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The use of complaints against nursing homes as an index of quality care
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Content
THE USE OF COMPLAINTS AGAINST NURSING HOMES
AS AN INDEX OF QUALITY OF CARE
by
Meredith Anne Hart
A Thesis Presented to the
FACULTIES OF
THE LEONARD DAVIS SCHOOL OF GERONTOLOGY
AND
THE SCHOOL OF PUBLIC ADMINISTRATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
MASTER OF SCIENCE IN GERONTOLOGY
and
MASTER OF PUBLIC ADMINISTRATION
May 198 2
UMI Number; EP58896
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Oissertation PüblisWng
UMI EP58896
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
ProQuest LLC.
789 East Eisenhower Parkway
P.O. Box 1346
Ann Arbor, Ml 48106 - 1346
VNIVERSITY OF SOUTHERN CALIFORNIA
LEONARD DAVIS SCHOOL OF GERONTOLOGY
UNIVERSITY PARK
LOS ANGELES^ CALIFORNIA 90007
This thesis, written by
Meredith Anne Hart
under the d.irector of h er Thesis Committee
and approved by all its members, has been pre
sented to and aoaepted by the Dean of the
Leonard Davis School of Gerontology and the
Dean of the School of Public A.dministration
or Urban Planning (underline one)^ in partial
fulfillment of the requirements for the degree of
Master of Science in Gerontology / Master of Public Administration
.... .....----------- ---- - ... -.......
k}oi.md d ■ ^ i u o m
Dean
Date
Dean
THESm COMMITT.
Chairman
i ACKNOWLEDGEMENTS ;
I
I I
' . Much of the intellectual debt for this work has been |
'acknowledged in the text. However, there have been several ;
contributions that could not be noted in this way. I am
indebted to the reform group. Nursing Home Residents' Ad-
jVocates in Minneapolis Minnesota, for confirming in every-
I
day practice that many of the recommendations presented
*here are both necessary and viable.
I I would like to thank Amanda Randall, Kathy Stennes, ^
jlris Freeman, Georgia Tarbell, Pam Parker, Don Clapp and
I
Axis for their working partnership during the time I ini-
Itially developed many of the ideas included in this paper.
Many thanks to Ruth Weg and Paul Kerschner for their
patience.
I Finally, a dedication to my father and mother.
11
j TABLE OF CONTENTS
; Page
,ACKNOWLEDGEMENTS .................................. ii
LIST OF TABLES ........................... ■....... v
Chapter
; I. ABSTRACT AND SUMMARY ...................... 1
A. Objectives
! B. Research Approach
C. Research Findings
D. Recommendations
!
i II. STATEMENT AND BACKGROUND OF THE PROBLEM . 7
i
! A. The Nursing Home Setting
! B. The Nursing Home Problem
C. Quality in the Nursing Home
Setting
D. Measurement of Quality
III. LITERATURE REVIEW ......................... 33
A. Assessment of Quality in Nursing
Home Care
B. Standards of Quality
C. Commonly Used Indicators of
I Quality
D. Approaches to the Measurement of
Nursing Home Quality
E. Proprietary Status of Nursing
! Homes
1 F. Size of Nursing Homes
' G. Location of Nursing Homes
i n ;
TABLE OF CONTENTS (cont.)
Page
IV. RESEARCH METHODOLOGY ...................... 68
A. Sample of Complaints
B. Use of Complaints as Data
C. Hypotheses and Assumptions
D. The Minnesota System for
Receiving Complaints
V. RESEARCH FINDINGS ......................... 81
A. Sample of Nursing Homes
B. Variables Studied
VI. CONCLUSIONS, IMPLICATIONS,
RECOMMENDATIONS .......................... 8 8
A. Implications for Quality of
Life in Nursing Homes
B. Recommendations for Policy and
Program Development
C. Recommendations for Research
D. Conclusion
VII. REFERENCES ................................. 98
VIII. REFERENCE NOTES ........................... 103
IV I
LIST OF TABLES
Page j
TABLE 1. Sample Size By Variable Category............ 8 2 j
TABLE 2. Average Frequency Of Complaints
Per Bed By Variables.......................... 84
V
I. ABSTRACT AND SUMMARY
i
:A. Objectives |
I
I This study is concerned with the long term care system
for older and chronically disabled individuals. Although
the primary focus here is on Minnesota, the analysis and
overall approach can be extended to other areas of the
{
country as well. i
' There were several objectives of the present study.
The first was to determine whether nursing home quality
;of life data are better, the same or worse than regulatory
;survey data for identifying sub-standard nursing homes.
The second objective was to identify the relationship be-
;tween the frequency of quality of care complaints against
nursing homes and the size, proprietary status, geographi-
I
jcal location, and level of care of the nursing homes.
|The third research objective related the variables of the
second objective to administrative-related complaints
against nursing homes. The final objective was to relate
|the nursing home quality of care literature to the results
of this study.
I B. Research Approach
The principal method of investigation involved second
ary analysis of the Minnesota Department of Health's Office
of Health Facilities Complaints' verified and substantiated
complaints against thirty Minnesota nursing homes submitted
i I
• over a twelve month period, June 1978 - May 1979. The i
! I
research methodology also included a literature review of
related research.
i
I C. Research Findings
I The analysis of this study must be viewed as pre-
: liminary. Resident-related and administrative-related
I
! complaints were analyzed for thirty nursing homes in rela- ■
tion to four variables - size, proprietary status, geo-
: graphical location and level of care available. Resident
related complaints were considered synonymous with nursing
, home quality of life data and administrative-related com-
I
plaints were considered a surrogate for nursing home li-
; censure and certification survey data. Resident-related
‘ complaints and administrative-related complaints consis-
i
' tently showed the same variables affecting the frequency
of complaints. In other words, quality of care data re-
■ vealed the same characteristics of substandard nursing
I homes as did regulatory survey data.
' Four specific hypotheses were raised for evaluation. '
In summary form, these were: (a) as the size of the nursing
home increases, it will receive a higher frequency of com- '
plaints; (b) nursing homes with a proprietary status will
have a higher frequency of complaints; (c) nursing homes
with more than one available level of care will have a
I
lower frequency of complaints than those facilities offer-
i
ing just one level of care; and (d) nursing homes located i
I '
' in an urban setting will have a higher frequency of com-
' plaints than those located in a suburban setting.
Size of the nursing home was found to decrease as com-
!
j plaints frequency increased. The hypotheses relating to
I proprietary status, geographical location and level of care'
I :
i available were verified by the findings of this study. In '
; relation to available levels of care, the frequency of com-
, plaints was highest when only skilled care was available
i and lowest when only intermediate care was available.
I
D. Recommendations
In terms of specific policy recommendations at this
■ early stage, three are suggested.
First, to improve the quality of nursing home resi-
!
' dents' lives, the goals of nursing homes must be directed
I I
: toward fulfilling resident expectations. It is understood ,
that this is not a completely realistic goal. It would be
quite difficult to satisfy the expectations of any group
i of individuals. Ignoring this fact of life, however, will |
not improve the life of the institutionalized elderly.
Quality of life goals are at least as realistic as health
maintenance goals and a reassessment of the priority empha
sis of health maintenance versus quality of life in nursing
homes is certainly in order.
I Second, to improve the quality of nursing home resi
dents' lives, the existing system of surveying and regu- ;
, lating nursing homes must be more stringently enforced. |
I
: The results of this study reveal that complaint data are
I equally as likely as survey data to indicate a substandard
j or inadequately operating long term care facility. Every
I state has the mechanism and structure in place to identify '
I such facilities but the abuses and scandals connected with i
I
I nursing homes continue. Abuses continue to occur because
; not enough is done with the data obtained from the com-
' plainant or survey reports. Occasionally, nursing homes
t
■ are fined, reprimanded or placed on probationary status
I
; with the regulatory or reimbursement authorities in a
I state. However, the existence of swift, strong and fair
enforcement actions to chastise the few unscrupulous
I
owners, operators and staff of substandard nursing homes
still is not a reality. Emphasis on strengthening and
I improving the enforcement aspect of the nursing home regu-
I latory system should be a primary consideration for policy
makers. ,
Third, to improve the quality of nursing homes resi- ,
[dents' lives, the variables affecting the existence of
!quality in nursing homes must be examined further. It is
I imperative for consumers seeking nursing home care that all
I information concerning the assessment of such care be avail-
! - I
'able. Traditionally, there has been difficulty in obtain- ^
ing copies of regulatory survey reports on a particular
; nursing home and consumers have been forced to make unin
formed decisions. Complaint data on a particular facility
imight also be inaccessible. If it is possible to ascertain
probable quality of a nursing home by the examination of
I !
