Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016

Nursing facilities vary in the type of residents they serve.  Resident characteristics affect the environment of the facility. Moreover, the special characteristics of nursing facility residents require different levels and types of staff resources and affect the facility’s success in providing high quality care.  A number of nursing facility resident classification systems have been developed and are often referred to as “case mix” indicators (see Appendix for more detail on data sources on resident characteristics). Below, we summarize characteristics of residents using data available in the OSCAR/CASPER database.

Level of Need for Assistance with Activities of Daily Living

While nearly all residents in a nursing facility require some level of assistance, some facilities may have residents with a greater level of need. Table 6 shows the average score for residents needing assistance with eating, toileting, and transferring from surfaces, such as to and from a bed, chair, or wheelchair, or to and from a standing position, in facilities by state.  Each state has an average score from 1 to 3 in terms of residents’ need for assistance, where 1 indicates the lowest need and 3 the greatest need.  The U.S. average resident need was 1.67 for eating assistance, 2.08 for toileting assistance, and 2.04 for transferring assistance in 2016. Each of these scores has been fairly consistent since 2009. Table 6 also shows the average summary scores for these three activities of daily living for all facilities in each state. The average resident need score for eating, toileting, and transferring for all facilities surveyed in the U.S. was 5.80 in 2016.

Mobility Impairments

Mobility impairments range from difficulty walking to inability to get oneself out of bed and are another indication of the level of need among residents. As shown in Table A, on average 3.7 percent of residents were bed-bound in 2016, meaning they were in a bed or recliner for 22 or more hours per day in the week before the survey. The share of residents who are bed-bound declined slightly between 2009 and 2012 but has increased slightly since then. A larger share (65.3%) of residents are chairbound, meaning they depend on a wheelchair for mobility or are unable to walk without extensive or constant support from others.  Contractures, which are restrictions in full range of motion of any joint due to deformity, disuse and pain, are common problems of nursing facility residents. In 2016, more than one in five (22.0%) residents was reported as having contractures.

Lack of mobility can lead to health problems for nursing facility residents. Pressure ulcers (or bedsores) are areas of the skin and underlying tissues that erode as a result of pressure or friction and/or lack of blood supply.  The severity of the ulcer ranges from persistent skin redness (without a break in the skin) to large open lesions that can expose skin tissue and bone.  The acquiring of pressure sores in a facility is considered an indicator of poor quality of care, as it reflects patients spending extended time in one position or location. Sometimes, residents receive special skin care, which is non-routine care according to a resident care plan or physician’s order, usually designed to prevent or reduce pressure ulcers of the skin. In 2016, more than three quarters (76.4%) of nursing facility residents received special skin care, while 6.2 percent of residents had pressure sores (Table A).

Physical Health and Special Care Needs

Some nursing facility residents need advanced care (beyond assistance with activities of daily living) for physical health problems. Rates of receipt of this type of care are an indication not only of the health needs of residents but also of the scope of services provided by facilities.

Among the most common special health care needs of nursing facility residents are treatments related to bladder or bowel incontinence (Table B). In 2016, more than six in ten (63.5%) nursing facility residents had bladder incontinence, and more than four in ten (44.8%) had bowel incontinence. Some residents receive services through bladder (23.5%) or bowel (14.9%) training programs, which are designed to assist residents to gain and maintain bladder control (such as by pelvic exercises or frequent toileting) or bowel control (through the use of diet, fluids, and regular schedules). Participation in both types of programs has increased substantially since 2009. However, there is still a notable discrepancy between the high percentage of residents with incontinence problems and the low percentage of training programs. Sometimes, indwelling catheters, tubes used to drain urine from the bladder, are used, although the use of catheters is considered an indicator of poor quality of care.  In 2016, about 6 percent of facility residents were reported to be using catheters, a rate that has been fairly stable since 2009. Last, a small share of residents (less than 3 percent) receives ostomy care, which includes special care for a skin opening to the intestinal and/or urinary tract such as a colostomy (opening to the colon).

Rehabilitation services are provided under the direction of a rehabilitation professional (physical therapist, occupational therapist, etc.) to improve functional ability. In 2016, nearly 32 percent of residents in nursing facilities received such services, up slightly from 26 percent in 2009. Rates of rehabilitation services have been increasing over time, perhaps related to changes in the Medicare prospective payment system for nursing facilities.¹

Other less common special health care services include injections to deliver medication and intravenous therapy and/or blood transfusions to provide fluid, medications, nutritional substances, and blood products for residents.  In 2016, 21.3 percent of residents received injections and less than two percent received IV therapy. Respiratory treatment is provided through respirators/ventilators, oxygen, inhalation therapy, and other treatment, and in 2016, more than 15 percent of facility residents received respiratory therapy. Last, nearly 5 percent of residents required tube feedings to provide nutritional substances directly into the gastrointestinal system.

Cognitive and Behavioral Health

Cognitive and behavioral health is of particular concern for nursing facility residents. Federal regulations from OBRA 1987 require screening of all new residents to ensure that those who have intellectual, developmental, or cognitive disabilities are placed in appropriate facilities where they receive services designed to meet their needs. State officials are required to certify that those individuals with intellectual or developmental disabilities who are placed in nursing facilities are receiving appropriate services. In 2016, approximately 2 percent of nursing facility residents were reported to have a developmental disability (including mild to profound mental retardation), a slight decrease since 2009 (Table C).  Other cognitive problems, often associated with aging, are more common among nursing facility residents. Nearly half (45.3 percent) of residents were reported by facilities and states as having a dementia diagnosis in 2016.

With respect to behavioral health problems, the percent of residents with other psychiatric conditions, such as schizophrenia, mood disorders, and other diagnoses, was 32% in 2016. Psychoactive medications, including anti-depressants, anti-anxiety drugs, sedatives and hypnotics, and anti-psychotics, are often used to treat behavioral health problems. In 2016, nearly two-thirds (63.1%) of residents in facilities in the U.S. were reported to be receiving such medications. Federal regulations prohibit the use of anti-psychotics and other psychoactive drugs unless such drugs are shown to be necessary for particular resident conditions. However, because depression is frequently under-diagnosed and anti-depressants may sometimes be under-prescribed, educational efforts are focused on the appropriate use of anti-depressants.² As detailed in the discussion section of this report, over-use of anti-psychotic medications has been the focus of recent policy attention, particularly their use among residents with dementia. CMS is now reporting the use of anti-psychotic medications as a poor quality measure on the Nursing Home Compare website.³

Physical restraints include physical or mechanical devices, material or equipment that cannot be easily removed by residents to restrict freedom of movement or normal access to one’s own body.  Physical restraints are used to prevent falls or other injury among residents, but research has found that there can be significant negative physical and psychosocial effects to use of restraints.⁴ Since 1987, federal law has limited the use of physical restraints to prohibit their use for discipline or staff convenience, and the use of restraints has declined significantly.⁵ However, research has also shown that restraints are more likely to be used for residents with cognitive impairment or mental illness.⁶ The share of residents with physical restraints has declined over time, reaching 0.9 percent in 2016. The reduction may have been related to regulations and ongoing training about the negative effects of restraints on residents.