Nursing Home Safety: Current Issues and Barriers to Improvement

Abstract

The past few decades have seen increasing concern about the quality of nursing home (NH) care. As with other health care sectors, NHs have attempted to embrace a culture of safety, but the additional barriers that they face place the NH industry at a distinct disadvantage. In this review, we provide a summary of current models of NH quality and an overview of two important clinical areas for quality improvement: pressure ulcers and falls. Despite heavy regulation of the NH industry, hoped-for improvements in quality have been limited. We argue that systemic barriers, such as staffing shortages, NH organization, and an adversarial regulatory environment, preclude advances in NH quality.

INTRODUCTION

The past 30 years have seen a tremendous increase in concern over the quality of nursing home (NH) care. High-profile cases of neglect and abuse brought these issues to the general public’s attention. In response, the Institute of Medicine (IOM) published the landmark report Improving the Quality of Care in Nursing Homes (1986), which established some of the steps necessary to remediate the problems with NH care and provided the basis for for the Nursing Home Reform Act, which was embedded in the Congressional legislation Omnibus Budget Reconciliation Act of 1987 (commonly called OBRA ‘87) (95). Since then, there have been undeniable improvements in some areas of care, such as a decrease in the use of physical restraints, but a number of issues persist (35). Additionally, our conceptualization of NH quality has become more complex, and this has highlighted newer areas of concern.

In this review, we hope to provide the reader with a basic understanding from which to think about NH safety. In the first section, we introduce contemporary frameworks within which to consider the concept of quality NH care. We then address the central role of safety and discuss the more recent culture of safety movement. For more in-depth examples of NH safety issues, we provide a review of literature on two key clinical areas: pressure ulcer care and falls. In the second part of the review, we focus on the major issues that impede overall quality improvement in NH care, and we pay special attention to the role that regulation has played in shaping the NH environment.

DEFINING NURSING HOME QUALITY

A critical but often overlooked component of understanding quality is defining it. Although many investigators have attempted to identify quality indicators, others have pointed out that there have been far fewer attempts to develop conceptual models of quality (68). This is understandably difficult given that quality is an abstract concept that incorporates judgement and value (53, 77). What most authors do agree on is the multidimensional nature of NH quality, but the identification and measurement of this concept have proven more difficult (52, 67).

Features of medical and clinical care remain the most studied domains of NH quality. This is likely attributable, at least partially, to the fact that these measures are generally less complicated to study. Data are often available from medical records, and national implementation of the Minimum Data Set (MDS) effectively created an unparalleled data source of standardized measures (51, 64). Furthermore, the predominance of Donabedian’s structure-process-outcomes model in the quality literature has established a fairly robust framework for studying the clinical care domains of quality. The notion that the physical and organizational characteristics of a facility (structure) predispose its ability to provide specific aspects of care (process) and ultimately impact resident well-being (outcomes) is amenable to traditional care but perhaps less easily extended to other areas of interest in NH quality (21). In a review of 24 models of NH quality, Sainfort et al. (1995) report that the most frequently studied components of quality were the appropriateness of medical care, structural features of the NH, and aspects of care planning.

However, because NH residents are dependent on the NH for more than their medical care, models of quality must incorporate other domains. Unlike most other medical care sites, NHs are responsible for each resident’s physical surroundings and opportunities for meaningful social interaction. Glass (26) identified four main goals of NH care (a safe and clean environment, maximized functional independence, control and maintenance of health conditions, and promotion of positive feelings and resident dignity) and then used them to guide the development of an early multidimensional model of quality. This model consisted of only four dimensions, each of which were divided into two subdimensions: staff intervention (quality of care, quality of caring), physical environment (general, individual), nutrition and food services (nutritional adequacy, appeal), and community relations (inside out, outside in) (26).

More recent work has sought to develop a more complete model. Incorporating input from long-term care providers and NH residents and their families, Rantz and colleagues developed a model that placed individuals—including residents, families, staff, and other community members—at the center with peripheral dimensions of care, staffing, environment, communication, family involvement, and home (67, 68). Interestingly, providers conceptualized quality NH care as being resident and family focused, whereas residents and family members conceptualized staff as the crucial component to measuring quality.

