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.
The current indicators are:
- Percent of short-stay residents who self-report moderate to severe pain.
- Percent of short-stay residents with pressure ulcers that are new or worsened.
- Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine.
- Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine.
- Percent of short-stay residents who newly received an antipsychotic medication.
- Percent of long-stay residents whose need for help with daily activities has increased.
- Percent of long-stay residents who self-report moderate to severe pain.
- Percent of long-stay high-risk residents with pressure ulcers.
- Percent of long-stay residents who lose too much weight.
- Percent of long-stay low-risk residents who lose control of their bowels or bladder.
- Percent of long-stay residents who have/had a catheter inserted and left in their bladder.
- Percent of long-stay residents with a urinary tract infection.
- Percent of long-stay residents who have depressive symptoms.
- Percent of long-stay residents who were physically restrained.
- Percent of long-stay residents experiencing one or more falls with major injury.
- Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine.
- Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine.
- Percent of long-stay residents who received an antipsychotic medication.
Why Are Measures Sometimes Missing?
Not all nursing homes show scores for all 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 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 short-stay residents who self-report moderate to severe pain.
Lower percentages are better.
This measure captures the percent 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 7-day assessment period.
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. They choose to accept a certain level of pain so they can stay more alert.
Percent of short-stay residents with pressure ulcers that are new or worsened.
Lower percentages are better.
This measure captures percentage of short-stay residents (recently admitted to the nursing home following a hospital stay) who have developed pressure ulcers, or who had pressure ulcers that did not get better between their 5-day and 14-day assessments in the nursing home.
Pressure ulcers may:
- Be painful
- Take a long time to heal
- Cause other complications such as skin and bone infections
Pressure ulcers may worsen without proper interventions and may place residents at risk for further complications or skin injury.
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 short-stay residents assessed and given, appropriately, the seasonal influenza vaccine.
Higher percentages are better.
The measure reports the percent of short-stay residents who were given a flu shot during the flu season.
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 you from getting the flu or reduce your 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. If you are age 65 or older, you should get the flu shot once every year.
Residents should be given a flu shot during the flu season (October through March). You should not get another flu shot if you have already received a flu shot at another place, or if there is a medical reason why you should not receive it.
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine.
Higher percentages are better.
This measure reports the percentage of short-stay residents who were given pneumococcal vaccination.
The pneumococcal shot (pneumococcal vaccination) may help you prevent, or lower the risk of becoming seriously ill from pneumonia caused by bacteria. It may also help you prevent future infections.
Residents should be asked if they have been vaccinated for pneumonia, and if not, you should be given the pneumococcal shot unless there is a medical reason why you should not receive it.
Percent of short-stay residents who newly received an antipsychotic medication.
Lower percentages are better.
This measure reports the percent of short-stay residents who were given anti-psychotic medications.
Antipsychotic drugs are an important treatment for patients with certain mental health conditions. However, the FDA has warned that antipsychotic medications are associated with an increased risk of death when used in elderly patients with dementia and the medications have side effects. Therefore, these medications must be used appropriately. Interventions that do not involve medications should be used first if possible and the continued use of antipsychotics should be carefully monitored.
Consumers should ask nursing homes about their approach to managing behavior. Interventions that do not require medications, such as higher staffing ratios, many and varied activities, and consistent assignment, have been shown to be successful in many cases.
Percent of long-stay residents whose need for help with daily activities has increased.
Lower percentages are better.
This measure reports the percent of long-stay residents whose need for help doing basic daily tasks (e.g., feeding oneself, moving from one chair to another, changing positions while in bed, going to the bathroom alone) has increased from the last time it was checked.
It is important that nursing home staff encourage residents to do as much as they can for themselves. The resident's ability to perform daily functions is important in maintaining 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 long-stay residents who self-report moderate to severe pain.
Lower percentages are better.
This measure captures the percent of long-stay residents who are reported to have moderate to severe pain during the 7-day assessment period.
Residents should 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 long-stay high-risk residents with pressure ulcers.
Lower percentages are better.
This measure captures the percent of long-stay residents with a high risk for getting pressure ulcers, or who get a pressure ulcer in the nursing home. You have a "high risk" for getting a pressure ulcer 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.
Pressure ulcers may:
- Be painful
- Take a long time to heal
- Cause other complications such as skin and bone infections.
