It is important to note that a percentile ranking that is not in the top 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 area. It is possible that the indicator ranking reflects conditions or characteristics of residents that developed prior to admission to the facility or that may be the result of the end stage of a disease. 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 1) that any healthy individual may have and a deep open wound (a stage 4) 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. The exclusion of a newly admitted resident's initial MDS from the QI analysis does not adequately solve this problem. For example, it is not uncommon for a debilitated resident to 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 an excellent job of treating and healing a pressure ulcer that was acquired somewhere else. This creates an incentive for that facility to not offer admission to such an individual.
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.
While there may be areas where the Quality Indicator Report may be strengthened, this new tool provides consumers and regulators with tremendously important and unprecedented insight into the quality of a nursing home's delivery of care. The QI Report provides information never before available about the success or failure of a facility's care programs and processes.
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 with one of the most difficult and important decisions in a person's 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.
About the author:
Morris J. Kaplan is an attorney and licensed nursing home administrator. He pioneered the nationally recognized Alzheimer's Special Care Program at Gwynedd Square Nursing Center in Lansdale, PA, of which he is an owner. He is a Board Member of the Alzheimer's Association of Southeastern Pennsylvania. He has made numerous presentations at Alzheimer's Association conferences and has testified on behalf of the Association in the PA legislature. Morris is also an active member of the National Citizen's Coalition for Nursing Home Reform and has made many presentations at their annual conferences and has testified on their behalf in the US Congress.