark on the results of its probe said it included a tour of the unit as well as "review of all facility documentation related to the incident and resident interviews."
The conclusion read: "Review of the facility records indicated that your mother received appropriate treatment, according to the physician, and staff were directed to send her to the hospital for examination and evaluation."