Nursing Homes Underreport Patient Safety Events, Pressure Ulcers

Nursing homes are vastly underreporting patient safety events, like the occurrence of moderate pressure ulcers, to the Centers for Medicare and Medicaid Services, a practice that could impact the reliability of publicly reported Nursing Home Care Compare ratings intended to guide consumer care access decisions.

The data, gathered by researchers from the University of Chicago and published in the journal Medical Care, showed that nursing homes only reported 22.4 percent of the pressure ulcers that resulted in hospitalization in which pressure ulcer was the primary diagnosis.

When opening the criteria further, researchers found a starker problem. The investigators looked at hospitalizations with a secondary diagnosis of pressure ulcer and found that 45 percent of those went unreported by nursing homes.

These findings follow a previous study from the University of Chicago finding that nursing homes also underreport the number and severity of falls to CMS. This research series homes in on the reliability of the publicly reported Nursing Home Care Compare data used as part of star ratings informing consumer care access choices.

“Given how inaccurate the falls data turned out to be, we wanted to look at other Nursing Home Care Compare patient safety indicators,” Prachi Sanghavi, PhD, an assistant professor in the Department of Public Health Services at the University of Chicago, said in a statement. “So, we next considered pressure ulcers. There’s a lot you can do to prevent them, but they can have very bad outcomes if they’re not managed.”

The researchers used hospital admissions data for Medicare fee-for-service beneficiaries who were both nursing home residents and admitted to the hospital for pressure ulcers between 2011 and 2017. Patients needed a primary or secondary diagnosis of a stage 2-to-4 pressure ulcer (based on a 6-point scale) and needed to come from and return to the same nursing home.

Researchers then linked those events to the nursing home-reported data at the patient level, calculating the number of pressure ulcers that were appropriately reported by stage, long-stay versus short-stay resident, and race.

The researchers found underreporting of pressure ulcers among both long-stay (usually covered by Medicaid) and short-stay (usually covered by Medicare) residents. Among long-stay residents, 59.7 percent of stage 2-to-4 pressure ulcers were reported by nursing homes. Among short-stay residents, that figure was around 70 percent.

More severe pressure ulcers were more common among Black residents than White ones. Among short-stay residents, 40.8 percent of White residents, 50.4 percent of Black residents, and 46.1 percent of Hispanic residents suffered stage 4 ulcers. Among long-stay residents, those figures were 45.6 percent, 54.2 percent, and 48.9 percent, respectively.

However, the researchers did note that nursing homes were more likely to report more severe pressure ulcers, which could have skewed findings about racial disparities in patient safety events.

“Black and Hispanic populations had more severe pressure ulcers, but more severe pressure ulcers were much more likely to be reported, perhaps because they are more visibly apparent,” the researchers wrote in the discussion section of their report.

These findings indicate that the publicly available CMS data posted on the Care Compare website are not enough to predict whether a patient might develop a pressure ulcer in a particular nursing home. Said otherwise, the underreporting of this patient safety data does little to help inform consumer care access decisions.

“I don’t quite understand the logic of relying on data that nursing homes may find both administratively challenging to report – and have a strong disincentive to report – as opposed to using data sets that CMS already has that are far more objective and cover a large part of the nursing home population, either alternatively or additionally,” Sanghavi said.

“I’m hoping that CMS will recognize that their measures are inaccurate and misleading, and I hope that they shift to using more objective data sources for measuring quality of care in nursing homes,” she said.

Sanghavi and the research team plan to continue the assessment of publicly reported patient safety events, next by zeroing in on urinary tract infections and pneumonia cases. These are the two most-common infections nursing home residents experienced prior to the COVID-19 pandemic, the team said, so understanding reporting patterns around these could provide a window into the reliability of nursing home star ratings.