(its identifiable characteristics, then consumer knowledge
I
I and opportunity for choice would be greatly enhanced. It
iseems apparent from this study that such identifiable
i
characteristics might be agreed upon by experts in the
I field if enough attention were paid to the need for such
i
'easily understood data.
This study has only begun to examine the complex re-
!lationship between the existence of quality of life and
I
■many variables in a long term care facility. There are
I
! three potential areas for future research.
i
; First, replication of this study for validity and
vertification of the findings should be undertaken. The
; analysis of complaints and regulatory data on a scienti
fically determined sample of nursing homes would permit
jsome assurance of the validity, generalizability, and re- :
liability of the current findings.
I
Second, comparisons of the frequency of nursing home ■
complaints and variables other than the four analyzed in ‘
: this study would provide an understanding of the effect of
I !
other characteristics of the nursing home.
I
; Third, the formulation of public policies for high
quality nursing home care and their enforcement depends on
; the extent to which "quality" can be defined and measured. '
I
! Accurate and efficient measures of quality of life in a
jnursing home or institutional setting must be developed, ;
tested and utilized as one central facet of the regulatory
'system.
; The second chapter of this study examines the back-
iground of the problems in nursing homes. The third chapter
!
analyzes various measures of quality, including the govern
mental regulatory response, and reviews the literature in '
the field of quality assurance in nursing homes. Chapter
IFour presents the research methodology used in this study
and Chapter Five deals with the research results. Chapter
I Six discusses some conclusions, implications and recommend-
'ations suggested by the data from this study.
II. STATEMENT AND BACKGROUND OF THE PROBLEM
I — — - —— --------------------------------------
I A. The Nursing Home Setting
I I
^ Nursing homes are the principal setting for the im-
'paired, institutionalized elderly and disabled. About
1,300,000 Americans, including 5 percent of those 65 and
! over, live in 18 ,900 nursing homes nationwide (DHHS, 1979).
‘Twenty percent of the elderly will spend some time in a
inursing home before dying (LaPorte and Rubin, 1979).
I In 1979, nursing home expenditures amounted to $17.8
1 billion, excluding many medical services, such as physiciani
services, provided to nursing home residents (Fox and
!Clauser, 1980). Government expenditures accounted for 56.7
percent of this total; private payments accounted for the
: remaining 4 3.2 percent.
I Medicaid is the major public source of financial sup-
port of nursing home care, accounting for 87 percent of the
$10.1 billion in public expenditures. To be eligible for
•nursing home care under Medicaid, individuals must have
income and assets below state-established ceilings. Two
types of nursing homes are eligible for Medicaid reimburse-:
ment : (a) skilled nursing facilities (SNFs) , which provide
24-hour skilled nursing care under the supervision of a
1 physician; and (b) intermediate care facilities (ICFs) ,
I which are less intensive and are intended for residents who
I
jrequire care only on an intermittent basis.
^ Federal law mandates that states cover SNF services
for all persons over 21. Although an option, all states i
i
do cover ICFs. The proportion of residents in each type of!
facility varies enormously from state to state. In Louisi-.
'ana, Oklahoma, and Tennessee, only 2 percent of residents
I are in SNFs (and 98 percent in ICFs) compared with 89 per-
!
j cent in Florida (Vladek, 1980).
j Medicare accounts for another 4 percent of public '
jnursing home expenditures. The coverage is limited to 100 !
; days per period of illness for beneficiaries who have been
j I
j hospitalized for at least 3 days. Over the period 1976-
1978, among users of the SNF benefit, the average number of
ISNF days was approximately 29 per beneficiary (HCFA, Note
1). Other public sources, such as the Veterans Administra-
!
ition and various state and local programs, comprise the
I
! remaining 9 percent of public expenditures for nursing home
- care.
The predominant source of private funding is direct
out-of-pocket payments by residents and their families.
These payments account for only 1.5 percent and other pri- ,
vate payments, such as charitable contributions, account
for another 1.5 percent.
Ever since the growth of the private nursing home
i .
[industry, fostered by Social Security programs of 1935 and
I amendments of 1950, 1960 and 1965, the public has been
j aware of the difficulty of providing necessary health and
1 medical care to nursing home residents in a humane and dig-
I
nified setting.
The over-8 5 age group, that sector of society most
; likely to need nursing home care, is the fastest growing
segment of the population. As the demographic bulge gets
I older, the number of elderly will continue to grow, and
I
I continue to be financed by a decreasing proportion of the
jpopulation. This, along with staggering inflation, has
I created serious concern within the social security system
I and has equally significant implications for tax burdens
! on the working-age population. The increasing number of
'elderly will also have a far-reaching impact upon the long
term care system. Consequently, assuring quality while
containing cost is rapidly becoming an increasingly impor
tant issue in nursing home care.
j The rapid numerical and proportionate increase in the
I aging population and the concomitant higher incidence of
I chronic disease are major factors in the growth of nursing
! home care. Of particular relevance is the fact that the
very old among the elderly is increasing faster than the
total 65 and over group : between 1960 and 1970 people 75
and over increased three times the rate of the 6 5-74 group
(Brotman, 198 0). It is this group that has the highest
incidence of the mental and physical impairments that con
tribute to the need for nursing home care. Other factors
are also at work, such as the availability of federal funds^
for the purchase of nursing home care (through the Social
: I
Security Act, Kerr-Mills, Medicare and Medicaid) and fed-
I
:eral programs (grants and loans) that enabled sponsors to
! construct, equip and rehabilitate nursing home facilities
I (Cohen, 1974, details these developments).
I To increase the number of nursing homes to meet per-
. ceived needs of federal Old Age Assistance recipients. Con-,
,gress amended the Social Security Act in 1950 to permit
funding of public nursing homes (64 Stat. 549, 1950) and to
1
,require that states set and enforce standards for both pri-
'vate and public institutions receiving such funding (Con
gressional Research Service, Note 2). In 1953, Congress
; amended the federal Hospital Construction ("Hill-Burton")
I Act to provide construction monies for long-term care fa-
-cilities connected to a hospital or run by public or pri
vate non-profit organizations. The first federal study of
nursing home quality in 1956 revealed that care was univer
sally poor. Another Congressional report in 1974 confirmed
I
I this finding, citing problems of untrained administrators
and aides, too few staff, limited services (particularly ■
rehabilitative), lack of physician attendance or medical
10 I
J
I supervision, inadequate state licensing programs and gross
I
I safety hazards (U.S. Senate Special Committee on Aging,
1974) .
The establishment of Medicare and Medicaid programs ini
11965 was a Congressional response to these problems, re-
' I
quiring nursing homes participating in Medicare to comply ■
I
with specified federal standards. States were admonished
'to improve quality regulation and enforcement under Medi-
j :
Icaid (S. Rep., 1965). In its 1972 Social Security Act
i
I amendments, Congress combined standards for skilled nurs-
I
Iing facilities under Medicare and Medicaid with the process'
I of certification for participation under these programs
I (Social Security Amendments, 1972).
