Latest Data: Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2003 Through 2008

November 16, 2009

Nursing Facilities, Staffing, Residents, and Facility Deficiencies, 2003 Through 2008
Prepared by Charlene Harrington, Helen Carrillo, and Brandee Woleslagle Blank
University of California, San Francisco
Released November 2009

A new report has been completed by the University of California, San Francisco, showing trends in U.S. nursing homes by state for 2003 through 2008. The data are from the federal On-Line Survey and Certification System (OSCAR) reports that are completed at the time of the annual nursing home surveys by state Licensing and Certification programs for the U.S. Centers for Medicare and Medicaid Services.

The highlights of the new report for all US nursing homes show that:

Facility Characteristics

  • In calendar year 2008, 15,531 nursing homes with 1.6 million beds were surveyed by state agencies.
  • Nursing home occupancy rates declined from 85.5 percent in 2003 to 84.2 percent in 2008 showing excess capacity, at a time when the population is aging.
  • Of the 1.4 million residents in nursing homes, 64 percent had their care paid by Medicaid, 22 percent had care paid directly out of pocket or by private payers, and 14 percent of residents were paid by Medicare in 2008. The percent of residents paid for by Medicare has increased by about 20 percent since 2003 with a reduction in the percent paid by Medicaid.
  • The number of for-profit nursing homes increased from 65.5 percent of all homes in 2003 to 67 percent in 2008, while the number of non-profit nursing homes and public homes declined slightly. Nursing home chains were 54 percent of the total homes in 2008, showing a one percent increase over 2003.
  • The number of nursing homes operated by hospitals declined by 23 percent (from 9.9 to 7.6 percent) of total homes between 2003 and 2008.

Quality of Care

  • Across the country, about 144,000 deficiencies were issued to nursing homes for violations of federal regulations in 2008. The average number of deficiencies per facility increased by 7.5 percent (from 8.6 in 2003 to 9.25 in 2008). This suggests that there are many quality problems in the nation’s nursing homes.
  • In 2008, 26 percent of the nation’s nursing facilities received deficiencies for poor quality of care, where facilities caused harm or jeopardy to residents. This was a slight increase over 2003 showing that poor quality of care continues to a major problem in the US.
  • Wide variations in the average number of deficiencies per facility occur across states, ranging from 24 in Delaware to only 3 in North Dakota in 2008. Harm or jeopardy violations were found in 47 percent of Delaware’s facilities compared with 9 percent in Florida. Quality of care either varies widely across states and/or state agency enforcement activities vary widely; the latter is the most likely explanation.
  • In 2008, 44 percent of nursing homes failed to ensure a safe environment for residents. Violations of food sanitation regulations were found in 36 percent of nursing homes and 33 percent of facilities received deficiencies for failure to meet quality standards.
  • Of the total nursing homes, 31 received deficiencies for failure to meet professional standards, 26 percent for failure to provide comprehensive care plans, 21 percent for poor clinical records, 21 percent for pressure sores, 21 percent for giving unnecessary drugs, 21 percent for poor housekeeping, and 20 percent for poor infection control in 2008.

Staffing

  • The average number of registered nurse (RNs) hours per resident day declined by 25 percent between 1998 and 2003 (from 0.8 to 0.6 hours) and then remained about the same between 2003 and 2008. The number of licensed practical nurses (LPNs/LVNs), with about one year of training, increased by 14 percent and total nurse staffing increased by 5 percent between 2003 and 2008. Studies have shown facilities with more RN staffing have higher quality of care on average. The average staffing levels are far below the level recommended by experts which is 0.75 RN hours per resident day and 4.1 total hours of nurse staffing per resident day.

Resident Characteristics

  • The percent of residents with dementia increased slightly (to about 46 of residents in 2008) and the percent with other psychiatric diagnoses increased by 17 percent between 2003 and 2008. This indicates that the number of residents needing psychological and behavioral management is increasing.
  • The percent of residents with limitations in activities of daily living remained fairly stable over the time period. Although most nursing home residents have a number of care needs, the need for physical assistance is not increasing.
  • The percent of residents who were chair bound increased by 6 percent, while those in bed most of the time declined by 15 percent, and those in physical restraints declined by 53 percent between 2003 and 2008. At the same time, those residents with contractures (immobile joints) remained about the same (at 29 percent of residents).
  • The percent of residents in nursing homes receiving rehabilitation services increased by 27 percent (from 19 percent in 2003 to 25 percent in 2008).
  • Although the present of residents reported with pressure sores declined by 7 percent (from 7.4 percent in 2003 to 6.9 percent in 2008), about 96,000 residents have pressure sores. Most pressure sores can be prevented with adequate nursing care.

These trends in nursing homes should be of concern to policy makers, nursing home providers, and consumer advocates because they do not show major improvements over the past seven years. Moreover, they show continued wide variations in staffing, residents, quality of care and enforcement across states.