Measuring Nursing Home Quality

Although these models are needed to further our understanding of quality, many of the domains are often difficult to measure. Derived from their conceptual model, Rantz and colleagues developed a 30-item quality assessment tool that is completed through observation of the NH facility and its residents (65, 66). Although the tool is representative of their domains, the observational aspect excludes the residents’ perspectives. Kane and colleagues (36) developed a comprehensive assessment of 11 quality-of-life domains meant to supplement quality indicators included on the MDS. The assessment tool included items on comfort, security, meaningful activity, relationships, and enjoyment. They designed the instrument to be directly administered to residents and found that they were able to obtain useable data from many, but not all, cognitively impaired residents (36). As well, they have shown that the instrument can be used to obtain facility-level descriptors of quality of life (37). However, testing of the instrument has been done only with highly trained interviewers and has yet to be established as a practical means of NH assessment amenable to broad-scale implementation.

SAFETY AS A QUALITY ISSUE

Regardless of the model chosen to define quality in health care settings, a central component is the appropriateness of medical treatment. The emphasis has been increasingly on patient and resident rights to safety. The IOM’s report “To Err is Human: Building a Safer Health System” established patient safety and the occurrence of adverse events as quality issues (34). It also ushered in a way of thinking that explicitly acknowledged the role of institutional culture in patient safety and outcomes. Termed the culture of safety, this organizational philosophy emphasizes system-level supports for providers and de-emphasizes placing blame and punishment following adverse events (81). This includes open communication about the occurrence of adverse events and clear dialogue on strategies to prevent future incidents. The culture of safety stands in contrast to the more traditional culture of blame, characterized by punitive responses to medical errors and providers’ reluctance to admit where and how medical errors occur.

Whereas the broader health care system is working to embrace the culture of safety (41), NHs lag even further behind (15). Some have suggested that the shift from a culture of blame to a culture of safety may be even more difficult in the NH setting because of already-stretched resources, limited nursing leadership, high staffing turnover, and the current adversarial regulatory environment (39, 81). Yet a number of types of adverse events in NHs are affected by multiple inputs and require a complex organizational approach to address them. In the following subsections, we focus on two specific NH safety issues: falls and pressure ulcers. Although there are numerous other issues in NH safety [such as medication safety (28, 71), the use of physical restraints (25, 50), and infection control (3, 23, 96)], falls and pressure ulcers exemplify the need for comprehensive interventions for improvements. In addition, these indicators have been identified as nursing-sensitive measures with applicability to long-term care (57, 80). Although neither of these outcomes are entirely avoidable, research suggests that they are influenced by the amount and quality of care received. The extent to which their occurrences can be controlled is a reflection of proactive care (e.g., ongoing assessment, monitoring, and preventive care) and reactive care following an initial trigger incident (e.g., assessment and treatment of the immediate cause). For each indicator, we provide an overview of its importance as a measure of NH quality and a brief discussion on limitations of measurement and reporting. We chose to devote a portion of this review to measurement problems because accurately measuring a clinical condition is an integral part of identifying, tracking, and improving NH safety (7). As well, it will help to put into context any current discussions of the state of NH quality.

PRESSURE ULCERS

Importance as a Quality Indicator

Pressure ulcers (PUs) are one of the most frequently used measures of clinical quality. Their prevention requires a team effort from staff to ensure that at-risk individuals are appropriately assessed and monitored. Furthermore, there is clear consensus that exacerbations of early-stage PUs can be avoided and is, therefore, indicative of negligent care (8). Several large-scale efforts to promote quality improvement in health care, both in and out of the NH, have included PU control as a specific indicator (48).

