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Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 1998 through 2005.
Harrington, C., Carrillo, H., & LaCava, C. (2006). 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 1999 through 2005. 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 1999 through 2005 period:
Facility Characteristics
The number of nursing homes certified to take both Medicare and Medicaid residents increased by 6 percent (from 87.5 to 93.9 percent). Comment: This may improve the access of residents to Medicare and Medicaid payments. The number of nursing homes operated by hospitals declined by 36 percent (from 13.2 to 8.8 percent) of total homes. Comment: These hospital-based facilities are nursing homes that have the highest staffing and the most Medicare residents, which appear to have been impacted by the implementation of the Medicare prospective payment system in 1998. The percent of facilities that were owned or leased by multi-facility organizations (chains) declined from 55.8 percent in l999 to 52.1 percent in 2005. Comment: This is related to restructuring and downsizing of some of the large national chains after the implementation of the Medicare prospective payment system in 1998 and other changes in Medicare reimbursement. Residents whose care was paid by Medicare increased by 52 percent (from 8.6 to 13.1 percent of all residents), residents whose care was paid by Medicaid declined by 3 percent, and resident care paid by private payers and other sources declined by 9 percent. Comment: Medicare is assuming an increasing role in paying for nursing home residents and reducing care paid by Medicaid and private payers. - Nursing home occupancy rates continue to gradually decline to 85.4 percent in 2005, although there was wide variation across states. The Comment: Declining occupancy rates are occurring at a time when the population is aging. Nursing homes with low occupancy rates may have financial problems.
Staffing
- The average number of registered nurse (RNs) hours per resident day declined by 25 percent (from 0.8 hours to 0.6 hours) between 1999 and 2005. The number of nursing assistants (NAs) hours increased to make up for the reduction in registered nurse hours. Comment: This shows a dramatic decline in the skill and training of staff occurred after 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.
Resident Characteristics
The percent of residents with dementia increased by 10 percent (from 41.4 to 45.4 percent of residents) and the percent with other psychiatric diagnoses increased by 43 percent (from 13.8 to 19.7 percent of residents). Comment: The number of nursing home 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 substantially increasing. - The percent of residents who were in bed most of the time declined by 37 percent and residents in physical restraints declined by 37 percent between 1999 and 2005. At the same time, the percent of residents who were chair bound increased by 14 percent, who had contractures (immobile joints) increased by 20 percent, and residents with pressure sores increased by 4 percent. Comment: This shows some improvements in time spent in bed and the use of physical restraints but the increase in residents who are chair bound, have contractures, and have pressure sores is of concern because it may indicate poor quality of nursing care.
Quality of Care
The U.S. average number of deficiencies per facility increased from 5.7 deficiencies per facility in l999 to 9.2 per facility in 2004, but decreased to 7.1 in 2005. Comment: This suggests that that state survey agencies are issuing fewer deficiencies because it is unlikely that quality has improved. At the same time, the percent of facilities that that received one or more deficiencies that caused harm or immediate jeopardy to residents (rated as a G-level deficiency or higher). The average percent was 30.6 in 1999, which then declined sharply to 15.5 in 2004 and then increased to 16.9 percent in 2005. Comment. There is some evidence that some state agencies may be down grading the severity ratings for deficiencies. Wide variations in the average number of deficiencies are issued by state survey agencies. In 2005, the average number of deficiencies varied from 4.1 percent in Mississippi and Wisconsin to 14.6 percent in the District of Columbia. Comment: This suggests that federal oversight is yet to bring standard enforcement practices across states. The violation of food sanitation regulations by 34.7 percent of all US nursing homes continues to be the most common problem identified by state agency surveyors. Comment: Over one-third of all nursing homes have serious sanitary problems. - Quality of care is the second most common violation of federal regulations. The violations increased by 40 percent, from 21 percent to 29.5 percent of all US nursing homes between 1999 and 2005. Comment: Almost one-third 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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