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Uncovering Quality Concerns In Nursing Homes

Health Letter, October 2013

It was January 2011, and Maria Watterson* was concerned about her mother Myra, who was staying in the Trussville, Ala., Golden Living Center, a long-term skilled nursing facility. She had just learned that Myra had experienced dramatic weight loss in August, falling from almost 140 pounds to less than 120 pounds over the course of a few weeks. The nursing home staff had never mentioned this to Maria; she learned the news from a government inspector during a visit to the home five months later. She also learned that her mother, who has difficulty moving on her own, had suffered a bedsore that had healed by October and was now dealing with a second one. Maria knew that her mother had to be repositioned every two hours to allow the sore to heal, but no one came to turn her mother during Maria’s 3½ hour visit with Myra. Maria finally went out and found a nursing home employee to intervene and reposition Myra properly.

In another patient’s room, the inspector noticed another problem: A nurse was improperly cleaning a resident who had experienced an accidental bowel movement, putting the resident at risk for urinary tract infections.

Just miles down the road, at the Hueytown, Ala., Golden Living Center, conditions were very different. Inspectors visited the facility in February that year and found no unhappy family members, improperly treated bedsores or hygiene concerns. The only issues noted were fish filets served at lunch that were smaller than planned and two bottles of insulin that were used a few days past their expiration dates.

The Hueytown and Trussville Golden Living Centers are both run by the same national chain, and they are both Medicare/Medicaid-certified, employ licensed nurses and offer multiple types of skilled care. Yet weight loss is a common problem at the Trussville location, where 14.5 percent of long-stay residents (nearly twice the national average of 7.5 percent) lose too much weight, according to government inspection reports. By contrast, weight loss at the Hueytown facility is lower than the national average. Hueytown also has about half the number of patients with pressure ulcers as Trussville and about one-third as many patients with urinary tract infections. Even more striking, though the Hueytown facility is ranked highly by federal inspectors on quality measures, the Trussville facility has been identified for special focus by the Medicare program for its history of persistent poor quality of care and could have its Medicare provider status revoked if conditions do not improve.

Until just a few years ago, families like the Wattersons had no way of accessing any of this information, which was collected by government inspectors but not made easily accessible to patients and their families. Over the past five years, the federal government has been making public more information describing the quality of nursing home facilities across the country.

You can use new government tools to examine nursing home quality and uncover information about observations at nursing homes in your area. You also can learn how to protect yourself and your family from poor nursing home practices by understanding your legal rights and finding out how to seek government assistance when these rights are violated.

Comparing nursing home quality

When they chose the Trussville Golden Living Center, Myra and Maria Watterson probably did not know that in December 2008, the Centers for Medicare and Medicaid Services (CMS) had begun publishing quality ratings for nursing homes using a simple five-star rating system (see box below.) The rating system relies on information collected by state and federal agencies during inspections, as well as quality measures and staffing levels reported to the government by the nursing homes themselves.

CMS also now provides online access to detailed health inspection reports describing specific violations observed by government inspectors during their visits to facilities. Inspectors typically visit a home about once a year to ensure compliance with the regulations put in place to protect patients. Inspectors make observations about residents’ care, interview residents and families, ask how the staff talks to and treats the residents, look at records, and examine the condition of resident rooms and common areas. Observations made during the visit are written up in the reports that CMS makes available online. (Officials remove private information that could be used to identify residents and staff before posting the reports.)

National Rating System

The Centers for Medicare and Medicaid Services (CMS) publishes nursing home quality rating information and lets you compare up to three nursing homes side by side. The rating system is available at www.medicare.gov/nursinghomecompare.

The rating system is based on the relative quality of nursing homes within the same state: The top 10 percent of nursing homes receive a five-star rating, regardless of how they compare in quality with other states. So if you are trying to decide whether you would rather be near your son in Texas or your sister in Connecticut, the CMS rating system will not be able to answer which of these nursing homes has better performance on quality measures.

Don’t have access to the Internet? You can ask for help at your local library or senior center or call the Medicare 24-hour help hotline at 1-800-MEDICARE (1-800-633-4227). You can use the hotline to help look up star ratings for nursing homes in your area, access inspection reports and identify other useful resources. Ask the representative to mail you their booklet entitled “Your Guide to Choosing a Nursing Home” for more information on how to research nursing homes in your area.

Recognizing problems

Learning about a home’s quality rating is just one way to identify problems at nursing homes. Another excellent way to find a quality nursing home is to visit the facility yourself. Talk to staff and residents about their daily experiences and speak with other families and visitors. Be observant: Do the staff respect residents by, for example, knocking on doors before entering resident rooms, referring to residents by name, and talking to them before touching them or helping them with something? Are residents clean, well groomed and appropriately dressed for the season or time of day? Do you notice any unpleasant smells?

Another thing to look for is the extent to which a nursing home relies on chemical restraints (such as antipsychotic drugs) or physical restraints (such as bedside rails) to control residents’ behavior. Overuse of restraints can endanger residents (see box below), and nursing homes are legally prohibited from relying on such restraints for the convenience of the staff or to discipline residents for bad behavior. (Drugs or bedside rails can justifiably be used to address a medical condition, such as schizophrenia, or to mitigate the risk of falling.) When you visit the nursing home, ask about the circumstances in which physical and chemical restraints are used in the facility and what steps the home has taken to reduce their use.