Briefly, PUs are defined as localized injury to skin and/or underlying tissue that results from sustained physical pressure, shear, or friction. If left untreated, PUs can result in further morbidity and mortality. Risk factors for PU developments include impairments in circulation, mobility, and nutritional adequacy including the ability to feed oneself, as well as incontinence and loss of skin sensation (10, 12). Given the prevalence of these risk factors in the NH, it should not be surprising that PUs have a relatively high prevalence in this population. Estimates range from 2.3% to 23% (9, 12, 60) with up to 35% of residents admitted to the NH with an existing PU (82). Cross-sectional comparisons have shown little change in PU prevalence over time (16).

Staffing is an important component of PU prevention. More nurse staffing, in particular staffing levels that meet recommended targets, has been associated with less PU development, whereas staffing reductions over time have been associated with a slight increase in PU development (29, 32). Staffing alone, however, will not prevent PU development; a broader organizational committment is required for sustained improvement (8). Guidelines, such those established by the Agency for Healthcare Research and Quality, have been promulgated to aid nursing staff in the identification and management of emergent PUs. Yet, actual implementation of guidelines still appears sporadic and highly variable between facilities (78). In one study, investigators found that staff in NHs that had undertaken quality-improvement initiatives perceived greater use of guidelines, but this perception was not reflected in PU prevention activities recorded in the medical charts (6).

Resource availability has a clear association with quality. Although it occurs infrequently, NH closure is often seen as a sign of poor quality. One study found that facilities that closed had higher PU rates than other NHs in the periods leading up to closure (14). Higher Medicaid reimbursement rates for NH care have been associated with lower rates of PU development, and this association is strongest for those facilities that are most reliant on Medicaid funding (27). This is not surprising because these NHs have fewer resources, including high-quality staff and leadership (54).

Issues in the Measurement of Pressure Ulcers

Many problems persist in the identification and reporting of PUs in NHs. This is exemplified in the difficulty of summarizing the literature to obtain uniform epidemiologic measures. Studies on the determinants of PUs range on a variety of important factors, including populations, epidemiologic measures, and PU staging criteria (60). Prevalence and incidence studies have been further criticized because they fail to provide adequate information on the PU history and healing process. As well, they are unable to differentiate adequately between superficial and deep wounds, which differ in their cause, evolution, and potential consequences even though they may appear similar at the point of measurement (88). Even more problematic, however, may be the reliance on MDS data to study PUs in NH residents. Some researchers have argued that the MDS items on skin condition are not reflective of current clinical knowledge and do not provide specific enough information to differentiate between types of wounds. Also, because the MDS items are not completed for individual wounds, its usefulness for monitoring PU healing may be limited (58).

Aside from problems in study design, problems exist in PU detection. First, deep-tissue injury may often appear as only superficial injury at the very early stages. These wounds may be mistaken for stage 1 PUs, even though they consist of ischemic injury to the adipose or muscle layers (2). Complicating the issue is the fact that these deep-tissue injuries are seldom included in PU staging criteria. In response, the National Pressure Ulcer Advisory Panel has recently released a revised set of staging criteria with a specific category to capture suspected deep-tissue injury without observable ulceration (59).

This is further complicated by differences in PU detection by resident race. Studies have shown a much lower incidence of stage 1 PUs in Black residents than in White residents but show the converse with respect to stage 2 PUs (5, 40). Black residents are also more likely to have multiple PUs (73). A stage 1 PU is defined as an area of redness, and this symptom may be more difficult to detect on darker skin tones. Under-detection of low-grade PUs prevents adequate skin care and may result in progression to more serious wounds (40).

FALLS AND FRACTURES

Importance as a Quality Indicator

Falls are the most frequently reported adverse event in NHs. Fall rates range from 2.3 to 4 per resident-year, but more than 60% of residents experience at least one fall each year (87, 91). In the average 100-bed NH, this statistic can translate into 100–200 annual fall reports (75, 76). The consequences of a fall can range from minimal to severe. Many falls do not have an impact on functioning and do not require medical attention beyond a postfall assessment. Others may result in a fear of falling, bruising, lacerations, short- and long-term changes in functioning, and death (83). The most common severe outcome is fracture. Nearly 25% of falls result in fracture (74), and falls are the primary cause of more than 80% of fractures in NH residents (84).