Much of the recent attention to nursing home care is
'generated by rising expenditures. The Congressional Budget
Office (CBO) has estimated that total national spending on
'long-term care was between $18.1 and $20.4 billion in 1976
I(Congressional Budget Office, 1977). This estimate in-
j eludes both public and private spending for all long-term
] I
,care services, institutional and non-institutional, for
I the elderly, the physically handicapped, the mentally ill,
; the mentally retarded and alcoholics. Thus, the Congress
ional Budget Office estimate is based on a population
broader than is being considered in this paper. ;
The increase in nursing home expenditures has been
11
particularly rapid, rising from $7.2 billion in 1973 to
over $17.8 billion in 1979. Between 1973 and 1979, nursing
home expenditures grew 148 percent, compared with an in-
jcrease in the consumer price index of 64 percent and a
growth in the gross national product of 81 percent. In
! ■ I
19 79, nursing home care was the fastest growing component |
( .
of personal health care expenditures.
This escalation of nursing home costs is reflected in
,federal and state budgets. Total public expenditures on
inursing home care increased from $3.6 billion in 1973 to
I ;
I$10.1 billion in 1979. This expenditure growth is a func- !
Ition of both increases in the cost per day and in the num- :
Iber of days of nursing home care used. For nursing homes
'certified to participate in Medicare and Medicaid, per diem
costs between 1973 and 1977 increased 55.2 percent, 50 per-
I
cent faster than the consumer price index (Fox and Clauser,
1980). The number of residents increased 21.1 percent,
I compared to a 12,7 percent growth in the elderly (over age ■
j '
I 65) population (U.S. Department of Health and Human Ser-
: vices, 1979) .
I
B. The Nursing Home Problem
I The provision of decent, humane, long-term care in
'institutions for the aged has drawn the attention of legis-
:lative bodies throughout the United States over the last
one and a half decades. In the fall of 1961, the Sub-
‘committee on Nursing Homes of the Senate Special Committee
12 ,
on Aging held hearings on the condition of American nursing
homes in Oregon, Washington, Connecticut, Massachusetts,
and Missouri. The testimony taken in those hearings ran to
853 pages. In 1963, the same Committee held hearings in |
I I
I I
I Washington, D.C., taking testimony from federal officials I
! I
of the Department of Health, Education and Welfare, the '
I
Bureau of Family Services, the Public Health Service, and
the Veterans Administration. The following year, the
; litany of problems, projected solutions, facts and figures
: were repeated in three hearings, a testimony of 300 pages.
; In 1965, a series of hearings were held throughout the na
tion, reprinting studies and recommendations for a grand
total of more than 900 pages. In 1969 and 1970, the pro-
!
'cess was repeated in an attempt to search for solutions to
; what was apparently an intractable problem. In 1971, no
fewer than 19 separate hearing sessions were conducted by
the Subcommittee on Long-Term Care of the Special Committee
j on Aging of the U.S. Senate.
, The problem of unsafe, unsanitary, non-therapeutic,
! dehumanizing conditions within existing nursing Homes re-
1ceived the attention of the White House Conference on Aging
; in 1971, and President Nixon felt impelled to comment twice
! during that same year on the problems of producing quality
care in nursing homes (Nixon, 1971). In 1973, the Special ,
Committee on Aging of the U.S. Senate and the Subcommittee
13
I on Aging of the Committee on Labor and Public Welfare pub-
ished the Post White House Conference on Aging Reports
carrying recommendations of the White House Conference, the
Administration's response to those recommendations, and the
I i
' final report of the Post Conference Board of the 1971 White'
House Conference on Aging. In 1974, the Subcommittee on
■ Long-Term Care initiated the publication of a ten volume
series under the general title, "Nursing Home Care in the
I
; United States : Failure in Public Policy," which outlined
I the characteristics of those in nursing homes, of the in
dustry, nursing home personnel, and industry funding.
I The above is only a brief review of national-level
, concern. In connection with the White House Conference on
t
Aging, virtually every state in the country went through
I a similar review and expressed similar concern about the
quality of care and the quality of service.available in
long-term care facilities.
I From 1974 to 1976 the Senate Special Committee on
I Aging, under Chairman Frank Moss, issued nine reports on
I most major aspects of the nation's nursing home industry,
i
the results of 15 years of hearings on these issues. These
I
lengthy reports and the 19 74 publication of Tender Loving
'Greed (Mendelson, 1974), a best-selling popular expose of
nursing home problems in Ohio, disclosed scandalous pro- j
fiteering by nursing home operators at the expense of nurs-:
I ing home resident care.
:
In December 19 74, the Subcommittee on Long-Term Care
of the U.S. Senate Special Committee on Aging released
Supporting Paper No. 1, "The Litany of Nursing Home Abuses
,and an Examination of the Roots of the Controversy." The
i
.report concluded that nursing home abuses include both
physical mistreatment ranging from battery to murder, and
psychological mistreatment, such as neglecting to remove
from rooms occupied by others the bodies of those who die.
fIn an attempt to answer the question of how many nursing
ihomes are substandard, the Subcommittee determined that
I over fifty percent of U.S. long-term care facilities are
substandard to the extent that they have serious and life-
; threatening (as opposed to technical) violations of state
! licensing and federal certification regulations.
Instances of resident abuse by nursing home staffs
abound, ranging from deliberate physical injury to refusal
'of assistance to residents in the performance of daily
! activities such as walking to the bathroom, dressing or
I
(bathing. Nursing homes often sedate residents, physically
!
; restrain them, and deliberately injure them for staff con
venience , and residents' property and funds are frequently
lost or stolen. Resident privacy also is violated, and
,little consideration is given by nursing home staff to the
: effect of their actions upon resident dignity. For example
I
Supporting Paper No. 1 cited instances of male and female
15
iresidents being bathed together in spite of the extreme
embarrassment this may have caused the resident involved.
Residents sometimes are charged for services not received,
;or they are charged at artifically inflated prices. An-
1
iOther problem frequently encountered is the refusal of some
' I
facilities to take Black or Medicaid residents (U.S. Senate I
Special Committee on Aging, 1974).
The average nursing home resident in the United States
|is an 8 2-year old white woman, widowed, possessing no via
ble relationships except possibly with a collateral rela-
jtive of roughly the same age. She has approximately four
chronic or crippling diseases, and is probably suffering
,from some mental impairment. She cannot walk unassisted,
and she probably requires help in taking a bath, dressing,
and going to the bathroom. She takes large quantities of
drugs. Upon entering the nursing home she is afraid. She
thinks that she will never leave the nursing home alive,
jshe is probably right (U.S. Senate Special Committee on
j
jAging, 1974) .
i It is unclear whether observations concerning mental
'impairment are medically valid in light of the large
'amounts of drugs prescribed for nursing home residents
(Butler, 1975). In 1972, the average^.nursing home resident
consumed $300 per year in drugs. Approximately 20 percent
of the drugs consumed were tranquilizers, the most often
16
prescribed being Thorazine and Darvon. There is evidence ‘
that many elderly persons have become drug addicts while
residents in nursing homes (Butler, 1975; Townsend, 1971; '
!u.S. Senate Special Committee on Aging, 1974).
i The nursing home industry, which is largely propri-
I
etary, is often guilty of interlocking kickback arrange
ments with external service providers. In states that have
■adopted flat reimbursement formulas for Medicaid residents,;
' I
.the formulas act as disincentives to high quality care.
! This is true because the owner 's profit comes out of the ,
Î :
! flat rate after operating costs are paid. Such a proce- •
I
; dure encourages the owner/operator to cut corners on resi-
I dent care to increase profits (U.S. Senate Special Com-
I
:mittee on Aging, 1974).
Residents also suffer as a result of Medicare and
'Medicaid regulations. Regulations may limit the freedom, of
residents to leave the nursing home for short therapeutic
visits, such as during holidays. Medicaid utilization re
view regulations, a cost control device designed to insure
that only residents who truly need health care receive it,
may adversely affect residents. Such reviews may result
! in the transfer of a resident from the nursing home to a
i
I distant community with little notice and without an effec
tive oppotunity to contest the proposed transfer. Another
consequence may be the refusal by Medicare to pay for the
residents' care without the opportunity to contest the
! 17 I
decision (Health Law Program, Note 3).
