Misdiagnosis

The ratings given to Bay State nursing homes are not as informative, or as consistent, as they may first appear

it’s one thing to use five-star ratings to rank restaurants and movies, but is it possible to rate nursing homes the same way?

The federal government thinks it is. Just over a year ago, the Centers for Medicare & Medicaid Services (CMS) launched a new five-star rating system, available on its Nursing Home Compare website, that assigns star rankings to the more than 15,000 homes across the nation that accept public insurance. The rankings range from one star, for a home much below average, to five stars for a home much above average.

This system was intended to make it easier for families to research and compare nursing homes. But an analysis of the ratings for the 428 licensed homes in Massachusetts reveals flaws that can make the ratings misleading and confusing, in some cases disguising serious problems.

Within the January 2010 ratings, some homes receive top overall scores despite significant patient-care deficiencies. Because the ratings are based on a complex formula that weighs a number of factors, families who rely on the overall ratings to choose a nursing home may be missing critical information.

Ratings are heavily weighted by nursing home inspections, conducted by state surveyors, that vary considerably in scope and depth from state to state. National data show that Massachusetts homes overall benefit from a kind of grade inflation, driven in part by the relatively few citations of deficiencies given by the state Department of Public Health.

The uneven quality of the rating system led Martha Coakley and the attorney generals of 29 other states to petition CMS last year to suspend and revamp the five-star system. They argued that the system does not allow consumers to compare nursing homes across the country because facilities are graded on a curve within each state.

Some industry officials and consumer advocates say the rating system is well-intentioned but flawed. “This falls pretty short of being able to provide consumers with useful and complete information,” says Elissa Sherman, president of the Massachusetts Aging Services Association, whose members include the owners of not-for-profit nursing homes. “There’s not only inconsistency from state to state, there’s inconsistency within the state, depending on who’s doing the inspections.”

Edward F. Mortimer, technical director of the Survey and Certification Group for CMS, says the system is not intended to compare homes across state lines. He also says the star ratings should be only the starting point in the search for a nursing home, and he urged consumers to dig deeper into the information provided on the website and to visit homes in person.

“This is one tool to help families make decisions,” Mortimer says. “Consumers should look closely at inspection history, staffing levels, and quality measures and use this information as a springboard for a conversation with the administrator of a nursing home.”

Quotas may skew results

National data show that Massachusetts nursing homes are rated considerably higher than homes in most other states. What’s unclear is whether the homes are actually better or their scores are fueled partly by grade inflation.

Of the 428 Massachusetts nursing homes included in the Nursing Home Compare ratings in January, 79, or 18.5 percent, received the highest rating of five stars — compared to 13 percent of nursing homes nationally. Only 62 Massachusetts homes, or 14 percent, received a one-star rating — well below the national average of 20 percent.

Massachusetts homes are rated highly, but it’s unclear whether grade inflation is fueling scores.Part of the reason Massachusetts nursing homes rank so high is that they do well on state inspections and quality-of-care measures. On the federal website, each nursing home receives an overall star rating, but that rating is derived from stars awarded in three sub-areas. The most weight is given to results of the last three years of inspections, which are conducted in person by state surveyors every nine to 15 months.

The rating from inspection results is then adjusted up or down depending on two other categories: staffing levels and quality-of-care measures, both of which are self-reported by the nursing homes. Quality-of-care measures gauge key aspects of residents’ health, including the percentage whose mobility declines, whose need for help with daily activities increases, who are physically restrained, and who lose too much weight.

Some long-term-care advocates complain that the ratings are also subject to a quota system that, they say, skews the results. Under CMS rules, homes that rank in the top 10 percent in health inspections in each state receive five-star ratings in the inspection sub-area, while the bottom 20 percent receive one-star ratings. The quotas can allow homes with serious deficiencies to score high, as long as their inspection records are better than their peers, while homes with minimal problems could be pushed into the below-average tier.

“The quota system is a real problem,” Sherman says. “[Homes] are purposely put on a bell curve, which isn’t always representative of their actual performance.”

Some reports suggest that Massachusetts surveyors may not be as thorough in citing nursing homes for deficiencies as their peers in other states. A 2008 report by the inspector general of the Department of Health and Human Services found that Massachusetts ranked the second lowest nationally in the proportion of nursing homes that are cited for deficiencies — 80.3 percent in 2007. Thirty-five states had citation rates of greater than 90 percent.

The report also found that Massachusetts health inspectors reported fewer deficiencies in the nursing homes they surveyed than did inspectors in most other states — 5.5 per home, on average, compared to nine in Connecticut, eight in Vermont and 13.3 in Delaware. Only 14 states had lower deficiency averages than Massachusetts in 2007.

