Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2004 Through 2009

Prepared by Charlene Harrington, Helen Carrillo, Brandee Woleslagle Blank, and Tenna O'Brian

University of California, San Francisco

Released October, 2010

A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for 2004 through 2009. 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:

Facility Characteristics

  • In calendar year 2009, 15,658 nursing homes with 1.66 million beds were surveyed by state agencies.
  • Nursing home occupancy rates declined from 85.5 percent in 2004 to 83.7 percent in 2008 showing excess capacity, at a time when the population is aging.
  • Of the 1.4 million residents in nursing homes, 64 percent had their care paid by Medicaid, 22 percent had care paid directly out of pocket or by private payers, and 14 percent of residents were paid by Medicare in 2008. The percent of residents paid for by Medicare has increased by about 16 percent since 2004 with a reduction in the percent paid by Medicaid.
  • The number of for-profit nursing homes increased from 65.9 percent of all homes in 2004 to 67 percent in 2009, while the number of non-profit nursing homes and public homes declined slightly. Nursing home chains were 54 percent of the total homes in 2009, showing a 3 percent increase over 2004.
  • The number of nursing homes operated by hospitals declined by 24 percent (from 9.2 to 7.0 percent) of total homes between 2004 and 2009.

Quality of Care

  • Across the country, about 156,000 deficiencies were issued to nursing homes for violations of federal regulations in 2009, indicating many quality problems in the nation's nursing homes. The average number of deficiencies per facility declined by 4.5 percent (from 10.4 in 2004 to 9.6 in 2009)
  • In 2009, 24.7 percent of the nation's nursing facilities received deficiencies for poor quality of care, where facilities caused harm or jeopardy to residents. This was a 3 percent increase over 2004 showing that poor quality of care continues to a major problem in the US.
  • Wide variations in the average number of deficiencies per facility occur across states, ranging from 22 in District of Columbia to only 5.7 in North Carolina in 2009. Harm or jeopardy violations were found in 49 percent of Idaho's facilities compared with 8 percent in Florida. Quality of care either varies widely across states and/or state agency enforcement activities vary widely; the latter is the most likely explanation.
  • In 2009, 45 percent of nursing homes failed to ensure a safe environment for residents. Violations of food sanitation regulations were found in 40 percent of nursing homes and 35.5 percent of facilities received deficiencies for failure to meet quality standards.
  • Of the total nursing homes, 34 received deficiencies for failure to meet professional standards, 30 percent for infection control, 29 percent for failure to provide comprehensive care plans, 24 percent for giving unnecessary drugs, 22 percent for poor clinical records, 21 percent for pressure sores, and 21 percent for poor housekeeping in 2009.

Staffing

  • The average number of registered nurse (RNs) hours per resident day declined by 25 percent between 1998 and 2003 (from 0.8 to 0.6 hours) and then increased to 0.67 hours in 2009. The number of licensed practical nurses (LPNs/LVNs), with about one year of training, increased by 16 percent and total nurse staffing increased by 4 percent between 2004 and 2009. Studies have shown facilities with more RN staffing have higher quality of care on average. The average staffing levels are far below the level recommended by experts which is 0.75 RN hours per resident day and 4.1 total hours of nurse staffing per resident day.

Resident Characteristics

  • The percent of residents with dementia increased slightly (to 46 of residents in 2009) and the percent with other psychiatric diagnoses increased by 19 percent between 2004 and 2009. 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. The percent of residents who were chair bound increased by 6 percent, while those in bed most of the time declined by 13 percent. Those residents placed in physical restraints declined by 89 percent between 2004 and 2009 but about 49,000 residents (3.5 percent) are still in restraints (which should be avoided). Residents with contractures (immobile joints) remained about the same (28.6 percent), which can be prevented with good restorative nursing care.
  • The percent of residents in nursing homes receiving rehabilitation services increased by 28 percent (from 20 percent in 2004 to 25.7 percent in 2009).
  • Residents receiving psychoactive drugs increased by 3.5 percent between 2004 and 2009, with 65 percent of residents receiving such drugs.
  • Although the present of residents reported with pressure sores declined by 14 percent from 2004 to 2009, about 96,000 residents (6.5 percent) have pressure sores. Most pressure sores can be prevented with adequate nursing care.

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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