Nursing homes often have a resident council or family council, allowing residents and family members to meet to address concerns and improve the quality of care and life for residents. Find out if the nursing home has a council and ask if you can attend the next meeting. This is a great way to find out what concerns are important to residents and whether their needs are being appropriately addressed.

Before you make a final choice to enter a nursing home, it’s a good idea to visit at least twice, on a different day of the week and time than your initial visit.

Chemical, Physical Restraints Overused in Nursing Homes

Many nursing homes rely on physical restraints (such as bedside rails) and chemical restraints (such as antipsychotic drugs) to control residents who become agitated or cause problems. Bedside rails used to prevent people from getting out of bed pose unnecessary risk, because elderly or disabled people may fall while attempting to climb over the rails or may slip between the bedside rail and the bed and become trapped, leading to strangulation and death. The Consumer Product Safety Commission reported in 2012 that portable bedside rails have been associated with at least 155 fatalities, mostly from strangulation incidents in which an elderly victim became stuck, wedged or trapped between the mattress and the rail.

Chemical restraints, including antipsychotic drugs, also put patients at risk. The Food and Drug Administration has placed a black box warning on atypical antipsychotic drugs stating that elderly patients with dementia-related psychosis were at more than 50 percent increased risk of death compared to those who received a placebo in randomized trials. There also is some evidence that conventional antipsychotics carry increased risk of death, but randomized trials have not been conducted on these drugs, which are older and therefore more likely to be off-patent.

The use of chemical and physical restraints can be reduced through better personal care by nursing home staff. A study published on the British Medical Journal’s website on March 23, 2006, showed that antipsychotic drug use in nursing homes could be decreased by close to 20 percent if staff were trained on alternatives to drugs for managing agitated behavior in dementia patients. Other studies have indicated that institutions can prevent serious injuries and reduce the use of bedside rails as restraints by implementing programs to address the risk of falls in other ways.

Knowing your rights

Under federal law, nursing home residents staying in Medicare- or Medicaid-certified facilities have a right to care that meets certain quality standards. (See box below.)

Myra Watterson’s right to have her family notified of major medical changes was violated when the nursing home failed to tell her daughter about Myra’s bedsores and weight loss. Her right to be free of neglect was violated when the nursing home staff failed to turn her at proper intervals to allow her bedsore to heal and prevent new sores.

Avoid becoming a victim of similar quality-of-care problems. Learn your rights and know how to seek help when your nursing home fails to respect them.

The first way to address such a problem is to go to the head of the nursing home. All Medicare/Medicaid-certified nursing homes must have a grievance procedure for complaints. If your issue cannot be resolved informally, ask about filing a formal grievance through this process. You also can go to the resident council or family council to get extra assistance.

If your concerns are not resolved promptly, you can contact your local long-term care ombudsman or State Survey Agency. State Survey Agencies are organizations that oversee health care facilities participating in Medicare or Medicaid programs. These organizations inspect health care facilities and investigate complaints to ensure that health and safety standards are met. They can help with questions or complaints about the quality of care in nursing homes. Find out how to contact your local State Survey Agency by calling 1-800-MEDICARE (1-800-633-4227).

Assessing quality at nursing homes can be a daunting task, but by doing your research, paying attention and using the available resources, you can avoid being caught in a nursing home that puts health and safety at risk.

Rights for Nursing Home Residents

Nursing home residents have many rights under federal law, including the right to:

  • Be treated with respect: This includes making your own schedule, including when you get up and go to bed, and when you eat your meals.
  • Participate in activities: You have the right to participate in activities that are designed to meet your needs and the needs of other residents.
  • Be free from discrimination: A nursing home cannot discriminate based on race, color, national origin, age, disability, or religion.
  • Be free from abuse and neglect: A nursing home cannot mistreat you (abuse) or fail to meet your needs (neglect).
  • Be free from restraints: Nursing homes can’t use any physical restraints (like side rails) or chemical restraints (like drugs) to discipline you for the staff’s own convenience.
  • Make complaints: You have the right to complain without fear of punishment, and the nursing home must address the issue promptly.
  • Participate in medical decisions: You have the right to be informed and participate in decisions about choice of doctor, medications, and other decisions affecting your care.
  • Have your representative notified: The nursing home must notify your doctor and legal representative or family member if you are involved in an accident or your medical condition changes significantly, or if you are transferred or discharged from the nursing home.
  • Manage your money: You have the right to manage your own money or choose someone you trust to do this. If you choose the nursing home to manage your money, they must allow you access to your bank accounts, cash and financial records. The nursing home must manage your money responsibly.
  • Get proper privacy, property, and living arrangements: You have the right to keep and use personal belongings as long as it doesn’t interfere with the rights, health, or safety of others, and the nursing home should protect your property from theft. You also have the right to private visits, private phone calls, and private mail and e-mail. The nursing home should allow you to share a room with your spouse if you request it.
  • Have your family and friends involved: Family and friends are allowed to contact the nursing home and help make sure you get good quality care. They can visit and get to know the staff and nursing home’s rules. They can help with your medical care, with your permission.

Adapted from information available at:


* Fictional patient and family member names have been created for a case anonymized to protect patient privacy.