The relative lag in citations of deficiencies is notable because Massachusetts fares poorly in national comparisons of some quality measures that can indicate problems in care. According to CMS data from the third quarter of 2009, Massachusetts had the 12th highest rate of nursing home residents who were physically restrained, and the 18th highest rate of residents whose mobility declined.

In addition, a November 2009 report by the US Government Accountability Office cited Massachusetts as one of four states in which a high proportion of state health inspectors — more than 40 percent — reported that the process for resolving disputed deficiencies favored the concerns of nursing home operators over residents’ welfare.

Alice Bonner, a nurse practitioner named director of the quality bureau at the Massachusetts health department last October, said that while Massachusetts reports fewer overall deficiencies per home than other states, state inspectors cite serious deficiencies — those that cause actual harm to residents — at almost twice the national rate.

“If you’re being judicious in how we use the resources we have,” she said, noting reductions in survey staff in recent years, “it would make sense to target lower-performing facilities, as opposed to just a broad brush where we look at all facilities.”

She acknowledged that there is “a lot of inconsistency” among surveyors, both within the state and nationally, and that consistency is “something we’ll continue to strive for” in the department. She also said that Massachusetts nursing homes enjoy high ratings nationally because overall, their staffing levels and quality of care scores are strong.

“It’s a very tricky business to get the ratings right,” she said. “What we currently have is a very rough cut on this data and not a very precise matrix.”

Overall scores mask flaws

The uneven quality of ratings from state to state that was cited by the attorney generals is easy to see in a check of national data.

For example, a home in Rhode Island that received five stars for nursing care — the Alpine Nursing Home — provides one hour and 24 minutes of licensed nursing staff care per resident per day, the same as the national average. But a home in Tennessee, called Bethesda Health Care Center, which provides more licensed nursing staff care per resident — one hour and 38 minutes — received only two stars for staffing.

CMS officials said that, generally, ratings on staffing look not only at hours of care, but also take into account the overall needs of a home’s patient population, which can range from minimal to excessive. Still, CMS national data show that, regardless of patient care needs, staffing levels vary widely from state to state; the daily average of direct-care staffing per patient ranges from three hours in Illinois to 5.7 hours in Alaska.

“We strongly support a nationwide criterion-referenced evaluation methodology for establishing proficiency at all levels for nursing homes, as opposed to the normative state-by-state methodology presently utilized by CMS,” Coakley and her peers argued in their petition.

Even within individual states, the weighting of the different factors that go into a star rating means that some nursing homes can score high overall yet still have serious deficiencies. In Massachusetts, dozens of nursing homes that receive four or five stars nevertheless have deficiencies that consumers should be aware of. Some of these deficiencies are outlined on the federal website, but others are not. The only way a consumer can learn about them is to request detailed state inspection records.

A total of 51 Massachusetts nursing homes received “above average” overall ratings as of January, despite “below average” or “much below average” scores in quality-of-care measures, staffing, or health inspections. Some homes that received the above-average overall ratings had health care deficiencies that resulted in serious injuries of residents.

The Maristhill Nursing & Rehabilitation Center in Waltham, which received four stars, was cited for multiple deficiencies in a 2009 inspection, including negligence that caused “actual harm” to residents, according to inspection reports obtained from the state Department of Public Health. The reports indicate that the facility failed to provide adequate supervision for three residents at risk of falling. All three suffered falls resulting in fractures, lacerations, and other injuries. In one of the cases in which the staff was faulted for failing to keep a resident in a supervised area during the day, the resident was found on the floor of her room “in a large puddle of blood,” suffering from a head laceration that required five sutures.

The nursing home was also cited for medication errors, failing to provide diabetic foot care, and failing to ensure that food served to residents was “palatable” and served at the proper temperature, records show.

Maristhill administrators said by phone and in documents that they took steps to correct all of the deficiencies, including taking precautions to prevent injuries among “a number of very frail, ill residents” who were prone to falls.

Roscommon Extended Care Center of Mattapan, which also received four stars overall, was cited in March 2008 for serious deficiencies that caused “immediate jeopardy to resident health or safety.” An inspection report shows that the home failed to properly monitor a 76-year-old resident who was suffering from dementia and who had a history of “elopement,” or wandering away from the facility. The resident was found in the early morning of February 11, 2008, at a train station three miles away from the nursing home, dressed only in a “johnny” and jeans, in sub-freezing weather. He was taken to a hospital where he was treated for hypothermia.

According to the report, a nurse on duty acknowledged that she knew the man was not wearing his “wanderguard” bracelet; the report also indicated that the home was understaffed. The incident led federal officials to fine the home $5,850 and to deny federal payments for new admissions for two weeks. The home filed a corrective plan and has been cited for several less serious deficiencies since then.