Many of those nursing home residents subjected to
abuse are afraid to report it to relatives or other out-
jsiders for fear nursing home personnel will retaliate.
•Because of infirmity, and fear, the typical nursing home
resident is particularly vulnerable to mistreatment (U.S.
Senate Special Committee on Aging, 1974).
' Even in the absence of such conditions, the large in-
jStitutions, by their very nature, have a dehumanizing, de-
\
jbilitating, stagnating effect on their resident populations
fostering dependency, parasitism, and helplessness (Coff
man, 1961). Coffman has described the mortification pro-
jcess which must be endured by inmates in total or closed
institutions. Rosenhan (1973) has described the avoidance
I
'techniques of the staff in such institutions, and remarks
upon the curious perversion of values which causes those
with the most prestige and training to have the least resi-
ident contact, and those lacking such credentials to have
jthe most. Residents become non-persons; they may be physi
cally and verbally abused in the presence of others, their
possessions may be examined for any reason, and conversa
tions of a private nature may be carried on in their pre
sence as if they were not listeners (U.S. Senate Special
Committee on Aging, 1974) . Moreover, a range of civil
liberties are frequently denied to those who are institu
tionalized. Due process rights may be blandly ignored in
18|
the conduct of internal administrative procedures (Ferleger,
1973).
Even before the 1974 Subcommittee studies were public,
the federal government acknowledged the abysmally poor
'State of care in nursing homes funded primarily through
! ■ ■ I
government money. In 19 74 President Nixon and then Secre
tary of HEW Weinberger launched the "Long-Term Care Facili
ty Improvement Campaign." This included training federal ,
nursing home inspectors and redesigning the federal Medi-
jcare/Medicaid nursing home quality standards and enforce-
i '
ment process to determine whether residents were obtaining
jneeded care, rather than whether facilities were theoreti-
I '
jcally capable of providing it (HEW, Note 4).
I State governments have also investigated nursing home
I
problems within their boundaries. From the 1975 Moreland
Act Commission Report in New York to the 1978 Report of the
Ohio Nursing Home Commission and the 198 0 Report of the
(Florida Long-Term Care Ombudsman Program, these studies
have uniformly revealed a pattern of resident abuse and
neglect, poor administration, fire safety hazards and
^illicit financial schemes (California Joint Legislative
Committee, Note 5; Colorado Attorney General, Note 6; Flor-
jida Nursing Home Ombudsman Committee, Note 7; Illinois De
partment of Public Health, Note 8; New York State Moreland
Act Commission, Note 9; Ohio General Assembly Nursing Home
Commission, Note 10; Texas Attorney General, Note 11).
! 19*
One of the most striking characteristics of the nurs- '
ing home system in the United States is its wide diversity,
I
not only among facilities, but within facilities. Even I
though chains of nursing homes exist, a fairly large number ;
of facilities are owned and operated by individuals or
partnerships. Although federal and state regulatory bodies,
1
have attempted to impose a certain degree of uniformity on ’
the nursing homes in this country, a great diversity re
mains .
Although some nursing homes are fashioned to develop
I specialties in long-term care, the majority include resi- |
I dents with many different diagnoses, levels of independence
I and most importantly, attitudes toward their illnesses and
1
disabilities. Senility is the precipitant for admission
! to a nursing home in over 50% of the cases, but this diag-
'nosis is only a grab-bag of many differing diagnoses
(National Center for Health Statistics, 1979). Family
; involvement, long-identified as a critical factor in the
i
I quality of life for a nursing home resident, also differs
I
I widely from resident to resident.
i
IC» Quality in the Nursing Home Setting
i The question of whether it is feasible to impose
I uniformity, in the form of federal and state standards for
I
; nursing home care, on such a diversified system is one
: I
which calls for a thorough and exacting examination of the
20
I sensitivity of such standards of quality. Different admin-
iistrative styles, different mixes of types of residents and
i
differing labor supplies and economic conditions all con
tribute to the doubt that federal and state standards alone,
i :
can achieve quality in nursing homes. If a single standard'
or the set of federal and state standards does not prove to
be a possibility for assuring quality, then the equally
I complex question of what facility and resident characteris
tics can be used as valid predictors of quality must be
j considered.
I ‘ ^
Residents within institutions experience a double lim-
Iitation of their rights : one created by their disabilities
I and the other by the very organization of the institutional
' system. While the actual disability which requires resi-
'dential care may limit a resident somewhat, the prejudge-
’ment of his or her capacities by the staff may constitute
a far greater obstacle. In the nursing home facility, this
means that the simplest request— for aspirin for headache,
; the right to call home— is subject to evaluation, inter-
'pretation, and possible rejection if it is viewed as "not
I
,in the resident's interest." Even in the most enlightened
'institutions, there would inevitably be a strain between
! the needs of the individual to live a life without outside
domination, and the institution's need to deliver service
efficiently. In a long-term care institution, such organi
zational factors can be dehumanizing and promote frustra-
i 21
tion, resignation, and despair (Annas and Healey, 1974). '
There has been a considerable outcry about the detri- '
mental effects of institutionalization and institutional
life. Coffman's (1961) descriptions are perhaps best known,
I but the publications of others (Aldrich, 1964; Barton,
: ' !
1969; Lieberman, 1969) have helped to make clear the dele- ;
,terious effects of mass custodial care in poor institu-
!tions. Descriptions of the personalities of residents who
have been subjected to such living conditions have been
{summarized by Lieberman, Prock, and Tobin (1968).
! How elderly individuals view themselves and their i
I !
social environments during and after transition from commu-
Inity living to residence in a nursing home was explored by
I
Lieberman and Lakin (1963). Basic data, consisting of
clinical impressions, case histories and interviews, were
obtained prior to admission and three to five months fol
lowing entrance to the institution. The meaning of insti
tutional life varied by sex : males saw it as a loss of
power, while females interpreted it as rejection or being
unwanted.
Bennett (1963, 1964) analyzed institutional life and
living in terms of various meanings for the aged residents
'of nursing homes, for the personnel in nursing homes and
for society at large. Nursing home staff members saw them-(
! selves as caretakers for a group of powerless clients in
22 1
jneed of services, and saw residents as passive recipients '
of care. The residents eventually responded to the expec
tations of institutional life and accepted the roles as
signed to them by personnel.
i !
There is little to suggest that, in general, living ;
in an institution has a beneficial effect on the individ- I
I
ual. Possible exceptions could include those who, because
of economic problems, lead a marginal existence in the
icommunity. There are indications that those who survive
I
iin institutions and adapt best have personalities congruent,
; !
! with the practices of the institutions in which they reside
1
^ and do not exhibit symptoms which the institution cannot
I handle (Stotsky, 1970; Turner et al., 1972; Weinstock and
i
! Bennett, 19 71).
I
; In a paper that has come to be a classic on the sub-
iject of institutions, long-term care facilities and other
residential institutions are conceptualized by Goffman
j (1961) as "total institütions" and are described as ". . .
: the forcing houses for changing persons in our society.
'Each is a natural experiment, typically harsh, on what can
be done to the self." Goffman defined a total institution
I as one which is "symbolized by the barrier to social inter
course with the outside." It acts in a way to "break down
. . . the kinds of barriers separating statuses" in that
all aspects of life are conducted in the same place, each
23
I phase of a resident's daily activity is carried out in the
I immediate company of others, all phases of the day's activ-
I
j ities are tightly scheduled and the contents of the various
! activities are "brought together as parts of a single ra-
i
Itional plan purportedly designed to fulfill the official
I
aims of the institution" (Goffman, 1961, p. 46).