Although originally thought to be an inevitable consequence of declining functional ability, falls are now viewed as the result of multiple potentially modifiable risk factors. In one study, as many as 10% of NH falls were directly attributed to environmental hazards such as loose mats or rugs, uneven lighting, and a lack of grab bars around seating (45). Common controllable medical conditions such as orthostatic hypotension (47, 61), diabetes (20, 46), and anemia (19) each contribute to the risk of falls. Sixty percent of NH residents are estimated to be deficient in vitamin D (22). Studies suggest that high levels of vitamin D supplementation (800 IUD) can directly decrease the risk of falls (11) and the risk of osteoporosis, a major risk factor for subsequent fracture (86). Psychotropic medications, particularly antidepressant and antipsychotic medications, appear to increase the risk of falling (17, 24, 43, 84).

Intrinsic resident characteristics may also increase the risk of falling. Likely characteristics includes dementia (91), incontinence (44), and visual impairments (90). Not surprising, mobility is consistently found to be associated with fall risk. Studies have shown that increasing dependence in physical functioning, unsteady gait, foot problems, and wandering each increase the risk of falling (24, 74, 84). A nonlinear relationship has been observed between detailed measures of mobility and fall risk. Residents who had the highest risk of falling were those who could rise independently but not stand unaided, whereas those who had the lowest risk were residents who could do neither or both unaided (44).

In 2001, the American Geriatrics Society, the British Geriatrics Society, and the American Academy of Orthopaedic Surgeons published guidelines on the prevention of falls in older persons (1). The central component of their recommendations is fall-risk assessment with varying intensity based on an individual’s history of falling. Although they do not recommend specific assessment instruments, a number of them can be identified from the literature. To aid clinicians in selecting an instrument, Perell and colleagues (63) reviewed 14 fall-risk assessments. However, many of these tools have been criticized for being too focused on individual risk factors rather than being truly comprehensive assessments (49). Some investigators have argued that many of these instruments were created in isolation without building on prior research (55). In NHs, these instruments may not be useful in differentiating resident risk because the most commonly reported measures—cognition, history of falls, and mobility impairment (63)—are highly prevalent in this population.

Many multicomponent interventions have been tested to reduce fall rates, and they generally show encouraging results. These have included environmental modifications including physical restraint reduction, exercise programs to increase strength and balance, and medication reviews, although there have been no trials on medication reduction strategies (31, 70, 92). The largest trial of a multifaceted intervention is the Fall Management Program (FMP). The FMP was modeled on quality-improvement initiatives to allow for sustained implementation and consisted of components to address organizational factors that influence implementation as well as staff education and incident documentation (89). Evaluations of FMP found improved documentation of care processes related to falls management and a greater reduction in physical restraint use in intervention NHs. They also found that control NHs experienced a slight increase in fall rates following restraint reduction, but intervention NHs experienced no change in fall rates (69).

Issues in Falls Measurement

The biggest issue in fall measurement is ascertainment of the actual fall. We do not know how many falls are not reported to nursing staff by the resident. Furthermore, near misses are infrequently reported, even when witnessed, but we do not know how frequently these occur. Some studies have shown that observed fall rates differ by ascertainment method. In one study, falls were more frequently recorded in the medical chart than in incident reports, whereas both overestimated the occurrence of falls compared with self-report (38). Others have found that falls were underreported in the MDS when compared with charts, but the frequency of this underreporting varied by pertinent resident characteristics (30).

Although NHs are required to complete an incident report following a resident fall, there is no standardized tool for this. Many facilities use a form with open-ended questions that does not gather enough information on the circumstances around the fall. An assessment of a menu-driven incident reporting system found that its use resulted in better documentation of footwear, restraint and bedrail use, and near misses compared with controls. However, that the reporting system was partially computerized created an obstacle to its full implementation by staff (93).