Even some homes that were awarded five stars still got sub-par ratings on quality or staffing levels.The Golden Living Center in West Newton also received four stars overall in January, despite a below-average rating on health inspections stemming from numerous deficiencies in recent surveys. Among the citations in a December 2008 inspection was the failure of the facility to investigate a resident’s claim of sexual harassment by a roommate and failure to follow care plans for some residents needing special care to prevent illness and injuries, records show. The home filed a plan to correct the deficiencies.

Emerson Rehabilitation & Transitional Care Unit in West Concord received four stars overall, but it received only one star (“much below average”) for quality measures. Nearly half of all short-stay residents suffered from pressure ulcers or bedsores — more than triple the national and state average of 14 percent. Similarly, TCU–Brockton Hospital received four stars overall but got only one star on quality measures, in part because 36 percent of short-stay residents suffered from bedsores — more than double the state and national average.

Even some homes that received the top rating of five stars overall had below-average ratings on quality measures or staffing. The Jewish Rehabilitation Center for the Aged of the North Shore in Swampscott received only two stars on quality measures, including a higher-than-average proportion of long-stay residents whose need for help with activities of daily living increased.

The Tremont Rehabilitation & Skilled Care Center in Wareham also secured a five-star rating, despite the fact that registered nursing hours per resident per day fell far below the state average. The home provided 25 minutes of registered nursing care per resident per day, compared with the national average of 36 minutes and the average in Massachusetts of 42 minutes, according to a 2009 report.

One trend highlighted by the federal star ratings is the overall superiority of nonprofit nursing homes compared with for-profit homes, both in Massachusetts and nationally.

Among for-profit homes in the state, only 45 percent received four or five stars overall, compared to 61 percent of nonprofits. Nonprofits also did better on health inspections, with 45 percent receiving four or five stars, compared with 32 percent of for-profit homes.

But the difference is most striking on staffing levels. Only 55 percent of for-profits received four or five stars for staffing, compared with 87 percent of nonprofits. Only 7 percent of for-profit homes received the top rating of five stars on this measure, compared to 27 percent of nonprofit homes.

The state ratings mirror national results. A statistical review of nursing home research studies, published last year in the British Medical Journal, found that nonprofit homes, most based in the US, had more or higher-quality staffing, less prevalence of pressure ulcers or bedsores, and less frequent use of physical restraints. Experts say non-profits are able to devote more resources to patient care since they have no profit margins to meet.

According to federal data, more than 70 percent of Massachusetts nursing homes are for-profit — the 19th highest proportion of for-profit homes among the 50 states. The percentage of for-profit homes has climbed slightly in recent years; in 2003, 68 percent of Massachusetts homes were for-profit.

Digging below the stars

Elder-care experts and industry officials say the federal ratings are helpful, but only as long as consumers dig below the “stars” for detailed information on deficiencies, staffing, and quality.

“The rating system is useful, but it shouldn’t be the end of the story,” says Eric Carlson, a specialist in long-term-care issues at the National Senior Citizens Law Center and a leading consumer expert on nursing homes.

Janet Wells, director of public policy for an advocacy group called the National Consumer Voice for Quality Long-Term Care, agrees that while the rating system is a useful tool for consumers, it allows for “some huge outliers,” including some four- and five-star homes that have been cited for negligence that resulted in deaths or injuries of patients.

“People need to look at the star ratings as a way to ask questions, not as getting all the answers,” Wells says. She also noted that staffing information is questionable because it is “self-reported” by homes, despite advocates’ longstanding efforts to push CMS to use payroll records to determine accurate staffing levels.

“People need to look at the star ratings as a way to ask questions, not as getting all the answers.”W. Scott Plumb, senior vice president of the Massachusetts Senior Care Association, which represents nursing homes, says the rating system is a mixed bag.

“On the one hand, we [Massachusetts] look really good compared to other states, so we like it,” he says. “On the other hand, I don’t think it’s particularly useful, partly because it’s driven so much by the survey process, which is not a good proxy for the actual quality of patient care. Staffing and quality measures are in some ways more objective measures.”

Plumb says he is especially concerned that hospitals, lenders, and even insurance companies are starting to use the ratings to make decisions about nursing home performance. “We’re starting to see some groups attach too much significance to this thing, with all its warts,” Plumb says. “Our concern is that it’s starting to be used inappropriately.”

Meet the Author
The Massachusetts Department of Public Health has its own website with information on nursing homes, including a tool that shows deficiencies and enforcement actions from the last three standard surveys and that evaluates homes in five areas: administration, nursing, resident rights, kitchen/food services, and environment. The website (www.mass.gov/dph) also includes nursing home satisfaction surveys, conducted in 2005 and 2007.

“The very best way to assess a nursing facility is to visit it,” advises Ann Harstein, the state’s secretary of elder affairs. “Be sure the facility’s services meet the patient’s needs. Visit the patient floors. Are they clean? Do the patients seem engaged? Is the staff accessible and friendly? Talk to patient family members and talk to the local ombudsman, whose name should be prominently displayed at the facility.”