Nursing homes care for people who are too old or sick to care for themselves. They also care for patients after a hospital stay who cannot yet live independently. Deciding to move a loved one to a nursing home is a big, often overwhelming decision. Of course, you want them to be safe and comfortable. But, nursing home patients are vulnerable and often cannot speak up for themselves. And, staffing issues can lead to serious problems. If you’re choosing a facility, how can you evaluate nursing home safety issues? How do you decide which facility to use?
Before we go further into this topic, I want to clear up some terminology. Nursing homes are sometimes referred to as skilled nursing facilities. There are more than 15,000 skilled nursing facilities in the US, 90% of which are also certified as nursing homes. Skilled nursing services include wound care, IV therapy, injections, physical therapy, and the monitoring of vital signs and medical equipment.
Staffing generally consists of:
- RNs (registered nurses)
- LPNs (licensed practical nurses)
- CNAs (certified nursing assistants)
- Specialists such as physical, speech and occupational therapists.
What kinds of nursing home safety issues exist?
Nursing home patients can be harmed in a variety of ways. The US Department of Health & Human Services (HHS) categorizes nursing home safety issues as follows:
- Quality of Care/Treatment – Insufficient or incorrect medical care, including delays or failures in care, medication errors, inadequate monitoring, preventable blood clots, excessive bleeding and kidney failure. Quality of care issues can lead to worsening health and sometimes unexpected deaths.
- Resident Neglect – Staff may ignore patient needs, including not providing timely incontinent care, not providing adequate food and liquids, inadequate care of bedsores that lead to infections, and improper patient handling which can lead to falls.
- Resident Rights – The denial of patient rights includes not allowing patients to refuse or delay any medication or treatment, not allowing patients to leave their room, and denying requests to move to another facility.
- Physical Environment – Patients may suffer due to environmental issues, including inadequate heating and/or cooling.
- Resident Abuse – Patients can suffer physical and/or sexual abuse by staff or fellow patients.
- Other – This category includes a wide variety of issues, including financial abuse, infection control, and stolen property.
Of these categories, quality of care/treatment issues have led to the highest number of consumer complaints, many of them categorized as “immediate jeopardy” or “high priority”.
COVID-19 pandemic shines a light on nursing home infections.
The time to consider the spread of infections in nursing homes is now. Nursing homes are hot spots for COVID-19 infections and deaths. In fact, as of April 10 2022, the CDC estimates that 151,972 nursing home residents died from COVID.
However, dangerous infections in nursing homes is not a new problem. Nursing homes in the US have struggled to follow basic infection protocols created to halt the spread of any kind of virus and bacteria, including flu and MRSA infections.
According to a Kaiser Health News article, government health inspectors have cited more nursing homes for infection-control issues than for any other type of violation. Overall, federal inspectors cited 63% of nursing homes for one or more deficiencies in their infection-control procedures.
Unsurprisingly, violations in infection control were more common in nursing homes with fewer nurse and aides, as compared to those with higher staffing levels.
The good news? To address the COVID-19 pandemic, the Centers for Medicare & Medicaid Services recently instructed their healthcare inspectors to focus on infection-control practices at nursing homes and hospitals. Will this be enough to tackle these prevalent issues? My guess is a resounding “no”.
What kinds of infection-control issues prevail?
Inspection reports from around the US show many simple infection-control practices are not followed in nursing homes. For example, inspectors found workers who did not wash their hands between patients, and others who did not wear masks, gloves and gowns when in the rooms of contagious patients in isolation.
Furthermore, recent news reports indicate that many nursing homes do not have adequate personal protective equipment, such as masks and gowns, for employees. And the risk of patient infection grows as many nursing home employees continue to work while sick, likely due to low pay and limited time-off.
How common and serious are nursing home safety issues?
A study published in 2014 by the HHS found that 1/3 of patients in skilled nursing facilities were harmed in treatment. Of the 653 patients whose records were evaluated, 22% suffered events that led to lasting harm, and an additional 11% suffered temporary harm. In 1.5% of the cases, the patient died from poor care.
Based on these findings, the study estimates that across the US there would be almost 22,000 patient injuries and more than 1,500 deaths in a single month. This reflects a higher rate of medical errors than in hospitals.
And the harm may be even greater than quoted in the HHS study. According to a Kaiser Health News article, it’s possible that as many as 3.8 million infections occur in nursing homes each year, killing nearly 388,000 residents. And that’s just infections!
For-profit vs nonprofit homes.
Unfortunately, many nursing homes (and hospice care organizations) are now for-profit companies, purchased by private equity firms. Sadly, this trend had decreased the quality of care while increasing the death rate among for-profit nursing home residents.
As mentioned above, COVID-19 took a severe toll on nursing home residents. However, patients at for-profit centers fared worse. In fact, 6 studies showed that the risk of infection or death from COVID-19 was significantly higher in for-profit nursing homes. Why? Nurses who work in for-profits care for more patients than in nonprofit homes. Moreover, they also have less access to personal protective equipment that would protect both workers and residents.
