A Good Home?
Little agreement in debate about nursing home quality

By Anne Federwisch, OTR
Photo: Corbis
September 6, 1999

With more than 1.5 million residents in 17,000 nursing homes nationwide, you’d expect problems to crop up now and then. But a recent study found that more than a quarter of the facilities had deficiencies that caused actual harm to patients or placed them at risk of death or injury. The number shocked nursing home operators and reformers alike—though for different reasons.

Both sides agree there are problems in the nursing home industry, and they both propose solutions. But while one side thinks the issues boil down to inadequate staffing, the other thinks appropriate funding should be at the center of the debate.

One study, two reactions

Nursing home operators were shocked by the recent findings because the percentage of deficient facilities seems far higher than it should be. The study, conducted in March by the General Accounting Office (GAO), categorized isolated, minor incidents as severe violations, according to Tom Burke, spokesperson for the American Health Care Association in Washington, D.C., which represents 12,000 long-term care facilities. “The fact of the matter is, based on current federal regulations, only about one-half of 1 percent of nursing homes nationwide are cited and penalized for a pattern of widespread problems that cause actual harm to residents,” Burke said.

Advocates for nursing home residents, on the other hand, were shocked that there hasn’t been more of a public outcry and call for reform because of the findings, said Dwana Pinchock, the communications and public affairs editor for the Washington, D.C.-based National Citizens’ Coalition for Nursing Home Reform. Pinchock thinks the GAO numbers accurately portray the state of nursing homes. While acknowledging that some nursing homes provide quality care, she cites further statistics in the report showing that “the percentage of nursing homes that also have potential for harm brings that figure up to 70 percent.”

Hire more staff

Nursing home reformers are generally pushing for higher staffing ratios. “Many of the problems that we find, especially in deficiencies [problems with malnutrition, dehydration, pressure sores], can be related directly to inadequate or poorly trained staff,” Pinchock said. “Even if you have the best people in the world, if you don’t have enough staff” care will suffer, she said.

The National Citizens’ Coalition for Nursing Home Reform advocates increasing staffing ratios to 4.13 hours of direct nursing care per resident day. California law mandates 2.8 hours per resident day. But the law allows facilities to double hours worked by RNs and LVNs when figuring out the ratio.

Pending legislation (Assembly bill 1160) would eliminate that part of the law and require a minimum of 3.0 hours of direct care staffing per resident day starting Jan. 1, 2000. The ratio would increase to 3.6 hours by Jan. 1, 2003. At press time, the Senate Appropriations Committee was still reviewing the bill.

The legislation is a step in the right direction, said Prescott Cole, a staff attorney for California Advocates for Nursing Home Reform. But Cole thinks that strong lobbying by the nursing home industry is likely to water down the bill to make reform imperceptible by the time it passes. The bill has already been revised to make the initial minimum requirement 3.0 hours instead of 3.2 hours.

Staffing isn’t everything

But nursing homes contend that staffing ratios miss the point. “We’d prefer that the system really focus on resident outcomes rather than on these intermediate measures like staffing ratios,” said Robert Greenwood, associate director of public affairs for the American Association of Homes and Services for the Aging, a Washington, D.C., trade organization for nonprofit long-term-care facilities.

Determining adequate staffing levels involves too many variables—such as patient acuity, staff motivation, and training—to distill down to a single target number, Greenwood said. “You could have all kinds of staff present, but if they’re not doing a good job, the outcomes still are not going to be good,” he said.

Where the money goes

Advocates for residents argue that inadequate staffing isn’t the only issue for nursing homes. Spending practices are also in need of change, said Charlene Harrington, PhD, RN, FAAN, a professor in the School of Nursing at the University of California, San Francisco. She said that, on average, nurses in long-term care facilities earn 15 percent less than those in hospital settings. And administrative costs and profits absorb much of the money paid to nursing homes. “Twenty-seven percent goes to administrative costs. Ten percent goes out in other costs and profits. Only 36 percent of the total dollars go to direct patient care,” she said.

Those who run nursing homes say reimbursement is a factor in the level of quality that can be delivered, and current funding levels don’t cover expenses. “Upwards of 80 percent of the population of nursing homes are generally underpaid for by the government service that funds their stay in the nursing home,” Burke said.

A complex problem

In addition to staffing, spending priorities, and reimbursement, “there are more pieces to the puzzle,” said Cole. Better enforcement of existing laws and more community involvement could also go a long way toward improving care.

No matter what the eventual measures for reform, the bottom line has to focus on quality of care, said Pinchock. “We know there is a high cost for poor care,” she said. Poor care, like that caused by inadequate staffing levels, leads to costly complications, Pinchock said. “We’re paying for pneumonia. We’re paying for pressure sores. We’re paying for dehydration. We’re paying for malnutrition,” she said. “At some point people need to realize: Poor care costs more than good care.”