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Saint Louis University Journal of Health Law & Policy

Document Type

Article

Abstract

Quality and compliant care delivery in nursing homes remains elusive. Four main interests are currently misaligned, thereby putting nursing home residents at risk of harm. Without a clearly defined commitment to quality and compliant care and alignment of these interests, nursing home residents will remain vulnerable to severe harm.

The first key interest concerns nursing home ownership and management. Currently, over seventy percent of nursing homes are owned by for-profit entities. Previous ownership models, including non-profit, religious-based, and county-owned facilities, have largely closed or transitioned to for-profit entities. The shift in ownership significantly impacts quality and compliant care delivery. Unfortunately, the consolidation of ownership has not led to improvements in care quality.

The next interest relates to the regulatory system governing nursing homes. This paper will briefly review the history of regulation and enforcement activity (or lack thereof), its effectiveness in terms of focus and uniformity, and its impact on quality and compliant care delivery and resident protection. While increased regulation is a common response to complaints about quality, improvements in care delivery are rarely driven solely by regulation. The inspection process is highly subjective and often overlooks major health and safety issues, significantly affecting residents’ quality of care and life.

The third main interest is the nursing home’s operations, particularly in terms of staffing. This includes the numbers of nursing employees, their education, competencies, recruitment, and turnover. Multiple studies have demonstrated the relationship between quality of care and the sufficiency of nursing staff. A lack of a sufficient number of competent staff in nursing homes has been shown to increase the risk of harm, including falls, pressure injuries, elopements, medication errors, and other serious adverse outcomes.

The fourth key interest concerns nursing home residents and their families. As individuals transition from a home or hospital setting, they and their families often have reasonable expectations regarding care delivery but lack the knowledge or power to select a quality facility. Hospital discharge planners are often unfamiliar with the recommended nursing home, placing uninformed consumers at risk. The incentive to discharge hospitalized patients “sicker and quicker” forces families to accept a transfer to the first available bed. Although it would be highly beneficial for consumers to be knowledgeable regarding the continuum of older adult services (adult day care, Home and Community-Based Services through the Area Agency on Aging, home health care, and hospice), many are unaware of these alternatives to skilled nursing facility (SNF) placement. Planning for the future, including having knowledge of area SNFs, is often neglected until a healthcare crisis arises, requiring hospitalization and post-acute admission. Additionally, the Medicare.gov website, designed to improve consumer behavior through the “Five Star” rating process, remains underutilized by older adults and their families.

This paper proposes changes to the regulatory system, emphasizing important systemic issues that identify care failures. It will suggest enhanced protocols for consumer education and discuss how effective ethics and compliance programs can improve staff performance, increase resident safety, and enhance quality care delivery. The paper will use case examples focusing on pressure injuries as a mechanism to identify and remediate care delivery failures from both an internal and external quality assurance and performance improvement perspective.

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