But it’s not just COVID-19 that causes concerns in for-profit homes. For instance, when private equity companies take ownership of nursing homes, death rates of residents increase by 10%. At the same time, quality of care drops, as evidenced by staffing and other measures. Conversely, quality of care improves when nursing homes change from for-profit to nonprofit.
Moreover, the issue of poor quality in for-profit nursing homes is also a matter of racial justice. because for-profit nursing homes are more likely to care for Black and Hispanic patients.
What’s the government’s role?
On February 28, 2022, President Biden committed to improving the quality of our nursing homes. His reforms include providing adequate staffing ratios, holding poorly performing nursing homes accountable, and providing the public with clear information regarding nursing home conditions.
Although President Biden’s reforms are a good start, experts believe a more comprehensive and system-level plan is needed to improve nursing home care. Fortunately, the National Academies of Sciences, Engineering, and Medicine created a 17-member committee to make bold, actionable recommendations that will improve nursing home care. Read this article for a summary of their recommendations.
Medicare’s efforts to protect nursing home residents.
The Centers for Medicare & Medicaid Services (CMS) annually inspects nursing homes. Additionally, they inspect facilities after they receive serious complaints.
CMS’ Five-Star Quality Rating System helps the public compare nursing homes. The rating system relies on a combination of self-reported data as well as on-site evaluations by state health inspectors.
As you’d expect, CMS considers 5-star facilities well above average for quality. Conversely, 1-star homes have quality rated much below average. CMS gives each facility an overall score, as well as separate scores based on health inspections, staffing and quality measures. Importantly, realize that for-profit nursing homes are twice as likely to have poorer rankings than nonprofits homes.
However, it’s important to realize that high CMS star ratings don’t guarantee patient safety.
Although Medicare has tough safety standards, they are not uniformly enforced. Some inspectors are tougher than others, and some states do not conduct their onsite investigations in a timely manner when serious complaints have been filed. In fact, the 2017 HHS report found that almost 1/4 of the states did not meet Medicare’s performance threshold for timely investigations.
CMS star rating system provides a false sense of security.
New York Times recently conducted a robust investigation of over 10,000 nursing homes to evaluate safety records and CMS star ratings, and what they found is alarming. The investigation found that the CMS rating system provided “a badly distorted picture of the quality of care at the nation’s nursing homes. Many [nursing homes] relied on sleight-of-hand maneuvers to improve their ratings and hide shortcomings…”.
Highlights of the New York Times’s findings:
- Of the 3,500+ 5-star homes, over 2,400 were cited for problems with infection control or patient abuse.
Much of the information nursing homes submit to CMS is wrong. Almost always, the incorrect information makes the homes appear cleaner and safer than the reality. For example:
Some nursing homes artificially inflate their staffing levels. For instance, some include employees on vacation in their staffing count.
Homes frequently understate the number of patients on dangerous antipsychotic medications.
Residents’ accidents and health problems often go unreported.
The government rarely audits the self-reported data provided by nursing homes.
Data suggest that at least some nursing homes know in advance about ‘surprise inspections’.
Although health inspectors routinely found problems with abuse and neglect at 5-star homes, they rarely deemed the problems serious enough to lower the ratings.
- Residents of 5-star facilities were roughly as likely to die of COVID-19 as those in 1-star homes.
- Poor care led to patients in 5-star homes to develop bed sores so severe their bones were exposed. Other patients lost their ability to move.
Nursing homes aren’t always honest in their reports to Medicare.
Clearly, the CMS website Care Compare is only as good as the data it contains. Unfortunately, nursing homes may not report all required incidents to CMS, misleading patients and their families.
For instance, recent research shows that nursing homes vastly underreport occurrences of moderate pressure ulcers (aka bed sores), a patient safety event they are required to report to CMS. The researchers at the University of Chicago found that nursing homes only reported 22% of the pressure ulcers that led to hospitalizations in which pressure ulcer was the primary diagnosis.
Furthermore, when investigating hospitalizations of nursing home patients, they found that among patients with a secondary diagnosis of pressure sores, 45% of the occurrences of pressure ulcers were not reported to CMS.
Could nursing homes underreport other patient safety measures? It seems likely to me.
The US Government’s low payments keep employees’ wages low.
As outlined above, CMS plays an important role in nursing home safety by inspecting nursing homes and investigating complaints. Ironically, CMS’ reimbursements for nursing homes patients also influences quality and safety, but not in a positive way.
The payments made by CMS for Medicaid patients in nursing homes is often lower than the daily cost of providing such care. Although Medicare pays at a higher rate than Medicaid, in general, the majority of residents at nursing homes are covered by Medicaid, not Medicare.