I :
Goffman has defined a "total institution" as one which
I is "a place of residence and work where a large number of
like-situated individuals, cut off from the wider society,
for an appreciable period of time, together lead an en-
! closed, formally administered round of life." Nursing [
I homes have many of the characteristics of total institu-
i
,tions, though most would not rate as high on totality as
would most prisons or state psychiatric hospitals. The
I characteristics of the total institution result in dehuman-
i
ization of the inmate or resident. Some of these charac-
!teristics are: (a) handling of blocks of people by bureau-
Icratic means, (b) indefinite duration of institutionaliza-
I
jtion, (c) all or most segments of living occurring in one
I
I
i setting such as a single building or cluster of buildings
[on the same plot of ground, (d) the application of indus-
! trial production techniques to human affairs (e.g., treat-
1
ing persons as categories), (e) disregard for the person's
normal privacies, (f) decreased responsibility of resident
for own domestic arrangements, (g) stripping of self-
24
identification, (h) personal possessions handled by others
without resident's permission, and (i) regimentation of
activities governed by a routine and measured pace.
In short, the sociological significance of the long-
I term care institution is its potential for the modification
of behavior. From a psychological perspective this poten- i
tial is characterized by a totally encompassing environ-
, mental setting which controls inter-personal interactions, ,
: defines roles and behaviors, and sets limits. The more
: total the institution the greater the restriction upon
: any effort to act or react to events outside that institu-
i tional setting. This carries with it a considerable degree^
of difficulty for the individual since certain behaviors
^ reinforced by the larger social system may yield negative
‘ and aversive reactions within the particular institutional
setting.
The therapeutic purpose of institutionalizing a
I chronically ill or disabled person in a nursing home should
j be to assist that person to live with disease or disability
! while carrying on activities of daily living and maintain- '
: ing independent function to the greatest extent possible.
' To determine whether this purpose is met, and hence whether
: the facility provides high-quality care to its residents,
there should be an examination of precisely what care each ,
resident requires in order to treat or manage illness and
; to achieve independence and self-care. One must also
' 25:
j examine the more elusive and intangible factors which con- :
1
tribute to the quality of life in a nursing home : the dig
nity of service, the physical surroundings, the quality of
the staff's caring for the humanity of the residents. i
: These factors are most difficult to quantify and evaluate,
I
but their presence is critical to a rehabilitative suppor-
I
■ tive atmosphere.
' D. Measurement of Quality
I Parallel to the growing demand outlined earlier in
jthis paper for public accountability in the nursing home
! :
’ field (Vladek, 1980) new methodologies for the assessment !
I of such quality of care have recently been developed.
: These procedures have generally been called medical care
evaluation studies, or synonymously, medical audit, nursing
audit, etc. They have been developed by the various dis
ciplines involved, the methodology usually restricted to
a particular single discipline. This has led to fragmen-
:tation of the evaluation mechanism by the separate disci-
iplines. More recently, there has been added emphasis on
I the necessity for resident care evaluation of an inter-
I disciplinary type. This has paralleled the change in the
I
j approach to health care with the growing concern for the
! total resident as a unique individual and a realization
that care requires an interdisciplinary approach.
To evaluate the quality of care, methods had to be
26
developed to measure quality. Until the recent past, mea
surement instruments were based on measurements of the
structure in which care was delivered. Such measurements
were applied not only to the care provider, but also to the|
I facilities and services necessary to deliver resident care..
In an ideal market setting, there would be no need for :
I
; the regulation of quality. The decisions of well-informed
'consumers would alone prompt suppliers to meet certain de-
:mands and the needless bureaucratic tangle of any regula-
I tory process could be avoided. There are many reasons why
I a completely competitive market with no regulatory process
I is not viable in the nursing home industry. In the nursing|
I home field, the consumer is usually infirm and often unable
to make critical decisions such as what facility optimally
'meets his or her needs. Families, who usually carry the
'burden of these decisions, often have difficulty in weigh
ing cost considerations against quality factors.
! It is not feasible to set the consumer adrift and hope
'that demand will encourage the industry to self-regulate.
Federal government, which directs roughly $50 billion into
long-term care, has an obligation to assure that its money
is well spent and that the services provided are reasonably
free of fraud and abuse. Considering the large amount of
money spent on financing nursing home care, the percent \
spent on regulation, or quality control, is relatively
27
jsmall. For example, Massachusetts in 1979 spent approxi-
Imately $12-15,000 a year financing nursing home care for
! each resident, but allotted only $54 per resident for sur-
j
Iveying and enforcement of regulations governing those same
I
nursing homes.
j
Ensuring quality of care to nursing home residents,
I
'at least as "quality" is measured by state and federal
licensing and certification standards, is currently the
,responsibility of state government, using a federally de-
I signed system. States both license health facilities under
I state law and certify their compliance with federal Medi-
t
Iciad and Medicare standards. Government's response to the
; nursing home scandals has not been encouraging. The states
I
! have been criticized for not developing meaningful quality
I standards, for not enforcing standards evenly and aggres-
’sively, and for preferring to consult with rather than to
police the industry. A few states have worked diligently
I to overcome these problems. Nevertheless, state nursing
I home quality assurance programs in general do not seem to
I have greatly improved nursing home care. This is not
'exclusively the fault of the state agencies. Most are
! hamstrung by very limited enforcement remedies - revocation
; of a license or Medicaid certification - which makes their
I
only choice either closing a facility and moving frail
elderly residents or maintaining a substandard facility.
28
A shortage of nursing home beds and lack of noninstitution--
j al long-term care services in most states complicate the
I !
I enforcement problem.
In addition, many,states are chronically understaffed ,
I '
due to limited legislative appropriations. The mandate
i
that states use the federal forms and procedures for Medi-
, caid certification provides a disincentive for states to go
I beyond minimum federal standards. A further difficulty
I
, faced by state enforcement agencies is the effectiveness
I
I with which nursing homes and the nursing home industry
I
I have used the courts to demand lengthy pre-revocation hear-
jings. The industry has challenged the substance of license
: revocation decisions as subjective and based upon vague
I standards. Even when these motions are ultimately unsuc-
i cessful, the delay stifles agency action and demoralizes
I
I employee initiative.
! Nursing homes today are being licensed under a variety
I of definitions by state agencies in accordance with a set
I of standards which are minimal in many jurisdictions, and.
i ■ '
I varied in content and enforcement from one state to another.
The nursing home field contains a variety of other problems'
which have yet to be resolved, including : a shortage of
'beds; shortages of professional skills such as trained
I medical staff, registered and licensed practical nurses,
1 therapists and social workers ; low salaries for nursing
ihome personnel; inadequate nutritional standards among some
291
facilities; substandard physical plants ; operators without
: proper qualifications; and divergent philosophies between
non-profit hospitals and profit motivated nursing homes.
There are many reasons why the nursing home field has '
been plagued by a negative image. Each of the reasons :
contains a truth but also serves as a rationale for inac- I
I :
,tion. The majority of nursing homes are profit motivated.
'They often state that they provide those services, however
; minimal, which a state requires for licensure. They main-
i
I tain they cannot provide additional or the same services
'at a higher quality level, especially in regard to welfare '
i
jrecipients, unless the state is willing to reimburse them
1
; at a higher rate. The responsibility thus passed to the
state, its authorities often say that they not only lack
I the personnel to enforce the licensure standards but if
'they did enforce them, the faulted facilities would cease
operations without the state having other facilities in
I which to place welfare recipients. In addition, the public
!
I
jauthorities often state that they do not have the budget to
I
jpurchase better care because the public does not wish to be
I
; taxed for such purposes anymore than is absolutely neces
sary. The responsibility thus passed to the taxpayer, he
'and she justifiably ask how much taxation is enough and why,
additional taxes are necessary when there is not even the
certainty that current tax revenues are being spent as
30
jjudiciously and as carefully as possible.
