Reports spotlight quality, patient-safety concerns at nursing homes
New studies and government audits are calling attention to quality and safety deficiencies in U.S. nursing homes, such as overprescribing of antipsychotic drugs and inadequate infection control.
In a scathing May 9 report, HHS’ inspector general’s office found that about half of atypical antipsychotic drugs prescribed in nursing homes were given to patients with no medical indication for them. The report cited a number of troubling reasons for the overuse, including potential kickbacks from drug companies.
Fourteen percent of the more than 2 million nursing-home residents over the age of 65 received at least one antipsychotic drug during the first six months of 2007. And of those claims, 83% were for off-label uses, or for conditions other than schizophrenia or bipolar disorder, the inspector general said in the report. The bill for erroneous Medicare claims for such drugs totaled $116 million.
Also, 22% of the atypical antipsychotic drugs administered, amounting to $63 million, were deemed unnecessary by CMS standards.
In the report, the inspector general expressed worry that antipsychotics are being prescribed to patients with dementia, in spite of warnings from the Food and Drug Administration that atypical antipsychotics such as Seroquel and Risperdal can increase the risk of death for those patients. Patient advocates also warn that such drugs are often used in nursing homes to calm agitated residents rather than treat mental health issues.
Dr. David Gifford, senior vice president for quality and regulatory affairs for the American Health Care Association, a large industry group representing nursing homes, said the report highlighted an issue—behavioral problems in the elderly and the use of antipsychotic drugs to manage them—that is a source of concern for nursing homes and patients’ family members.
But Gifford argued that off-label use does not mean inappropriate use. “Doctors prescribe drugs for off-label use all the time and I think that is the biggest misunderstanding,” he said.
He did acknowledge that the percentage of nursing-home residents being treated with such drugs “is probably too high.”
“Can we do better?” Gifford said. “Yes, but people are doing a reasonable job. Taking care of the elderly is a team effort, and the solution needs to come from nursing homes, hospitals, physicians and family members.”
Overuse of antipsychotic drugs is not nursing homes’ only concern. Despite the more than 380,000 deaths and up to $2 billion in additional costs attributed to infections among nursing-homes residents each year, a study published in the May issue of the American Journal of Infection Control found that roughly 15% of nursing homes are cited annually by CMS surveyors for deficiencies in infection control.
Inspections, which take place over the course of one week each year, require certain infection-control standards be met to avoid a citation, known as an F-Tag 441.
Researchers found a strong correlation between facilities’ infection-control citations and their registered-nurse staffing levels, said Nicholas Castle, professor in the department of health policy and management at the University of Pittsburgh Graduate School of Public Health, and the study’s lead author.
“RNs may have more training in infection control, so this wasn’t surprising,” Castle said. “Many nursing homes are understaffed with respect to RNs, but more training of other employees might be of use too.”
The goal of the study was to raise the issue without demonizing resource-strapped nursing homes, added Castle, who also has another study about nursing-home hand hygiene currently under review.
“The takeaway is that a lot of the great work in infection control has been done in hospitals, but in our healthcare system, folks bounce back from hospitals to nursing homes again and again,” he said. “Nursing homes are lagging behind hospitals in this area, and we need to do more analysis to see what the barriers are and what can be done to help them control infections in the future.”
The Government Accountability Office also recently targeted nursing-home oversight. In a May 9 report, the GAO urged the CMS to beef up the oversight process for state complaint investigations. Specifically, the report recommended the agency clarify its performance standards and make improvements to its complaints database.
Lyn Bentley, director of regulatory affairs for the American Health Care Association, said the group welcomed the report because it highlighted inconsistencies among states in the way they identify and substantiate data related to complaints.
For patients and family members who are considering nursing-home care in multiple states, the way complaints are inputted and substantiated could have a significant impact on which facility they choose, she said.
“It’s good that this issue has been identified and CMS has said they’ll make an effort to improve the process,” Bentley added.