One measure of the safety and quality of nursing home care is the presence of a pressure ulcer on its residents. CMS reports these numbers to the public as a star-ranking on Nursing Home Compares and penalizes nursing homes with more observed pressure ulcers than anticipated. The system relies on the self-reporting of pressure ulcers to CMS. A new study finds that nursing homes “substantially underreport” these events.
A Pressure Ulcer Primer
Before jumping into the study, let me say a few words about bed sores, or as we call them in the trade, pressure ulcers. These occur in individuals that are increasingly not mobile. This may be due to a stroke, muscle loss associated with aging (sarcopenia), or excessive weight. Pressure ulcers are a problem of the debilitated, and they require care to prevent and treat these wounds.
The wounds form because of the constant pressure of the body’s bony parts and the bed—the pressure results in lessening blood flow, which in turn causes local tissue death and infection. The swelling associated with the infection can extend the sore by further reducing blood flow. Two other factors promote pressure ulcers, the friction and shear forces of the body’s movement against the mattress. There is a grading system for these ulcers as they redden the skin (Stage 1) to erode through the skin into the underlying soft tissue and finally expose muscles or bones (Stage 4). Pressure ulcers are not pretty in these later stages.
The risk and management of pressure ulcers can be mitigated by reducing the impact of the mattress, using air or water mattresses to distribute the body pressure; and by supranormal levels of oxygen, to increase the oxygen getting to these tissues, delivered by placing the patient in a hyperbaric chamber – like those used for SCUBA divers with the bends.
But because the primary driver of pressure ulcers is immobility, turning and repositioning patients is the mainstay of prevention and care - needed every 2 or 3 hours, 24 hours a day, seven days a week.  This requires not only coordination but one, or more frequently, two nurses or nurses’ aides; this is very labor intensive and, in some ways, is the canary in the nursing homes’ coal mine of quality care.
The Study and Its Results
The researchers used data on patients admitted to a nursing home between 2011 and 2017. Whether admitted for a short or long stay, these patients must undergo a “present-on-admission” examination, including the presence and extent of pressure ulcers. The Minimum Data Set (MDS) examinations are repeated every three months and at discharge. The patients' subsequent hospitalization records, which recorded the presence or absence of pressure ulcers while hospitalized while a nursing home resident, was linked to their MDS. Hospital claims also included whether the pressure ulcer was the primary reason for admission or a secondary diagnosis – a co-morbidity not necessarily related to the need for hospitalization. Based upon roughly 400,000 hospital admissions and 60,000 linked admissions to nursing homes:
- 75% of primary pressure ulcers were reported, and 70% were classified within 1 stage of the hospital diagnosis
- 52% of the secondary pressure ulcers were reported, and 46% were classified within 1 stage of the hospital diagnosis
- Primary ulcers were more severe than secondary ulcers, and “reporting substantially increased with higher stages.”
- For primary pressure ulcers, 22% were not reported by the nursing homes to CMS; that percentage doubled to 45% when accounting for secondary pressure ulcers.
In 2014, the best nursing homes (based on quintiles) had 0.4 pressure ulcers per 100 residents; the worst was 3.2 pressure ulcers per 100 residents. Despite the 8-fold difference in outcomes, 75% of the best nursing homes had 4 or 5 stars for quality, while the worst had 65% with 4 or 5 stars. As the researchers write, “… correlation coefficients between the claims-based pressure ulcer rates and NHC 5-star ratings were exceedingly low.” That showed a slight, tangible improvement in 2017. A closer look at the criteria for nursing home quality stars is instructive. Stars are based on a state inspection of the hospital, its staffing levels, and 11 of 18 outcome measures reported to the public by CMS on Nursing Home Compare. In the words of CMS, “The core of the overall rating is the health inspection rating” moved up or down based upon staffing and those real-world outcomes.
Here is the researchers' conclusion.
“… a high star rating did not inform the risk of developing a pressure ulcer in a nursing home that was subsequently diagnosed by a hospital. …one’s risk of developing serious pressure ulcers in a nursing home could not be gleaned from publicly reported ratings.”
When self-reporting bad outcomes, especially when associated with financial penalties, it is tempting to underreport problems. We see this, especially with those early stages of the pressure ulcers, the reddened skin, where only 12% are reported. As the pressure ulcer worsens, the veracity of reporting improves, till, in the presence of exposed muscle and bone, 88% are reported. The authors suggest additional penalties for false reporting, but who is to be the arbiter matching nursing home examinations to hospital examinations?
This is an example of how incentives and disincentives moderate our performance. In this case, not in the desired direction. Before adding on a new punitive layer of financial penalties for under-reporting, we might reweight the criteria for those CMS stars. Or maybe we should look for better ways to inform families faced with the decision to place a family member in a nursing home. Perhaps we should recognize that proximity to the family may override “quality” and that in many cases, the choice of the nursing home lies with the hospital and where a bed is currently available; when discussing health care, we are all patients, not consumers.
 I remember working in a community hospital that had a bell go off every two hours, just like the bell to change classes in high school, to remind the nurses to reposition their patients.
Source: Accuracy of Pressure Ulcer Events in US Nursing Home Ratings Medical Care DOI: 10.1097/MLR.0000000000001763