About Nursing Homes Quality

Nursing home quality measures provide an indication of how well a nursing home provides care for its residents. The measures come from assessments that nursing homes routinely make of all residents at specified intervals during their stay. The intervals typically include at admission, quarterly, annually, and upon significant change in a resident's status.

The information collected pertains to the residents' physical conditions and abilities, as well as preferences and life care wishes. Each measure reflects a resident's condition for a certain time period just prior to assessment -- either 7, 14, or 30 days, depending on the measure. For example, residents are assessed for pain over the past 7 days; bowel/bladder control looks back 14 days; and the depression/anxiety assessment looks back 30 days. Therefore, the quality measures may not represent the resident's clinical condition during the entire time period between assessments.

There are currently 19 indicators in all:

Percent of High-Risk Residents Who Have Pressure Sores
Percent of Low-Risk Residents Who Have Pressure Sores
Percent of Short-Stay Residents with Pressure Sores
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder
Percent of Residents with a Urinary Tract Infection
Percent of Residents Who Were Physically Restrained
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair
Percent of Residents Whose Ability to Move About In and Around Their Room Got Worse
Percent of Residents Whose Need for Help with Daily Activities Has Increased
Percent of Residents Who Lose Too Much Weight
Percent of Residents Who Are More Depressed or Anxious
Percent of Short-Stay Residents with Delirium
Percent of Residents Who Have Moderate to Severe Pain
Percent of Short-Stay Residents Who Had Moderate to Severe Pain
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination

Why Are Measures Sometimes Missing?

Not all nursing homes show scores for all 19 measures. A measure may be omitted if the number of relevant residents is too small to provide a meaningful indicator, if the measure is not applicable to the nursing home, or if the nursing home is not required to report a measure. For example, a nursing home that admits only short-stay residents will not show any of the measures for long-term residents. Meaningful indicators require that there be at least 20 residents during the reporting interval for short-stay measures, and 30 for the long-term measures. Additionally, some nursing homes do not receive Medicare or Medicaid payments, and are therefore not required to submit the data that is used to measure quality.

Are Lower Scores Always Better?

There are two types of measures: those where a lower percentage score is generally better, and those where a higher percentage is better. In the latter category are the immunization measures, which indicate the percentage of residents receiving influenza and pneumococcal vaccinations; more vaccinations is preferable. The former category includes the measurements of pain, discomfort, anxiety, and so forth, where lower scores are usually held to be preferable, with certain caveats.

For example, a nursing home that is better at ascertaining levels of pain among residents may show a higher percentage than a nursing home that does not measure pain as accurately. Similarly, the pressure sore measures do not differentiate between early and late stage sores. Thus one nursing home may show a relatively high percentage, but they're early stage sores that may be successfully treated before they become truly problematic, while a home with a lower percentage may involve neglected late stage sores, a far more serious concern. In examples like these, the nursing home showing the higher percentage may actually be offering better quality care. For this reason, these scores must be interpreted very carefully -- as a starting point for your investigation, rather than a final word.

You are encouraged to use the information available here to begin conversations with nursing home representatives and other health care professionals, as well as with family members, friends, and associates who may have direct experience with a nursing home. It is a good idea to visit any nursing home you are considering, to get a direct impression of the physical and social environment, how well the residents are treated, the professionalism of the staff, important rules and policies, and so on.

What are the Quality Measure Performance Rankings?

For each quality measure, the nursing homes in New York State have been divided into five groups according to their scores, with roughly 20 percent of the nursing homes in each group. The mathematical term for such a group is a "quintile," meaning a fifth (1/5). The group with the lowest scores for a quality measure is usually considered the most preferable group--a five-star ranking. The group with the highest scores is usually considered the least preferable group--a one-star ranking. (For the the immunization scores, the highest scores earn the five-star ranking.)

For some quality measures, there are many nursing homes with identical scores. When assigning these homes to a ranking group, all homes with the same score must be assigned the same rank. This results in the five-star group having more than 20 percent of the homes in it, and one or more of the other groups having fewer than 20 percent of the homes. This is okay, the normal result of tie scores. The situation is similar to a footrace in which the two front-runners have tied. They both share the #1 spot on the awards platform, but the runner who finished just behind these two runners stands on the #3 spot, because two runners finished ahead of him.