I
For many decades these rationales were and continue to
be heard. As a result of years of neglect the socioecono
mic problems of our society have emerged with the full
force of almost revolutionary momentum. It is easy to ^
understand how a small area of health care, such as nursing,'
homes, might easily rationalize its lack of importance in
the greater schemes of our society and be inert over the
past years in making changes for improvement of its own
I condition. But it is also easy in such a situation for any
^field, including nursing homes, to accept and be comforta-
Ible with the status quo or lack of progress by reasoning
I
j that public demand for other priorities makes its demands
,weak, impotent and ineffectual. The industry has become
'so comfortable that it becomes easier to resist changes
I
'even when opportunities are created to make progress in up
grading the field's quality. Other segments of our socie-
'ty in the past have created interest and aroused in the
^ public a concern that the problems affecting their parti-
!cular interests be solved. It seems reasonable then that
those same segments should have interest in the nursing
jhome field. This was and is a responsibility from which
I
I they cannot shirk. It is hard to believe they could have
been blind or lacking in knowledge about the problems which !
confronted them. However, many of the problems which beset
31
the nursing home field arise from those facilities which
are already licensed and, supposedly, regulated.
The problems within the nursing home area did not
suddenly appear with the passage of Medicare and Medicaid.
i
i What these federal programs accomplished was to focus the
public spotlight on troubles which always existed. Thus,
when the time came for these facilities to assume their
'rightful place in the health care continuum, the public
through its government found that many were unable to as-
jsume their assigned tasks and roles. Years of neglect and
I deficiency left them unprepared to do so.
Today the rationales that allow unsanitary, over-
■ crowded and unsafe nursing homes to operate are no longer
! excusable. The reasoning which allows public assistance
; authorities to place welfare residents in nursing homes who
'bid the lowest rates because of the lack of public support
or interest in the welfare system is unacceptable. It is
i
I not sufficient just to have standards which eliminate
I abuses cited in myriad studies. Rather, we must develop
I the necessary checks and controls to assure that abuses
; will not occur in the future even if the requirements are
incorporated into licensure standards.
32
Ill. LITERATURE REVIEW
The purpose of this study is to explore the relation- i
ship between the size, level(s) of care, profit/non-profit
I status, and geographical location of a long-term care I
'facility and the frequency and types of complaints it re
ceives, with complaints used as an index for measuring
quality. Previous research and observation of nursing home
i
care suggests that a correlation exists between complaints
I ■ '
I of nursing home residents and quality of care and life
i
; available to those residents. Most of the available liter-
I :
Iature, however, treats quality in nursing homes as an un- !
I
I measurable variable which can be more or less safely ig-
I
i nored when studying the more measurable concepts of cost
I or utilization.
I A. Assessment of Quality in
I Nursing Home Care
I Central to this study is the question of how to assess
I quality in long-term care. There are many factors that
: contribute to the difficulty of producing a reliable quali
ty assessment instrument. Many current research projects
I are attempting the development of such a quality assessment,
'tool. There are many incidents which document the illogic
'of correlating compliance with regulations with the ade
quate delivery of nursing home care. Massachusetts, for
: 33 !
I example, has devised a weighted system by which a specific
! number can be calculated to calibrate the degree of facili
ty compliance with resident-oriented regulations. The fact
that many nursing homes which have higher than average com-
Ipliance scores are in the process of decertification for ;
inadequate care is evidence one cannot simply equate regu- i
(
latory compliance with quality of care. It is expensive to
: survey the many long-term care facilities to determine if
they are in compliance with standards. Additionally, it is
i
; probable that there is only a loose and inconsistent link
between compliance and quality of care. Quite simply, it
I is not clear that nursing home regulations are linked to
; outcomes.
I It is recognized that nursing homes have many goals,
t
* and that "quality" with respect to organizational objec
tives may be somewhat incompatible with other organiza-
jtional goals. Nursing homes in the United States, for
I example, are 77% proprietary and seek to make a profit
I while also serving residents. A look at institutional
I quality from a strictly economic point of view, with insti-
I
,tutional profit defined as the primary objective, would be
I
I quite different from the analysis that follows. The per-
Ispective on quality that is adopted for the purpose of this
paper concerns quality of life in the institution as ex
perienced by the residents. The concern is with how well
34
{nursing homes meet resident-oriented goals.
I Presumably, regardless of the label or the types of
care provided, one of the major long-range goals of insti
tutionalization is to provide the nursing home resident
I -
with high quality care that best meets his or her.needs. i
In order to fulfill this goal, there is an effort to avoid, j
to the extent possible, the creation of new problems due
to the institutional residency.
I
Based on the above, quality of care can be defined in '
I
{terms of the extent to which care maximizes quality of
dife (including physical, social, cognitive, and emotional
{functions as well as feelings of life satisfaction). From
{this point of view, the problems in the determination of
'quality of life measures pertain also to measures of quali-
jty of care. The ultimate test of quality of care is in
terms of impact of the care on the health and well-being
I
of the recipient of the services. Perhaps because of mea
surement difficulties and assumptions made concerning the
jrelationship between structural or process variables and
resident outcome, the problem of the evaluation of quality
of care has been attacked from a variety of approaches
(Altman, Anderson and Barker, 1969; Donabedian, 1966,1968;
Kiresuk and Sherman, 1968 ; Kosberg and Tobin, 1972; Levey, ;
1
Ruchlin, Stotsky, Kinloch and Oppenheim, 1973; Linn, 19 76;
Donabedian, Note 12).
Quality of care has been approached in terms of such
!
I 351
{structural features as staff/resident ratios, qualifica- i
jtions of the staff, number of resources or options within
ithe facility available to the resident, medical surveil-
I lance, justified medical procedures, continuing education |
! ■ I
of staff members, degree of compliance with state or fed-
I
eral licensure or certification regulations, and the like.
In order to enforce a resident's right to high quality
'nursing home care, one must first have a fairly specific
, and objective standard which defines the level and com-
jponents of high quality care. The very term quality,
however, connotes a subjective judgement which is difficult
I
I
to quantify. One can say with some certainty that to be of
^high quality, nursing home care must meet resident's medi-
;cal, nursing, emotional, psychosocial, and rehabilitative
'needs, and should encourage resident's maximum independence
and self-care.
^B . Standards of Quality
Avedis Donabedian, the leading theorist on defining
quality, has divided quality of care standards into three
categories: structural, process and outcome measures,
according to whether they examine the framework or setting
i for care, the actual health services delivered, or the
'resident outcomes from a mode of treatment (Donabedian,
: 1966) . Other commentators have suggested two additional
: ways to view quality of care : according to its social
361
I
impact (the effect of care on the overall community) and
residents' perceptions of quality (Lebow, 1974; Regan,
1975) .
! While each of Donabedian's three approaches has been
applied to some extent with respect to acute hospital care,
1
quality measures for long-term care have to date emphasized;
structural standards which examine facilties and equipment,
{numbers and qualifications of staff, administrative organi
zation and operations, and fiscal systems. The Medicare/ '
I Medicaid Conditions of Participation include requirements
1
! that nursing homes have certain physical plant features !
I and also have policies regarding residents' rights and
■ care, staff organization and services provided. The survey
i
I process, however, does not generally examine the content of
I the policies or whether they are implemented. Fewer than
2 0 of the 541 items on the Medicare/Medicaid survey inspec
tion form (SSA 1569) require the examination of care given
to residents or require surveyors to observe residents -
(Ohio General Assembly Nursing Home Commission, Note 10).
Most of the surveyor's time in the facility is spent re-
I viewing documents, including staffing charts, menus, poli- ■
' cies and procedures. This approach is based on the assump-
' tion that if the structure is appropriate and the facility
has the capacity to provide good care, then good care will
be provided. Donabedian recognized the fallacy of such a
37
I general inference (Donabedian, 1966) and the Department
: of Health, Education and Welfare repeatedly recognized the
jlack of applicability of this approach with respect to
Jnursing homes in particular (Department of Health, Educa-
!
tion. and Welfare,.Note 4) .
Donabedian's process standards examine the actual care
delivered to residents and compare it to established norms
or empirical standards and to expert opinion or normative
I
I standards of appropriate care (Donabedian, 1966), Long-
* term care facility process standards would require survey-
:ors to examine, on a sample basis, the completeness of in
formation received about a resident through testing and
diagnosis, the appropriateness of prescribed therapies to
I
(address the diagnosis, and the technical accuracy of diag-
: nostic and therapeutic procedures. Peer review processes,
such as institutional utilization review (42 U.S.C. Section
1395x(k) and Professional Standards Review in Hospitals
(Price, Katz and Province, 1977), employ such a process
'approach, using standards developed from community norms
I
of medical practice. In long-term care, as contrasted
with acute hospital care, process standards are difficult
to determine. Norms of care are relatively easy to esta-
I
'blish in acute illnesses for which medical outcomes can be
{defined and evaluated. Treatment for chronic medical
!
conditions, however, is far more, complicated to validate.