Pressure ulcers may worsen without proper interventions and may place residents at risk for further complications or skin injury.
There are several things that nursing homes can do that may help to prevent or treat pressure ulcers, 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 ulcers even when the nursing home provides good preventive care.
Percent of long-stay residents who lose too much weight.
Lower percentages are better.
The measure captures the percentage of long-stay residents who have lost too much weight.
A loss of 5% or more of body weight in one month is usually considered unhealthy (for example, a 140 pound person should not lose more than 7 pounds in one month). Too much weight loss can make a person weak, change how medicine works in the body, or put the resident at risk for pressure ulcers.
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% of body weight in one month.
Percent of long-stay low-risk residents who lose control of their bowels or bladder.
Lower percentages are better.
The measure reports the percent of long-stay residents who often lose control of their bowels or bladder. This measure 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 do not have very limited ability to move on their own.
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 caused 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
- Certain medical conditions such as diabetes, dementia, spinal cord injury, or neurological disease may put a resident at higher risk of losing bowel and bladder control.
Finding the cause and treating a problem with bowel or bladder control is important for many reasons. Physically, it can help prevent infections and pressure ulcers. Mentally, treatment can help the well-being of the resident by restoring dignity and social interaction.
Percent of long-stay residents who have/had a catheter inserted and left in their bladder.
Lower percentages are better.
This measure reports the percent of long-stay residents who had a catheter inserted and left in their bladder for a period of time during the 14-day assessment period.
A catheter should only be used when it is medically necessary. It is used by residents who lose control of their bladder or need 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 long-stay residents with a urinary tract infection.
Lower percentages are better.
The measure reports the percentage of long-stay residents who had an infection in their urinary tract anytime during the 30 days before their most recent assessment.
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 long-stay residents who have depressive symptoms.
Lower percentages are better.
The measure reports the percentage of long-stay residents who have become more depressed or anxious in the nursing home since the last time they were checked.
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.
Feeling depressed 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 can be difficult in residents 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 long-stay residents who were physically restrained.
Lower percentages are better.
This measure reports the percent of long-stay residents in the nursing home who were physically restrained daily during the 7-day assessment period.
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.
Percent of long-stay residents experiencing one or more falls with major injury.
Lower percentages are better.
This measure reports the percentage of long-stay residents who experience one or more falls with major injury (e.g., bone fractures, joint dislocations, closed head injuries with altered consciousness, or subdural hematoma) in the last year (12-month period).
Each year, one in every three adults age 65 and older falls. One third of falls among nursing home residents results in an injury.
Falls can cause moderate to severe injuries such as:
- Bone fractures
- Joint dislocations
- Closed head injuries
- Subdural hematoma
- Altered consciousness
There are many things a facility can do to prevent falls and fall-related injuries.
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine.
Higher percentages are better.
The measure reports the percent of long-stay residents who were given a flu shot during the flu season.
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 you from getting the flu or reduce your 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. If you are age 65 or older, you should get the flu shot once every year.
Residents should be given a flu shot during the flu season (October through March). You should not get another flu shot if you have already received a flu shot at another place, or if there is a medical reason why you should not receive it.
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine.
Higher percentages are better.
This measure reports the percent of long-stay residents who were given pneumococcal vaccination.
The pneumococcal shot (pneumococcal vaccination) may help you prevent or lower the risk of becoming seriously ill from pneumonia caused by bacteria. It may also help you prevent future infections.
Residents should be asked if they have been vaccinated for pneumonia, and if not, you should be given the pneumococcal shot unless there is a medical reason why you should not receive it.
Percent of long-stay residents who received an antipsychotic medication.
Lower percentages are better.
This measure reports the percent of long-stay residents in the nursing home who have received an antipsychotic medication at least once recently. Some residents with serious mental illness (such as schizophrenia) are not included in this measure.
Antipsychotic drugs are an important treatment for patients with certain mental health conditions. However, the FDA has warned that antipsychotic medications are associated with an increased risk of death when used in elderly patients with dementia and the medications have side effects. Therefore, these medications must be used appropriately. Interventions that do not involve medications should be used first if possible and the continued use of antipsychotics should be carefully monitored.
Consumers should ask nursing homes about their approach to managing behavior. Interventions that do not require medications, such as higher staffing ratios, many and varied activities, and consistent assignment, have been shown to be successful in many cases.