Please note that the quality measure performance rankings are designed to show how nursing homes rank in relation to other nursing homes in New York State. The performance rankings do not indicate any relationship to national ranking, except on the page explicitly giving New York State average scores a performance ranking against the respective national averages.

Complaints

If you have a complaint about the quality of care you or a loved one received at a nursing home, you can call the New York State Department of Health's nursing home complaint hotline at 1-888-201-4563, available 24 hours a day, 7 days a week.

Explanations of Each Measure

Percent of High-Risk Residents Who Have Pressure Sores

This measure indicates the percentage of residents with a high risk for getting pressure sores, or who get a pressure sore in the nursing home. You have a "high risk" for getting a pressure sore if you are in a coma, if you don't get the nutrients you need (like water, vitamins, and minerals), or you can't move or change position on your own.

What is a pressure (bed) sore?

A pressure sore is a skin wound. Pressure sores usually develop on bony parts of the body such as the tailbone, hip, ankle, or heel. They are usually caused by constant pressure on one part of the skin. Pressure sores are sometimes called bedsores. These sores can be caused from the pressure on the skin from chairs, wheelchairs, or beds. Severe pressure sores may take a long time to heal. As a result, some of the pressure sores included in this data may be ones that facilities are in the process of successfully treating and improving.

Why is this information important?

Pressure sores may:

Be painful
Take a long time to heal
Cause other complications such as skin and bone infections

There are several things that nursing homes can do that may help to prevent or treat pressure sores, such as frequently changing the resident's position, proper nutrition, and using soft padding to reduce pressure on the skin. Some residents may get pressure sores even when the nursing home provides good preventive care.

Percent of Low-Risk Residents Who Have Pressure Sores

This measure indicates the percentage of residents with a low risk for getting pressure sores, or who get a pressure sore in the nursing home. You have a "low risk" for getting a pressure sore if you are able to be active, change positions, and get the nutrients you need (like water, vitamins, and minerals).

What is a pressure (bed) sore?

Why is this information important?

Pressure sores may:

Be painful
Take a long time to heal
Cause other complications such as skin and bone infections

Percent of Short-Stay Residents with Pressure Sores

This measure indicates the percentage of short-stay residents (recently admitted to the nursing home following a hospital stay) who have developed pressure sores, or who had pressure sores that did not get better between their 5-day and 14-day assessments in the nursing home.

What is a pressure (bed) sore?

Why is this information important?

Pressure sores may:

Be painful
Take a long time to heal
Cause other complications such as skin and bone infections

Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder

This measure indicates the percentage of residents who often lose control of their bowels or bladder. This information is only based on residents who have a low risk for losing control of their bowel or bladder. Residents have a "low risk" for losing bowel and bladder control if they do not have severe dementia (memory loss) or if they are well able to move on their own.

Why is this information important?

Loss of bowel or bladder control is not a normal sign of aging and can often be successfully treated. Loss of bowel and bladder control can be affected by:

physical problems (like constipation, muscle weakness, or a bladder infection),
location problems (like the bathroom is too far away),
reaction to medication,
limited ability to walk or move around,
diet and fluid intake,
toilet routine (timing trips to the bathroom),
whether someone can provide assistance when needed, and
certain medical conditions, e.g., diabetes, dementia, spinal cord injury, or neurological disease.

Finding the cause of a problem with bowel or bladder control and treating it is important for many reasons. Physically, it can help prevent infections and pressure sores. Mentally, treatment can help the well being of the resident by restoring dignity and social interaction. Fewer residents with bowel and bladder control can give the nursing home staff more time to provide other care.

Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder

This measure indicates the percentage of residents who had a catheter inserted and left in their bladder for a period of time during the 14-day assessment period.

What is a catheter?

A catheter is a thin, soft tube that is left in place and attached to a bag that collects the urine. It may be inserted into the bladder of people who lose control of their bladder or cannot use a toilet (for instance, someone in a coma.) Catheters may be used because there is a physical reason the urine cannot drain naturally, to keep a patient with pressure sores that are not healing clean and dry, or to measure the amount of urine being produced.

Why is this information important?