38
Thus, while some process measures exist for long-term care,
many are still in developmental stages.
Donabedian's third approach to regulating the quality
of care examines the outcomes of care : whether residents
I achieve an expected recovery or restoration of function, or
whether they stabilize rather than deteriorate. In apply
ing an outcome measure to a nursing home resident, the
means used to achieve the desired outcomes are not of con-
I
!cern so long as the result is achieved (Donabedian, Note
I 13) . However, Donabedian recognizes that if the outcomes
1
jwere not achieved, one would have to examine the process of
'care to determine the reasons (Donabedian, 1955). He fur-
Ither acknowledges that there might be legitimate reasons
j why a given individual does not reach an expected level of
recovery, regardless of medical or health intervention.
Outcome measures have traditionally been limited to gross
: mortality or morbidity assessments in acute care settings.
IA few have been investigated for chronic conditions such
i
I as stroke, heart attack, hip replacement and activities
jof daily living (Katz and Apkom, 1976). However, validated
{outcome measures do not exist at present for most of the
'traditional conditions of nursing home residents.
(
! Unfortunately, although outcome measures appear to be
the most rational standards by which to measure quality of
care, including nursing home care, they are time-consuming
39,
___ J
I to determine. This is especially true for chronic condi-
itions, and the use of outcome measures may subject resi
dents to undue risks of bad care for period between the
points of measurement of a particular expected outcome.
Furthermore, since outcome measures are not generally in
j
existence, such measures cannot currently form the basis
of a quality of care regulatory system.
As mentioned above, current nursing home standards
: under federal and state law provide primarily structural
1
[measurements of facility capacity to provide care. They
! have been severely criticized by consumers, providers, and
even the Department of Health, Education and Welfare itself
; in its 1975 "Long-Term Care Facility Improvement Campaign
'Introductory Report." To look beyond structure to process
I
or eventually, outcome measurements, requires far better
jfacility record-keeping, standardization of resident as-
:sessment data, and surveyors skilled in monitoring for
I
I quality with independent assessments of care and the judge-
!
jment of acceptability.
I While it did not deal with long-term care facilities
directly, Goss' (1970) review of the available research
I
: findings concerning organizational goals and quality of
'medical care has implications for hypothesis formulation
and research concerning quality of care for the long-term
care resident. Measures of quality of care being reviewed
40
include assessments of process (primarily qualified clini
cians' ratings of care based on medical records), and mea
sures of outcome which have included survival rates.
Available empirical studies were reviewed in terms of rela-.
■tionships between variations in the commitment of hospitals
to such goals as teaching, research, profit and service and
.any variations in the quality of medical care in the hos-
! pitals as measured by outcome or assessments of the care
■ process.
j While the American value system suggests that it may
I be reasonable to insist that variables such as cleanliness,j
Î adequate nutrition and a safe environment are minimal pre-
; requisites for adequate nursing home care, inferential
I
! leaps are often made concerning structural features (staff-
i
'resident ratios, for example) or even process features
(such as continuing education program), and resident out-
.come. It is recognized that in the absence of hard data,
'reliance must be placed on informed estimates. It is also
j possible, and it is the thesis of this study, that analysis
: of complaints against nursing homes may prove valuable in
assessments of quality of care (considering for assessment
purposes the institution as the basic unit of study.) If
! the complaint analysis assessment proves feasible in con-
!tributing to the assessment of the quality of nursing home
care, it would then be possible to develop and design
41
jeasily applied instruments for further use. As pointed out'
I by Anderson and Stone (1969) in their discussion of re-
jsearch findings concerning quality of nursing home care:
■ In an examination of standards— that
: is, assumptions about what quality
is--it becomes apparent that attention
I has been focused mainly on . . . char- |
acteristics which might be considered
good resources appropriate to the
provision of good care, rather than
on . . . how that care affects con
dition. Evaluating the quality of
nursing home care then becomes a task
I of relating the care actually given
I an individual to some statement of
I goal achievement potential. Then
, quality could be measured, not in i
j terms of input (facilities, staff,
j and other resources), or in terms
of output (what programs or activities
are undertaken or participated in),
! but in terms of outcome : is the
1 patient restored to and maintained
' at the best level of functioning
possible? (p. 23)
Researchers have generally taken one of two approaches
to the investigation of quality. One method is to devise
I
a list of probable indicators of quality, and to study what
I types of facilities rate highly. For example, Anderson and
i
I her colleagues thought that the following would be impor-
I I
I
I tant characteristics in the quality of nursing homes : the
'number of persons per room and bathroom; whether or,not the
I facility had been originally designed as a nursing home ;
the number of staff hours per resident ; resident participa
tion in various activities; and the therapeutic orientation;
42
,of the administration. They found higher quality in facili-
ities with fewer welfare residents, higher costs, rural lo
cation, larger size, and in those attached to hospitals,
{with fewer ambulatory residents, and in accredited facili-
1 i
jties (Anderson and Stone, 1969). One problem with this
method is that we often don't know what difference it makes
to the resident, for example, to have more nurses available.
I A second approach to the measurement of quality of
I
{care in a nursing home has been to study a probable indi-
jcator such as crowding or staffing patterns in relation to ,
I ■ ■ i
^various outcomes such as resident satisfaction, social !
'participation, or staff performance (Dick and Friedman,
1964; Pan, 1952). The problem with this type of investiga-
jtion is that even if we know that residents are happiest
!in small' facilities, new facilities, facilities with many
nurses or facilities in rural areas, we still do not know
I
much about the outcome of resident happiness in relation
jto quality.
I A third approach, rarely used, is that employed by
I
jTaietz in his 1953 study of three homes for the aged.
{Taietz selected homes of high, medium and low quality as
determined by professionals working in the area. He found
that resident happiness was indeed highest in the facili-
I
ties judged to be of best quality by outside observers.
However, he also found that the characteristics that made
I 43!
j this home the best in professional eyes were not in many
I cases what made it the happiest environment for the resi
dents (Taietz, Note 14).
^ C. Commonly Used Indicators
I of Quality
i Quality of nursing home care, like quality of other
'health and welfare services, appears to be an elusive
,phenomenon. Quality indicators are measures of factors
I which are assumed to be characteristic of nursing homes
where residents improve as much as possible and receive
good care. Quality of nursing home care has sometimes been
examined by dividing nursing home characteristics, nursing
! home care and nursing home consumers into three phases or
jlevels. These include: whether the resident gets better
I and/or stays as healthy as possible; whether the program of
care provided the resident is in accord with accepted stan-
'dards of resident care as determined by professionals in
the field, and whether the nursing home provides the resi-
I dent with certain desirable resources in terms of facili-
! ties and staff. The ultimate test of quality of care as
[defined by a majority of researchers is what happens to the
jresident— the outcome.
I Quality indicators that have been used in such an
examination of nursing homes include the following.
Residents per room. Generally a low ratio of resi
dents per room signifies a facility which allows greater
44
* privacy and accommodates to resident's individual desires.
I Space is used as one criterion for nursing home industry
jaccreditation of nursing homes.
Residents per bathroom. This indicator is the ratio
of average number of residents to number of bathrooms, both
public and private, in the nursing care section. It is
assumed that this provides a measure of adequacy and plea-
,santness of the physical facilities.
! Original use. Whether the facility was constructed
I as a nursing home or convalescent and nursing care facility
I a s o p p o s e d t o b e i n g c o n v e r t e d f r o m a p r i v a t e h o m e o r o t h e r
I
juse has been used to indicate the appropriateness of the
I physical plant to its present purposes.