BARRIERS TO IMPROVEMENT

Specific barriers to improvement impede PU and fall prevention. Further development of clinical knowledge, assessment and prevention strategies, and treatment protocols will be necessary to reduce these specific quality concerns. However, systemic problems preclude real advancements in quality improvement and the uptake of a culture of safety. Even broad-scale, multicomponent initiatives, such as the FMP, have been unsuccessful in offsetting these contextual problems (13). Although some of these problems are specific to the NH industry, others compromise improvements in other sectors of the health care system as well (41).

Staffing problems are among the most prominent barriers to broad quality improvement. The general nursing shortage is especially bad for NHs. A combination of low wages, heavy hands-on care, and lack of prestige makes it difficult to attract and retain licensed nursing professionals. At the same time, most direct care is provided by unlicensed staff who have little formal education or training. The top-down organizational structure of many facilities concentrates decision-making power in the hands of owners and administrators and often leaves direct-care staff with little say as to how day-to-day work should be structured (79, 85). The end results for both professional nursing staff and unlicensed care providers are turn-over rates that exceed 50% and a position vacancy rate of nearly 10% at any given point in time (18). In light of the well-documented need for sufficient staffing and strong nursing leadership to implement quality-improvement strategies (80), efforts to address this shortage as well as to support existing staff are essential (56).

Beyond the numbers of nursing staff, there appears to be a serious disconnect between the ideals of quality improvement and front-line staff comprehension and support of initiatives. In one study, investigators reported that NH staff did not have enough specific knowledge to implement a targeted quality-improvement program completely and were reliant on external support (4). Other studies have shown that NH staff perceive quality-improvement initiatives as isolated projects rather than as an ongoing management style (42). Although there has been little research on everyday clinical use of the MDS, it appears that staff have not yet realized its potential for use in care-planning and internal quality-improvement activities. For many NH staff, the resident assessment process associated with the MDS is government-mandated paperwork that is not relevant to regular care activities (62).The limited use of computers and other forms of technology in NHs certainly contributes to this problem. Lack of computer access likely prevents direct-care staff from observing potential applications of MDS and other potentially beneficial information-based reporting programs (85). This was reported as the most significant hurdle to obtaining NH staff acceptance of the menu-driven incident reporting system discussed earlier (93).

However, it may be the adversarial environment within which NHs operate that poses the largest barrier to quality improvement. Despite the enthusiasm for a culture of safety, it is the culture of blame, promulgated by internal policies, the legal system, and regulatory bodies, that continues to permeate the health care industry. Fear of chastisement and the perception of error reporting as a personal attack prevent NH staff from openly discussing resident safety issues (33, 81). The threat of legal action, both civil liability and criminal prosecution, and the potential for negative publicity for the NH similarly discourage honest discussion among stakeholders (39).

THE REGULATORY ENVIRONMENT

Like most health care providers, nursing homes are licensed by the state. Prior to the implementation of Medicare and Medicaid in 1966, states’ licensure programs varied widely. However, Medicaid’s payment for nursing home care opened the door to nationalized regulation that comes with the power of the purse. Within a decade of the introduction of Medicaid payment for nursing home care, most states had incorporated into their licensure statutes the Medicare/Medicaid rules governing the conditions of participation for receiving reimbursement. Indeed, only a few years after the introduction of Medicaid nursing home reimbursement, the Medicare/Medicaid program contracted with states to have their licensing inspection staff conduct facility inspections according to a set of guidelines in the conditions of participation. Although this inspection function has been delegated to the Joint Commission on Health Organizations for hospitals and other types of providers, the Centers for Medicare and Medicaid Services (CMS) have resisted efforts to delegate inspection authority to other organizations in the case of NHs largely because of the well-publicized quality problems in nursing homes.