A catheter should only be used when it is medically necessary. Residents may need a lot of help to get to the toilet, or they may have to go frequently. A catheter should not be used for the convenience of the nursing home staff. Using a catheter may result in complications, like urinary tract or blood infections, physical injury, skin problems, bladder stones, or blood in the urine. Some studies have shown that long-term use of indwelling catheters (over many years) may increase the rates of bladder cancer in patients with spinal cord injuries.

Percent of Residents with a Urinary Tract Infection

This measure indicates the percentage of residents who had an infection in their urinary tract anytime during the 30 days before their most recent assessment.

What is a urinary tract infection?

A urinary tract infection (UTI) is an infection in the urethra that left untreated, can spread to the bladder (bladder infection), and kidney (kidney infection).

If the area where waste (urine and bowel movements) leaves your body is not kept clean, bacteria from your colon may multiply and enter the urethra (the tube that passes urine from your bladder to outside your body), causing a UTI. A UTI may also be caused by bacteria on a catheter (a soft tube used to drain urine) being used to drain the urine from the bladder.

Why is this information important?

Most urinary tract infections can be prevented by keeping the area clean, emptying the bladder regularly, and drinking enough fluid. Nursing home staff should make sure the resident has good hygiene. Finding the cause and getting early treatment of a UTI can prevent the infection from spreading and becoming more serious or causing complications like delirium. It is important to find out whether the UTI is caused by a physical problem, like an enlarged prostate, so proper medical treatment can be given.

Percent of Residents Who Were Physically Restrained

This measure indicates the percentage of residents in the nursing home who were physically restrained daily during the seven-day assessment period.

What are physical restraints?

A physical restraint is any device, material, or equipment attached or adjacent to a resident's body, that keeps the resident from moving freely or prevents normal access to their body. Examples of physical restraints include special types of vests, chairs with lap trays, lap belts, enclosed walkers. Bed rails (side rails) are also considered restraints in certain situations, but they are not used in the calculation of this measure.

Why is this information important?

Restraints should only be used when they are necessary as part of the treatment of a resident's medical condition. Only a doctor can order a restraint. Restraints should never be used to punish a resident or to make things easier for the staff. Facilities are not allowed to use restraints based solely on a family's request, unless there is a documented medical need and a doctor's order. A resident who is restrained daily can become weak, lose his or her ability to go to the bathroom by themselves, and develop pressure sores or other medical complications.

Percent of Residents Who Spend Most of Their Time in Bed or in a Chair

This measure indicates the percentage of residents who spent most of their time in bed or in a chair in their room during the seven-day assessment period.

Why is this information important?

A decline in physical activity may come with age due to muscle loss, joint stiffness, fear of injury, worsening illness, or depression. Residents who spend too much time in bed or a chair may lose the ability to perform activities of daily living, like eating, dressing, or getting to the bathroom.

Staying in a bed or chair affects the resident in many ways. Unused muscles get weaker. It becomes difficult to participate in physical and social activities. Sleep quality can suffer. The risk of heart disease, stroke, diabetes, or blood clots can increase. Depression and anxiety can worsen. Staying in one position, and constant pressure on the skin can increase the chance of pressure sores. It is important for residents to be as active as possible.

Nursing home staff can help residents be more active. For instance, they can encourage residents to take part in physical activities, or take them for regular walks if they need help. Most residents value being able to take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves and stay as active as physically possible. Some residents will choose to remain in bed or in a chair, even though the nursing home staff makes a good effort to keep them more active. It is also important to note that some residents may be counted in this measure if their assessment period occurs when they are temporarily ill and remaining in bed due to a short-term problem.

Percent of Residents Whose Ability to Move About In and Around Their Room Got Worse

This measure indicates the percentage of residents whose ability to move about, either by walking or using a wheelchair, in their room and the hallway near their room got worse since their last assessment.

Why is this information important?

A decline in physical activity may come with age due to muscle loss, joint stiffness, worsening illness, fear of injury, or depression. Residents who lose mobility may also lose the ability to perform other activities of daily living, like eating, dressing, or getting to the bathroom. In some cases, however, the decline measured may be temporary and due to a short-term illness the resident is experiencing at the time of the assessment.

