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Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2000 Through 2006

Prepared by Charlene Harrington, Helen Carrillo, and Brandee Woleslagle Blank

University of California, San Francisco

Released September, 2007

A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for the 2000 through 2006. 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 2000 through 2006 period:

Facility Characteristics

• The number of nursing homes operated by hospitals declined by 29 percent (from 12 to 8.6 percent) of total homes. These hospital-based facilities are nursing homes that had the highest staffing and the most Medicare residents.

• Residents whose care was paid by Medicare increased from 9 to 13 percent of all residents while the residents whose care was paid by Medicaid declined by 4 percent and residents paid by private payers and other sources declined by 7 percent. Medicare is assuming an increasing role in paying for nursing home residents.

• Nursing home occupancy rates declined from 86 percent to 85 percent, at a time when the population is aging.

Staffing

• The average number of registered nurse (RNs) hours per resident day declined by 25 percent between 1998 and 2000 and by 14 between 2000 and 2006. The number of nursing assistants (NAs) increased to make up for the reduction in registered nurse hours. 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.

Resident Characteristics

• The percent of residents with dementia increased by 6 percent and the percent with other psychiatric diagnoses increased by 33 percent (from 15.4 to 20.5 percent of residents). The number of residents needing psychological and behavioral management is increasing.

• The percent of residents with limitations in activities of daily living remained fairly stable over the time period. Although most nursing home residents have a number of care needs, the need for physical assistance is not increasing.

• The percent of residents who were chair bound increased by 13 percent, in bed most of the time declined by 29 percent, with contractures (immobile joints) increased by 10 percent, and those in physical restraints declined by 36 percent. When resident conditions deteriorate, it may indicate poor quality of nursing care.

Quality of Care

• The average number of deficiencies increased from 5 in 2000 to 9.2 per facility in 2004 and then declined to 7.5 in 2006. Either quality improved slightly or, more likely, regulatory oversight is declining.

• At the same time, the percent of facilities receiving serious deficiencies for causing harm or jeopardy declined by almost 23 percent (from 23.5 percent in 2000 to 18.1 percent in 2006). This suggests that quality is either 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 occur across states, ranging from 15.8 in the District of Columbia to only 4.3 in Rhode Island in 2006. Either nursing home compliance with federal regulations varies across states or state enforcement varies widely; the latter is the most likely explanation.

• Violation of food sanitation regulations by 38 percent of all US nursing homes continues to be the most frequent deficiency issued by surveyors. Almost 40 percent of all nursing homes have sanitary problems.

• Quality of care is the second most common violation of federal regulations, increasing from 22 percent to 30 percent of all US nursing homes. 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 continued wide variations in staffing, residents, quality of care and enforcement across states.

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