Over 90% of Nursing Homes Have Violations, Staffing the Major Problem. 

Mon Sep 29, 2008 at 10:37:11 PM EDT

   In today's New York Times, there is an interesting article on a topic that is related to a topic I have ranted about before here on the Kos. The article, "Violations Reported at 94% of Nursing Homes"
gives us some scary, although not surprising figures to those of us who
actually work in the health care field. Here is a couple highlights..

...The inspector general said 94 percent of for-profit nursing
homes were cited for deficiencies last year, compared with 88 percent
of nonprofit homes and 91 percent of government homes.
"For-profit nursing homes had a higher average number of
deficiencies than the other types of nursing homes," Mr. Levinson said.
"In 2007, for-profit nursing homes averaged 7.6 deficiencies per home,
while not-for-profit and government homes averaged 5.7 and 6.3,
respectively."
On Monday, Mr. Levinson issued a compliance guide for nursing
homes that says some homes "have systematically failed to provide staff
in sufficient numbers and with appropriate clinical expertise to serve
their residents."...

What were some of the problems that are related directly to staffing?

Problems included infected bedsores, medication mix-ups, poor nutrition, and abuse and neglect of patients.

All of these are preventable complications, and I have to say Kudos
to those bringing this up for recognizing that staffing is the key
issue here. Now, let me ask this simple question. Why can't hospitals
be treated the same way? You see, hospitals are judged as safe based on
different standards, and every solution under the sun is proposed to
correct their problems. Every solution except addressing the staffing
issue that is. First, let's look at the standards analyzed by Joint Commission for the Accreditation of Hospitals when critiquing hospitals in regards to their safety and performance...

The Joint Commission worked closely with clinicians, health care
providers, hospital associations, performance measurement experts, and
health care consumers across the nation to identify the quality
measures. This collaborative process identified measures that reflect
the best "evidence-based" treatments for heart attack, heart failure,
pneumonia, and surgical care patients. These measures are the product
of The Joint Commission’s Hospital Core Measure Initiative that sought
to create a set of standard national measures that would permit
comparisons across organizations

Are those issues important? Of course they are. Should they be the
judging standard of a hospitals performance? I say no. Those are
related to standards of care in regards to medical practice. Everyone
should receive care based on evidence of effectiveness, that is common
sense, but it focuses more on medical "gold standards" of specific
treatment modalities, not on the safety or internal functioning of the
facility.
Now, let's look at the 2008 national patient safety goals,
and their recommendations. Notice how improved staffing would help all
of their goals, but improved staffing is never mentioned as an option...

Goal 1 Improve the accuracy of patient identification.
1A Use at least two patient identifiers when providing care, treatment or services.
Goal 2 Improve the effectiveness of communication among caregivers.
2A For verbal or telephone orders or for telephonic reporting of
critical test results, verify the complete order or test result by
having the person receiving the information record and "read-back" the
complete order or test result.
2B Standardize a list of abbreviations, acronyms, symbols, and
dose designations that are not to be used throughout the organization.
2C Measure and assess, and if appropriate, take action to
improve the timeliness of reporting, and the timeliness of receipt by
the responsible licensed caregiver, of critical test results and values.
2E Implement a standardized approach to "hand off" communications, including an opportunity to ask and respond to questions.
Goal 3 Improve the safety of using medications.
3C Identify and, at a minimum, annually review a list of
look-alike/sound-alike drugs used by the organization, and take action
to prevent errors involving the interchange of these drugs.
3D Label all medications, medication containers (for example,
syringes, medicine cups, basins), or other solutions on and off the
sterile field.
3E Reduce the likelihood of patient harm associated with the use of anticoagulation therapy.
Goal 7 Reduce the risk of health care-associated infections.
7A Comply with current World Health Organization (WHO) Hand
Hygiene Guidelines or Centers for Disease Control and Prevention (CDC)
hand hygiene guidelines.
7B Manage as sentinel events all identified cases of
unanticipated death or major permanent loss of function associated with
a health care-associated infection.
Goal 8 Accurately and completely reconcile medications across the continuum of care.
8A There is a process for comparing the patient’s current
medications with those ordered for the patient while under the care of
the organization.
8B A complete list of the patient’s medications is communicated
to the next provider of service when a patient is referred or
transferred to another setting, service, practitioner or level of care
within or outside the organization. The complete list of medications is
also provided to the patient on discharge from the facility.
Goal 9 Reduce the risk of patient harm resulting from falls.
9B Implement a fall reduction program including an evaluation of the effectiveness of the program.
Goal 13 Encourage patients’ active involvement in their own care as a patient safety strategy.
13A Define and communicate the means for patients and their
families to report concerns about safety and encourage them to do so.
Goal 15 The organization identifies safety risks inherent in its patient population.
15A
The organization identifies patients at risk for suicide.
[Applicable to psychiatric hospitals and patients being treated for
emotional or behavioral disorders in general hospitals—NOT APPLICABLE
TO CRITICAL ACCESS HOSPITALS)]
Goal 16 Improve recognition and response to changes in a patient’s condition.
16A The organization selects a suitable method that enables
health care staff members to directly request additional assistance
from a specially trained individual(s) when the patient’s condition
appears to be worsening. [Critical Access Hospital, Hospital]

Again, are some of their suggestions good? Sure, but without
appropriate staffing, they are just adding more work to already
overworked staff members. Now, increase staffing and add these safe
guards, and you really are creating a safe and effective environment.
If hospitals were analyzed the same way that nursing homes are, the
staffing situation would be something that the public would be more
involved with. But when you have hospitals paying Joint Commission to
inspect and accredit them, and little to no oversight over Joint
Commission themselves, this is what you get. Solutions that are low
cost, that help to hide the true issue that causes the dangers within
the facilities, and that help preserve the profit instead of actually
addressing the problem and improving health care. This is just one more
industry that has been torn apart by a lack of appropriate regulation.
Specifically, staffing regulations and oversight of governing bodies.