The Quality-Cost Connection

Are nursing home residents safe?

By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR

Health care quality managers often oversee patient safety activities in a variety of health care settings. One area of considerable media attention right now is the quality of nursing home care. Because many integrated health care delivery systems include some level of long-term care, quality managers need to understand high-priority resident safety concerns so that effective monitoring and improvement initiatives can be developed.

Ensuring the safety of nursing home residents can be challenging, given that Alzheimer’s disease and its related dementias account for two-thirds of all nursing home admissions. The turnover rate among caregivers in nursing homes is very high as well. Resident falls are the most frequent causes of liability claims against long-term care providers with treatment issues comprising the next highest category. Treatment issues frequently involve pressure ulcers (e.g., delayed treatment) and continence-related and nutrition-related problems.

Patient monitoring issues also are a problem area. These stem from wandering, elopement, and restraint-related issues (e.g., failure to supervise, failure to properly monitor restrained residents). Hazardous wandering and elopements are among the most costly patient hazards in long-term care environments. Cognitively impaired residents can wander into stairwells or other unsafe areas, leave the facility in search of home or familiar surroundings, or wander into others’ rooms. Elopers are differentiated from wanderers by their purposeful, overt, and oftentimes repeated attempts to leave the building and the premises. In addition to the potential for serious resident injury, elopement incidents may attract significant media attention and can severely damage a facility’s reputation.

Another concern for nursing home residents is the risk of abuse by other residents or by staff. Nationwide, there have been several criminal convictions against nursing home staff involving the use of physical force or restraint, forcible administration of medication, abusive searches, and failure to provide adequate food for residents.

The Centers for Medicare & Medicaid Services (CMS) nursing home requirements for quality of care are stringent. The regulations require that each resident receives, and the facility provides, care and services necessary to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with his or her comprehensive assessment and plan of care.

Falling under the government’s definition of quality of care are such areas as activities of daily living, pressure sores, urinary incontinence, range of motion, nasogastric tubes, medication errors, and accident prevention. Nursing home facilities must ensure that clinically avoidable pressure sores do not develop and existing pressure ulcers are appropriately treated. Facilities must be constantly vigilant to minimize accident hazards: any physical feature that can endanger a resident’s safety.

Accident hazards include, but are not limited to, physical restraints, poorly maintained equipment, bathing facilities lacking nonslip surfaces, electrical hazards, accessible wet floors, insecurely fixed handrails, and water temperatures in sinks and bathtubs that can scald or harm residents.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) long-term care accreditation standards go beyond CMS regulations in many respects, including risk and safety management requirements. For example, in its "environment of care" chapter, JCAHO requires a nursing home to appoint an individual to direct the overall safety management program.

Use the results of the resident comprehensive initial assessments and periodic reassessments to identify residents at high-risk for incidents or accidental harm. The CMS-mandated Resident-Assessment Instrument (RAI), which comprises the Minimum Data Set (MDS) and Resident Assess-ment Protocols (RAPs), provide resident-specific information that can be used for preliminary screening to identify potential problems.

Residents with urinary incontinence and indwelling catheters, behavioral symptoms, a history of falls, feeding tubes, and/or physical restraints are at higher risk for iatrogenic events. Appropriate preventive measures should be put in place.

Medication errors are another patient safety concern in long-term care. Errors can occur at any time in the process, from ordering to administration. The nursing facility should have a plan for preventing medication errors through detection and evaluation. It is important that all medication errors are reported to identify and correct problem-prone activities. Emphasize improving processes and systems to encourage error reporting; a punitive approach reduces the likelihood errors will be reported. In many long-term care facilities, the pharmacist assumes responsibility for reviewing medication errors and categorizing them according to type, e.g., prescribing, dispensing, administration, monitoring. The information gathered from error reporting should be used to educate caregivers and redesign problematic processes.

Treatment-related problems can be addressed through protocols or practice guidelines. The descriptions of how various conditions should be managed are just as useful in long-term care as they are in other health care facilities. The American Medical Directors Association (AMDA) has developed clinical practice guidelines for depression, pressure ulcers, heart failure, and urinary incontinence that are to be used by members of the interdisciplinary team ( Each guideline includes an algorithm to be used in conjunction with the written text. AMDA also recommends that the guidelines be used in conjunction with the MDS and appropriate RAPs.

Reducing resident abuse situations starts with a better understanding of the underlying causes. The National Eldercare Institute on Elder Abuse and the State Long-Term Care Ombudsman Services have identified three primary factors that may contribute to abuse situations:

  • Those with cognitive impairment often are resistant to care and difficult to help, especially when staff are poorly trained.
  • Training for nursing assistants, particularly training in how to cope with confrontational situations, often is inadequate. High staff turnover rates may result in haphazard training.
  • Many residents have no regular visits from family and friends who can monitor their care.

Factors such as high turnover rates and inadequate staffing levels can make it hard for staff to handle demanding situations. The challenges of caring for large numbers of chronic care patients can result in inappropriate use of physical or chemical restraints and highly stressful working conditions that can lead to abusive behavior.

Staff must receive training on how to manage resident aggression and interpersonal conflict among residents. Initial orientation and continuing education and training in these issues are essential. Medicare and Medicaid participation requirements prohibit nursing facilities from employing anyone as a nurse aid on a full-time basis for more than four months unless he or she completes a state-approved training or competency evaluations program (or meets certain exceptions). Temporary, per diem, or other nonpermanent employees must have completed an approved program.

It is important that professional staff constantly monitor residents for signs of abuse. Federal law requires that a physician actively supervise the resident’s care. The American Medical Association recommends that attending physicians and nursing facility medical directors help to identify and prevent resident mistreatment by these methods:

• Participating in the development and monitoring of the resident’s care plan.

• Assessing the need for physical restraints and antipsychotic drugs to ensure these are not being used primarily for behavior modification or control.

• Monitoring reports to identify potential problems, e.g., irregularities in a resident’s drug regimen, resident/family complaints, and findings of substandard care by the state’s inspection agency.

Quality managers must ensure that patients continue to receive safe health services after discharge from the hospital. It may be impossible to eliminate every chance for an incident, especially in those environments where patients are not monitored constantly. Nonetheless, much can be done to reduce error occurrence. Senior managers and boards in integrated health systems need to be proactive in the development of safety enhancement initiatives for all sites of care. In addition, improving communication and collaboration with patients and families can provide additional safeguards in the provision of care. Harm from health care services, as well as from the environment in which services are carried out, must be avoided and risk minimized in all care delivery settings.