A lack of movement affects the resident in many ways. It becomes difficult to participate in physical and social activities. Sleep quality can suffer. The risk of heart disease, stroke, diabetes, or blood clots can increase. Depression and anxiety can worsen. Staying in one position, and constant pressure on the skin can increase the chance of pressure sores. It is important for residents to be as active as possible.

Nursing home staff can help residents move around more. For instance, they can encourage residents to take part in physical and social activities, or take them for regular walks if they need help. Most residents value being able to move about on their own and take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves and stay as active as physically possible. Some residents will decline in their ability to move about, even though the nursing home staff makes a good effort to keep them more active.

Percent of Residents Whose Need for Help with Daily Activities Has Increased

This measure indicates the percentage of residents whose need for help doing basic daily tasks has increased from the last time it was checked.

The daily activities that this measure counts include:

feeding oneself
moving from one chair to another
changing positions while in bed
going to the bathroom alone

Residents are checked routinely to see how they function doing these basic daily activities. Some loss of function may be expected in the elderly. If they are in poor health or if they are ill (like if they have pneumonia, an infection, a recent injury, or a chronic problem like asthma that has flared-up), they may have a temporary loss of function. Sudden or rapid loss of one or more of these basic daily tasks could mean the resident needs medical attention.

Why is this information important?

Most residents value being able to take care of themselves. It is important that nursing home staff encourage residents to do as much as they can for themselves. In some cases, it may take more staff time to allow residents to do these tasks than to do the tasks for them. Residents who still do these basic daily activities with little help may feel better about themselves and stay more active. This can affect their health in a good way. When people stop taking care of themselves, it may mean that their health has gotten worse. The resident's ability to perform daily functions is important in maintaining their current health status and quality of life. Some residents will lose function in their basic daily activities even though the nursing home provides good care.

Percent of Residents Who Lose Too Much Weight

This measure indicates the percentage of residents who have lost too much weight.

Why is this information important?

A loss of 5 percent or more of body weight in one month is usually considered unhealthy (for example, a 150 pound person should not lose more than 7.5 pounds in one month). Too much weight loss can make a person weak, change how medicine works in the body, or cause the skin to break down which can lead to pressure sores. Too much weight loss may mean that the resident is ill, refuses to eat, is depressed, or has a medical problem that makes eating difficult (like weakness caused by a stroke). It could also mean that the resident is not being fed properly, their medical care is not being properly managed, or that the nursing home's nutrition program is poor. To help prevent unhealthy weight loss, it is important that the resident's diet is balanced and nutritious, and that staff spend enough time feeding people who can't feed themselves. Sometimes it may be necessary for a person to lose weight for medical reasons. In these cases, the medical staff may plan in advance for the resident to lose weight on a special weight loss program, but the person should not lose more than 5 percent of body weight in one month.

Percent of Residents Who Are More Depressed or Anxious

This measure indicates the percentage of residents who have become more depressed or anxious in the nursing home since the last time they were checked.

Why is this information important?

Depression is a medical problem of the brain that can affect how you think, feel, and behave. Signs of depression may include fatigue, a loss of interest in normal activities, poor appetite, and problems with concentration and sleeping.

Anxiety is excessive worry. Signs of anxiety can include trembling, muscle aches, problems sleeping, stomach pain, dizziness and irritability.

Feeling depressed or anxious can lessen your quality of life and lead to other health problems. Nursing home residents are at a high risk for developing depression and anxiety for many reasons, such as loss of a spouse, family members or friends, chronic pain and illness, difficulty adjusting to the nursing home, and frustration with memory loss. Identifying depression and anxiety can be difficult in elderly patients because the signs may be confused with the normal aging process, a side effect of medication, or the result of a medical condition. Proper treatment may include medication, therapy, or an increase in social support.

Percent of Short-Stay Residents with Delirium

This measure indicates the percentage of short-stay residents (recently admitted to the nursing home following a hospital stay) who have symptoms of delirium.

What is delirium?

Delirium is severe confusion and rapid changes in brain function, usually caused by a treatable physical or mental illness. Delirium is often misdiagnosed. Delirium may be caused by infection; a stroke; dehydration; reaction to surgery; anesthesia or medication; disease (like liver failure); uncorrected vision or hearing problems; improper restraint usage; or depression. Symptoms may develop over a short period of time, and change during the day.

