Morris
J. Kaplan, Esq., NHA
It is important, first, to understand the difference
between the state survey report and the Quality Indicator Report.
The state survey report (the only government survey information source
until August 1999) is based on a surveyor’s interpretation of state and
federal regulations, as directed by HCFA’s Interpretative Guidelines and
training. There can be considerable
variation in the interpretation of these regulations from one survey office to
another and/or from one surveyor to another. This can result in inconsistency in the quality of survey reports and in
enforcement action against nursing homes. Surveyors
can be either too easy on the nursing home, or they can be too tough.
For example, one surveyor may ignore a facility’s widespread failure to
use effective interventions to prevent weight loss and give no deficiencies at
all in that area. Another surveyor may penalize a facility for not keeping a
slice of French toast at 160 degrees even though that same facility ranks among
the best in the state in preventing weight loss.
By contrast, the Quality Indicator (“QI”) Report
focuses on specific objective indicators.) The QI Report looks at 24
specific indicators that reflect the status of residents and certain care
practices. These 24 outcomes or “quality indicators” have been selected by
HCFA (the Health Care Finance Administration) as key areas that can show either
quality or lack of quality in a nursing home’s delivery of care.
The QI Report is updated monthly and is based on data
contained in the “MDS” (Minimum Data Set) assessment form.
Nurses complete an MDS at least quarterly for each resident.
The MDS asks hundreds of questions about a resident’s health problems
and care needs. The most valuable
part of the QI Report for consumers is the column titled “Percentile Rank.”
The percentile rank shows which percentile the nursing home
falls in when compared to all nursing homes in the state. >A nursing home is given a percentile rank for each of the 24
quality indicators.
The lower the percentile rank, the better. A rank in
the first third (that is, the 0-33 percentile) on a particular quality indicator
can be a sign of good care practices. This should be the consistent score on a majority of the 24
quality indicators.
Some quality indicators that our facility thinks are
among the most revealing about the level of quality at a nursing home are the
following:
·
#6 -- the
use of 9 or more medications (overmedicating a resident, especially one with
dementia, can promote a rapid decline in overall health status)
·
#13 --
the prevalence of weight loss (in most cases, except in the end stages of a
disease, weight loss can be prevented and treated with appropriate
interventions)
·
#15 &
11 -- the prevalence of dehydration or fecal impaction (both of which should
rarely if ever occur except when near death)
·
#22 -- the use of physical restraints (there is nothing more degrading,
agitating and dangerous for any human being than to be tied down like an
animal).
·
#24
-- the incidence of pressure ulcers/bedsores (basic good toileting care,
incontinence care, skin care, nutrition and proper positioning should prevent
most pressure ulcers except in the end stages of a disease)
It is important to note that a percentile ranking
that is not in the first third (the 0-33 percentile) in a particular quality
indicator does not automatically indicate a failure of the facility to provide
good care in that particular area. But
it should raise a flag to the consumer. The
consumer should question the facility about that indicator.
There are some drawbacks to the QI Report.
The ranking for pressure ulcers treats all stages of pressure ulcers the
same. It does not distinguish
between a mere reddened area (a stage I) that any healthy individual may have
and a deep open wound (a stage IV) that should not develop except in the end
stages of a disease.
The QI Report also does not adequately distinguish
between pressure ulcers that developed prior to admission to the nursing home
(those acquired at home or in the hospital) and those that developed during the
stay in the nursing home. Facility QI reports exclude a newly admitted
resident’s initial MDS from the QI analysis.
But this does not adequately solve this problem.
For example, a debilitated resident may be admitted from a hospital where
he acquired a stage III or IV pressure ulcer.
With proper interventions, and provided the resident is not in the end
stage of his/her disease, the ulcer may heal 90% and/or heal to a stage I or II.
But if that high stage ulcer does not heal completely within 90 days (the
deadline for the next MDS), the QI report will count that pressure ulcer the
same as if it had been acquired in the facility and then left untreated.
The problem is that good facilities in this instance may be penalized
(with negative QI numbers) when they’ve actually done a good job of treating
and healing a pressure ulcer that was acquired somewhere else.
The danger in failing to differentiate between pressure ulcers acquired
before admission and those acquired after admission, and of treating stage I
pressure ulcers exactly the same as stage IVs, is that good facilities will not
want to admit someone with pre-admission pressure ulcers.
Also, by not counting the use of two full-length side
rails in bed as a restraint, the QI Report can understate the number of physical
restraints being used. The use of
two full-length side rails is in fact a restraint that prevents egress from the
bed and can contribute to serious injury to a resident who tries to climb over
or through the rails. There are
safe and effective alternatives to two full side rails.
Unfortunately, people usually know more about the car
they buy for themselves than about the care they buy for a loved one in a
nursing home. The Quality Indicator
Report is a valuable tool that can help you make one of the most difficult and
important decisions of your life. The
QI Report for a facility is only available at the facility.
You must ask to see it. If the facility has a good Quality Indicator
Report, it is most likely a facility with good care programs and good healthcare
outcomes.
