Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1998 through 2004.
Harrington, C., Carrillo, H., & Mercado-Scott, C. (2005). University of California, San Francisco.
A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for the 1998 through 2004. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S.Centers for Medicare and Medicaid Services.
The highlights of the new report for all US nursing homes show that in the 1998 through 2004 period:
The number of nursing homes certified to take both Medicare and Medicaid residents increased by 6 percent (from 87.5 to 93.1 percent). Comment: This increased the access of residents to Medicare and Medicaid payments.
The number of nursing homes operated by hospitals declined by 34 percent (from 14 to 9.2 percent) of total homes. Comment: These hospital-based facilities are nursing homes that had the highest staffing and the most Medicare residents.
Residents whose care was paid by Medicare increase by 24 percent (from 9.3 to 12.2 percent of all residents) while the residents whose care was paid by Medicaid declined by 2.5 percent and residents paid by private payers and other sources declined by 5.5 percent. Comment: Medicare is assuming an increasing role in paying for nursing home residents.
- Nursing home occupancy rates declined by 5 percent (from 87.4 percent to 82.7 percent). Comment: Declining occupancy rates are occurring at a time when the population is aging. Nursing homes with low occupancy rates may have financial problems.
- The average number of registered nurse (RNs) hours per resident day declined by 25 percent (from 0.8 hours to 0.6 hours). The number of nursing assistants (NAs) increased to make up for the reduction in registered nurse hours. Comment: This shows a dramatic decline in the skills and training of staff since the implementation of the Medicare prospective payment system in 1998. Studies have shown facilities with more RN staffing have higher quality of care on average.
The percent of residents with dementia increased by 8 percent (from 41.6 to 45 percent of residents) and the percent with other psychiatric diagnoses increased by 45 percent (from 13.2 to 19.1 percent of residents). Comment: The number of residents needing psychological and behavioral management is increasing.
The percent of residents with limitations in activities of daily living and with special nursing needs remained fairly stable over the time period. Comment: Although most nursing home residents have a number of care needs, the need for physical assistance and special care is not increasing.
- The percent of residents who were chair bound increased by 13 percent, in bed most of the time declined by 43 percent, with contractures (immobile joints) increased by 26 percent, with pressure sores increased by 6 percent, and those in physical restraints declined by 39 percent. Comment: This some improvements in time spent in bed and the use of physical restraints but the increase in residents who are chair bound, have pressure sores and contractors is of concern and may indicate poor quality of nursing care.
Quality of Care
The average number of deficiencies increased by 43 percent (from 5.2 to 9.2 per facility). Comment: This suggests that the quality of compliance with federal regulations is deteriorating.
At the same time, the percent of facilities receiving serious deficiencies for causing harm or jeopardy declined by almost half (from 30 percent in 1998 to 15.5 percent in 2004). Comment: This suggests that quality is improving or states are less likely to give serious deficiencies. These is little evidence of improved quality so it is more likely that a change in the survey ratings of deficiencies has occurred.
Wide variations in the average number of deficiencies occurs across states, ranging from 18.2 in the District of Columbia and 15.6 in California to only 4.8 in Wisconsin in 2004. Comment: This suggests that federal compliance with regulation varies across states or state enforcement varies widely, whereas the latter is the most likely explanation.
Violation of food sanitation regulations by 32 percent of all US nursing homes continues to be the most frequent deficiency issued by surveyors. Comment: One third of all nursing homes have sanitary problems.
- Quality of care is the second most common violation of federal regulations, increasing from 17 percent to 26 percent of all US nursing homes. Comment: One fourth of all nursing homes have quality of care problems.
These trends in nursing homes should be of concern to policy makers, nursing home providers, and consumer advocates because they do not show major improvements over the past seven years. Moreover, they show wide variations in staffing, residents, quality of care and enforcement across states that have not improved.
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