Many of us rely on ratings and reviews when making small (and big) life decisions, but when it comes to finding the right nursing home for your loved ones, counting on reviews – especially from federal agencies regarding patient quality of care – may not be all that reliable, according to a study published last month in the journal Medical Care.
The study specifically found pressure ulcers (also known as bedsores) were substantially underreported in Nursing Home Compare (NHC), a website created in 1998 by the U.S. Centers for Medicare and Medicaid Services (CMS) to publicly report patient safety and quality of care for every nursing home in the country.
“The objective of this study was to assess the accuracy of NHC’s pressure ulcer measures, which are chief indicators of nursing home patient safety,” the authors wrote.
Furthermore, the researchers discovered that about 30% of bedsores suffered by short-term nursing home residents and around 40% of bedsores in long-term residents were not reported at all to the database.
“These findings are important because they indicate that the publicly reported numbers are inaccurate and cannot be used as a basis for judging the nursing home quality of care,” said Prachi Sanghavi, PhD, senior researcher and an assistant professor of public health sciences at the University of Chicago.
What are pressure ulcers?
Pressure ulcers (bedsores) are injuries to the skin and underlying tissue often caused by prolonged pressure on the skin. These injuries often develop on bony areas of the body, including the heels, ankles, hips, tailbone, or the backs of the arms and legs.
Bedsores may also be caused by immobility and stillness, poor nutrition and hydration, or other medical conditions (such as diabetes) that affect blood flow.
Pressure ulcers are preventable if they’re properly managed but can come with significant morbidity and can even lead to mortality if they aren’t managed.
Based on roughly 400,000 hospital admissions and 60,000 linked admissions to nursing homes, the researchers found the following:
- 75% of primary pressure ulcers were reported and 70% were reported within one stage of the hospital diagnosis
- 52% of secondary pressure ulcers were reported and 46% were reported within one stage of the hospital diagnosis
- Primary ulcers were considered more severe than secondary ulcers and “reporting substantially increased with higher stages.”
- 22% of primary pressure ulcers were not reported by the nursing homes to CMS. That percentage doubled to 45% for secondary pressure ulcers.
The potential underreporting of bedsores raises a significant concern, said Amanda Lathia, MD, assistant professor at the Case Western University School of Medicine:
“If CMS is not able to reliably measure adverse events in facilities, such as falls and wounds, it will make it difficult for CMS to identify and address factors contributing to these events, such as insufficient nursing home staff members,” she said.
Underreporting also questions the accuracy of facility star ratings, she added, which are used by patients and families when selecting nursing facilities for both long-term care and post-acute rehab care.
Limitations to consider
Despite these findings, there are some limitations to the study. The authors admit they may have incorrectly identified some pressure ulcer cases, overestimated reporting rates and did not include pressure ulcers that occurred among residents who were not hospitalized.
“It is possible that some of the wounds that were coded as present prior to admission may have actually developed during the hospital stays,” Lathia said. “Also, the study does not look at the number of patients with wounds in facilities that are not hospitalized.”
Officials from the American Health Care Association and the National Center for Assisted Living shared in a statement they don’t believe this study is an accurate representation of nursing homes in the United States.
“Nursing homes have made dramatic improvements on all quality measures over the past decade and continue to focus on improving the quality of life for our residents,” they wrote. “There is no question that health care in any setting involves continual improvement, and lawmakers and health policy officials must work with us to implement lasting change by providing resources necessary to further enhance care.”
However, the researchers and other experts point out that the study calls for policy action to improve how nursing home data is reported—to inform choices and monitor patient safety.
“For anybody who wants nursing home care to improve in the United States, which it needs to, must know it will require investment, education, training and policy change,” said Dr. Scott Kaiser, MD, geriatrician and director of geriatric cognitive health for the Pacific Neuroscience Institute at Providence Saint John’s Health Center. “This study is not pointing the finger. It’s just saying we need to revisit the policies, including ones on funding and support of nursing homes and nursing home residents.”
How caregivers can take action
If you have a loved one currently living in a nursing home, Kaiser and Lathia said there are a few things you can do, especially if you’re worried about bedsores going underreported:
- Ask questions – It’s reasonable for families to ask about the process for wound identification and management. For example, ask staff members about how they identify or screen for potential pressure ulcers, how they prevent them and standard protocols to reduce the risk.
- Engage in the care planning process – Families should also be involved in the planning process on how staff members will care for their loved ones (e.g., knowing what their loved ones’ schedule will be, what activities they will engage in daily). Family members can also request modifications to be made, if necessary.
- Talk to other families or staff members about their experiences – Talk with other families who have a loved one in that nursing home to get their impressions, feedback, ratings and perspectives. Families can also speak with staff members about how they like working in the facility.
What to do if you notice a bedsore
- Talk to the facility about a plan to care for the wound or bedsore. The facility should identify factors contributing to the development of bedsores and develop a care plan to prevent them from worsening and to prevent additional sores from forming.
- Ask about modifying assistance devices like wheelchairs and beds. The facility may be able to order specialized mattresses to help relieve pressure on the body of bed-bound patients.
- Discuss a repositioning or daily activity/movement schedule with the facility.
- Work with medical providers to address each patient’s medical commodities, mobility, nutrition and medications to help decrease the risk of developing bedsores.