Clearly, these low reimbursement rates make it difficult for nursing homes to offer adequate pay to employees. In fact, experts estimate that close to 44% of direct care workers live in or near poverty.
The government isn’t stopping private equity firms from taking over.
Surprisingly, lobbyists have convinced many state legislatures to shield nursing homes from lawsuits. Instead of protecting these private equity owned for-profit homes, government should make sure these homes provide quality care. Some good news – in 2021, the New York attorney general recommended eliminating immunity provisions for nursing homes so accountability is not waived. We need more of that!
On a federal level, the US Department of Justice has caught many for-profit nursing homes engaging in fraud. But more work is needed. For instance, although the for-profit homes provide worse care, many receive millions in government funds.
Why aren’t these facilities safer?
So many reasons! First, the difficult work and low wages make it hard to find and keep staff, leading to personnel shortages. According to an expert, “most US nursing homes don’t have enough staff to provide the 4.1 hours of daily nursing care experts recommend”.
Additionally, nursing homes generally have extraordinarily high turnover among staff. A recent study, published in March 2021, found the annual average turnover rate was 128%, with some facilities experiencing turnover that exceeded 300%. The authors surmise this high turnover rate likely contributed to the shocking number of COVID-19 deaths at these facilities.
To fill the gap, many nursing homes use staffing agencies, which can cause its own problems.
Steady influx of new employees creates safety issues.
Between the high turnover rate and temporary staff, nursing homes usually have new employees who may not know the infection-control procedures and other safety protocols. And, this steady influx of new employees makes it hard for staff to develop emotional bonds with their patients – an unfortunate consequence since these bonds can decrease the risk of neglect and abuse.
Workloads may become unmanageable.
Moreover, these issues often lead to staff dealing with unmanageable workloads, which can lead to patient neglect and harm. For instance, overworked nurses and aides may cut corners, such as failing to wash their hands as often as needed, which can harm patients.
Furthermore, nursing home patients often have physical and/or cognitive impairments, requiring high levels of attention and care. Economics make it impossible to provide one staff person for every patient, which can lead to patients’ needs being neglected.
It’s not only about staffing.
Lastly, not all nursing homes have good management. In addition the above stated staffing issues, may other issues can impact quality and safety. For instance, staff may not receive adequate training in patient care. Or homes might lack the equipment and supplies needed to keep patients and residents safe.
With these challenges, it’s no surprise there are patient safety issues, including infections, neglect and abuse.
Loved one in a nursing home? Visit often!
If your loved one is in a nursing home, it pays to visit often. Of course, your loved one appreciate your time and attention. Additionally, your regular presence alerts the staff that family (and friends) are watching over the patient and will likely notice issues of neglect and/or abuse.
What should you do if you suspect a nursing home safety issue?
Firstly, try your best to move your loved one to another facility if you suspect neglect or abuse. If you cannot move your loved one, try to get any issues resolved as soon as possible. To start the process, gather information regarding any nursing home safety issues you notice. Take detailed notes of the suspected abuse/neglect, take photos, and gather medical records.
Contact the home’s ombudsman.
If your conversations with the nursing home staff do not lead to necessary changes, consider contacting the Long Long-Term Care (LTC) Ombudsman representative for the nursing home. Each home must conspicuously post the name and contact information for the ombudsman associated the facility.
What does the LTC do?
Every state, as well as the District of Columbia, Puerto Rico and Guam, have programs dedicated to resolving problems related to the health, safety, welfare, and rights of individuals who live in nursing homes and other long-term care facilities. The OAA (Older Americans Act) requires Ombudsman programs to:
- Identify, investigate, and resolve complaints made by or on behalf of residents.
- Provide information to residents about long-term services and supports.
- Ensure that residents have regular and timely access to ombudsman services.
- Represent the interests of residents before governmental agencies and seek administrative, legal, and other remedies to protect residents.
- Analyze, comment on, and recommend changes in laws and regulations pertaining to the health, safety, welfare, and rights of residents.
You can find the ombudsman office for your state here.
File a complaint with the state.
If the ombudsman cannot resolve your concerns about nursing home safety issues, or if you feel the process is moving too slowly, you can file a formal complaint with the state. They must investigate complaints of a serious nature if they receive the complaints within the required time frame.
If the state classifies your complaint as “immediate jeopardy”, the law requires an onsite investigation within 2 working days. If they categorize your complaint as “high priority”, they have 10 working days to conduct an onsite investigation.
By filing a complaint, you can help stem the cycle of abuse and neglect. To learn how to file a complaint with the state where the facility is located, visit the National Center on Elder Abuse state directory, or search online with the name of the state and the phrase “filing a complaint against a nursing home”.
For more information on elder abuse, visit the National Center on Elder Abuse website.
Want tips on how to evaluate a nursing home?
Now that you know more about nursing home safety issues, read my blog post How to Choose a Nursing Home before moving a loved one into a nursing home.
NOTE: I updated this post 11-1-22.