The history of the NH industry has been characterized by a cyclical pattern in which some form of scandal garners public attention, which generates regulatory crackdown. This has established a regulatory system focused on identifying and punishing “bad” behavior. This regulatory approach is exemplified in the certification process in which facilities undergo unannounced annual inspections and, if cited for deficiencies, may face monetary fines or denial of payment for new residents (95). This style of deterrent regulation pits the regulatory body against the NH industry and complicates the development of productive and responsive relationships between the two. The regulatory process, as it currently exists, does not formally include other important players in long-term care. There is no official role for resident advocacy groups, staff associations, or other professional organizations. Aside from excluding these stakeholders from the survey process, it also places all the regulatory accountability with state governments and the CMS. The CMS also serves as the primary payer of NH services, and their control of the regulatory process creates a dynamic that may not make quality improvement a priority (94). This occurrence is particularly unfortunate because CMS is the principal architect and funder of the Quality Improvement Organizations (QIOs). The main objective of the QIOs is to improve the quality of care provided to Medicare and Medicaid beneficiaries by working with health care providers on quality improvement efforts (4, 72). Under the current regulatory framework, state NH inspectors play the role of cop, whereas QIO staff plays the role of quality consultant. Although both roles are supported by CMS, to date, there has been limited interaction between these two sides.

In this adversarial regulatory context, it is not surprising that it has been so difficult for NHs to embrace a culture of safety. Clearly, the regulatory system as it currently exists cannot address the ongoing quality problems that it was intended to fix. Although there have been some improvements since OBRA’87, given a history of increasingly stringent regulation, more regulation is not the answer to closing the gap between what we want to see and what we do see. Rather, more efficient regulatory strategies that foster interagency relationships and better support for poor-performing facilities are needed for the NH industry, and not just for individual NHs, to make real strides in quality improvement. Resolving the inherent conflict between the regulatory role of cop vs. consultant is probably an important first step in advancing the quality-improvement agenda. Because the CMS fund and direct the activities of both the state-based regulatory agencies and the QIOs, it seems reasonable to assume that some coordination of the differing goals of these two groups is possible.

CONCLUDING REMARKS

Despite substantial efforts since OBRA’87, there have been only modest improvements in the overall quality of care provided to NH residents. It is not simply the case that the clinical demands and risk profiles of today’s residents are greater than ever before. Given the commensurate increases in resources, we should expect better outcomes. As we have illustrated, it is system-wide barriers and not individual issues that pose the greatest impediments to achieving significant improvements. For NH culture to change from one of blame to one of safety, a fundamental shift in NH organization and regulation is required. However, this cannot successfully occur without a greater emphasis on resident quality of life. After all, resident safety is a necessary but not sufficient component of quality NH care.

SUMMARY POINTS.

1. Despite ongoing concern from both the general public and governmental agencies over the past 20 years, there has been relatively little improvement in the overall quality of nursing home care.

2. Nursing home quality is a complex, multidimensional construct that includes clinical care, opportunities for interpersonal relationships, the physical environment, and satisfaction.

3. As in other sectors of the health care industry, there is a growing interest in developing a culture of safety within NHs.

4. Nursing homes face numerous systemic barriers that prevent real advancements in quality. These include management organization, workforce shortages, high rates of staff turnover, and the inability to move away from a punitive system of incident reporting.

5. The current regulatory system for the nursing home industry is developed around identifying and punishing “bad” behavior. This has established a highly adversarial environment that prevents the regulatory system from adequately addressing the ongoing quality problems that it was originally intended to mitigate.

Glossary

Nursing home (NH)

residential health care facility that provides care services to individuals whose needs cannot be met in their own homes

Culture of safety

an organizational approach that prioritizes patient rights to safety and incorporates facility-level protocols to achieve these goals

Pressure ulcer (PU)

localized injury to skin or underlying tissue that could result in morbidity or mortality if left untreated

Fall

unintentional landing on the floor or other lower-level surface

Minimum Data Set (MDS)

a federally mandated assessment instrument that is completed for all residents at least four times per year

FMP

Falls Management Program

Centers for Medicare and Medicaid Services (CMS)

government agencies that oversee long-term care reimbursement, regulation, and the operation of the Quality Improvement Organizations

Quality Improvement Organizations (QIOs)

federally mandated, state organizations whose mission is to improve the implementation of quality-improvement initiatives by health care providers