Symptoms may include:

Sudden problems with attention (not able to focus or concentrate thoughts or behavior)
Problems thinking and communicating
Loss of a sense of time or place
Changes in sensation and perception
Changes in level of alertness, consciousness or awareness
Changes in sleep pattern
Loss of short-term memory
Restlessness
Changes in personality

Why is this information important?

Delirium is not a normal part of aging. It should not be confused with dementia . Delirium is a serious condition requiring urgent medical attention. Left untreated, the death rate is high. Finding and treating the cause of delirium can ensure proper treatment of a physical or mental problem, and help restore the resident's health and quality of life.

Percent of Residents Who Have Moderate to Severe Pain

This measure indicates the percentage of residents who are reported to have moderate to severe pain during the seven-day assessment period. Pain can be caused by a variety of medical conditions. Checking for pain and pain management are very complex.

Comparing these percentages is different from the other measures because the percentages may mean different things. Generally, a lower percentage on this measure is better. However, this isn't always true. For example, two nursing homes could provide the same quality of care and have the same number of residents with pain. However, if one of the nursing homes does a better job checking the residents for pain, they could have a higher percentage on this measure. Or, if for personal or cultural reasons, more residents in one of the nursing homes refuse to take pain medication, that nursing home's percentage would be higher. In these examples, although the percentage for one nursing home is higher, it does not mean they are not providing good care.

Why is this information important?

Residents should always be checked regularly by nursing home staff to see if they are having pain. Residents (or someone on their behalf) should let staff know if they are in pain so efforts can be made to find the cause and make the resident more comfortable. If pain is not treated, a resident may not be able to perform daily routines, may become depressed, or have an overall poor quality of life. This percentage may include some residents who are getting or have been prescribed treatment for their pain, but who refuse pain medicines or choose to take less. Some residents may choose to accept a certain level of pain so they can stay more alert.

Percent of Short-Stay Residents Who Had Moderate to Severe Pain

This measure indicates the percentage of short-stay residents (recently admitted to the nursing home following a hospital stay) who are reported to have moderate to severe pain at any time, during the seven-day assessment period. Pain can be caused by a variety of medical conditions. Checking for pain and pain management are very complex.

Why is this information important?

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season

This measure indicates the percentage of long-stay residents who were given a flu shot during the flu season (higher percentages are better).

Why is this information important?

The "flu" (also called influenza), is a very contagious respiratory infection. Flu is spread very easily from person to person. People are usually infected when a person coughs or sneezes.

The flu shot (influenza vaccination) can prevent people from getting the flu or reduce the risk of becoming seriously ill from the flu. People who are age 65 and older are at higher risk for developing serious life-threatening medical complications from the flu. People age 65 or older should get the flu shot once every year.

Residents should be given a flu shot during the flu season (October through March) unless they have already received a flu shot at another place, or if there is a medical reason why they should not receive it.

Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season

This measure indicates the percentage of short-stay residents who were given a flu shot during the flu season (higher percentages are better).

Why is this information important?

The "flu" (also called influenza), is a very contagious respiratory infection. Flu is spread very easily from person to person. People are usually infected when a person coughs or sneezes.

Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination

This measure indicates the percentage of long-stay residents who were given pneumococcal vaccination (higher percentages are better).

Why is this information important?

The pneumococcal shot (pneumococcal vaccination) may help prevent or lower the risk of becoming seriously ill from pneumonia caused by bacteria. It may also help prevent future infections.

Residents should be asked if they have been vaccinated for pneumonia, and if not, should be given the pneumococcal shot unless there is a medical reason why they should not receive it.

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination

This measure indicates the percentage of short-stay residents who were given pneumococcal vaccination (higher percentages are better).

Why is this information important?

The pneumococcal shot (pneumococcal vaccination) may help prevent or lower the risk of becoming seriously ill from pneumonia caused by bacteria. It may also help prevent future infections.

Residents should be asked if they have been vaccinated for pneumonia, and if not, should be given the pneumococcal shot unless there is a medical reason why they should not receive it.