I
Staff hours per resident. The number of staff hours
I per week per resident is an indicator farther along the
I continuum from resources to resident outcome. It is ob
tained by dividing the reported total hours worked per week
by all staff members (excluding clerical and maintenance
personnel) by the average number of residents in the facil
ity. This ratio is used as a measure of the amount of
! attention the resident could potentially receive.
I
I Registered nurse - other nurse staff hours ratio. The
mainstay of the medical nursing home staff are the nurses
and nursing assistants, and of them, the registered nurse
brings the most sophisticated medical expertise to the
45
resident. Accordingly, another indicator of quality that I
is used is the proportion of total number of nursing hours ,
worked per week attributable to registered nurses, as :
opposed to licensed practical nurses or nursing assistants.
I :
I Physician hours per resident. Another aspect of the
' !
resident's medical treatment is the amount of physician ;
i
care he or she receives. Facilities vary greatly in the
' provisions for physicians' care; some have a specified
I physician on call, while others make use of the resident's
j private physician on all occasions. The physician hours
per resident indicator is obtained by dividing the reported
' number of hours per week spent in the facility by medical
J doctors by the average number of residents in the nursing
! homes.
I
I
^ Staff variety. Some nursing homes provide only medi
cal care, others offer a variety of psychological, social ;
and even vocational rehabilitation. The staff variety
j measure is the number of employee categories represented
I on the facility's staff. A high staff variety score indi-
! cates the presence of professional personnel responsible
I
' for therapeutic services such as occupational therapy, phy
sical therapy or social work services.
Resident participation. Rather than a measurement of
environment or staff, this indicator concerns participation
^ by residents in nursing home programs aimed at social or
; psychological rehabilitation, including entertainment,
4 6 i
self-government, hobbies and other scheduled activities.
A total of the percentages of residents participating in
each activity is obtained for this indicator.
Therapeutic orientation. Ideal nursing home care ,
; might well be that which rehabilitates and returns the
1 I
resident to independent living. Whether this goal is seri-'
I
. ously considered by administrative personnel may indicate
I the quality of care provided in a nursing home. According-'
Ily, administrator attitudes related to the purposes of ;
I !
I nursing homes have been measured, and responses combined '
j into a scale of orientation toward rehabilitation. :
I The variables correlated with the quality indicators
I
I are measures of characteristics which are believed to be
I related to the kind of care a nursing home gives. They
I include : (a) location (urban physical location vs. rural),
(b) hospital-attachment (hospital-attached nursing homes
I
vs. free-standing non-proprietary facilities), (c) owner-
I ship (proprietary vs. non-proprietary facilities), (d) es-
i
I timated cost per resident day, (e) average charge per
I month, (f) percent of residents having white collar, pro-
I prietor, or professional background (the total percent of
I residents falling in these categories), (g) percent of
residents on welfare, (h) percent of ambulatory residents,
(i) average rate of reimbursement by the county in which
the facility is located, (j) occupancy (average number of
471
Presidents in the facility divided by the number of beds),
(k) size, and (1) accreditation.
In the development of a workable approach to the con
ceptualization, measurement, and eventually the manipula- ,
'tion of quality, the variables outlined previously which I
are involved can be broken down into two broad groups :
(a) objective components, and (b) subjective components.
The objective components are more easily specified and
I
I include measurable qualities such as: good health, higher
j socioeconomic status, comfortable physical surrounding,
I j
j and education. '
' Perhaps more important, and yet more elusive, are the
i
; subjective variables which affect quality. These variables
I
I are defined by individual perception and interpretation and
' vary widely from person to person. Individuals who experi-
I ence a sense of worth or purpose in their lives, those v/ho
! believe that they exercise some control over the world, who
jreport meaningful personal interactions, and those who
I experience a unity or unifying force greater than them-
; selves are the individuals who also report higher levels
I
: of quality in their life.
' The concept of quality is obviously diverse and multi-
I dimensional. Because of its complexity and variability, it
is difficult to describe in operational terms. Even when
restricted to a specific and in some respects a uniform.
48
Igroup of people such as elderly residents of nursing hbmesT^
ithe translation of the abstract notion of quality into
specific procedures, programs and approaches is a difficult
; task.
i i
D. Approaches to the Measurement i
of Nursing Home Quality |
A major problem in all studies is the measurement of ;
quality of care. Another tendency has been to use some set ■
of standards as a measure of quality, often with the ex
plicit assumption that there is a relationship between a
j
particular set of standards and the needs of the resident. ,
,The studies of Beattie and Bullock (1964) and Taietz (Note'
14) illustrate this approach. Another approach, utilized by
Townsend (1962), Anderson et al. (Note 15) and Kelleher and
Shaughnessey (Note 16) emphasizes structural characteristics
|(residents to resident rooms, total staff or nursing staff
hours per resident.) A similar approach was taken by Pen-
chansky and Taubenhaus (19 75) who argued that the mixture
of residents requiring different levels of care, the small
size of most nursing homes, and the fixed reimbursement
system of public welfare payments for nursing home care are
the major barriers to better resident care. The Anderson
group has pointed out that their quality indicators "are ^
actually measures of factors which are assumed to be char
acteristic of nursing homes where patients improve as much
as possible and receive good care" (Note 15, p. 19). At
49 !
jthe same time they have repeatedly emphasized the limita-
itions of this approach and the need for better measures
(Anderson and Stone, 1969; Holmberg and Anderson, 1968).
A major weakness of such approaches is that they ig-
j I
nore the dimension of resident need, or more accurately, '
I
they take resident needs as given and known to the investi-,
I ;
Igator. For example, Kelleher and Shaughnessey (Note 16)
jhave noted that nursing time available per resident per day
I
is meaningful only when information is available relative . :
to the actual requirements of the resident. In their study,
of Massachusetts nursing homes, they found that small facil-|
|ities had more nursing time available per resident per day '
I
ithan medium or large facilities and that the ratio of nurses
I I
iof all licensure status to residents was greater in small
I
ithan in medium or large facilities. Nevertheless, they com
ment that without careful analysis of the difference in re- ,
sident needs between small, medium and large homes, this
, apparent advantage is meaningless.
i ' ‘
I Kelleher and Shaughnessey (Note 16) approach the pro
blem of measuring the quality of care by beginning with the
j
, needs of the resident and ending with the application of
Istandards instead of beginning with standards and assuming
Ithat they met resident needs. The extension of such an
approach to other needs and its refinement seems necessary
in order to find a solution to the problem of quality of
care measurement. Until this problem is faced, there can
be little progress in the study of the relationship between
quality of care and nursing home care.
Quality represents the degree to which specific ele
ments of input, such as staff qualifications, or output,
.such as caseworker visits, comply.with standards based upon'
: j
resident needs. Effectiveness is obviously impossible to j
,assess without clearly articulated goals and quality be-
'comes a matter of individual taste without reference to
I measurable standards. Efficiency is essentially a ratio of
iunits of input to output. Although we can measure it in
! quantitative terms, we can assess it only in terms of
'applicable standards. Explicit goals and standards and
I measures of efficiency, effectiveness and quality have been,
! lacking in the field of nursing home care, and consequently,
I
I research has been severely hampered. As Lawton (Note 17)has
; said in a related context, "the substantive findings about '
the process of quality are too fragmentary to make profita
ble any search for consensus among findings" (p.32)
The precursor of several attempts to measure qualities
I of different types of institutions was a survey by Townsend
(1962). He used on-site observation in 1973 British insti
tutions to survey interrelationships among physical facili-
I
! ties, staffing, services, administrative policies, resident
I
I freedom, and social opportunities. Although he found that
'size (small homes were better) and auspice (nonprofit homes
I
I were better) relate to quality, his goal was to produce an
; 1
■ 51:
jindex rather than to compare institutions.
I A few years later, Bennett and Nahemow (19 65) were
i
Iable to define a scale of institutional totality based on
I
:Goffman's work (1962). When the scale was applied to four
I
[institutions for the aged, it was found that socialization
I
was fostered in less total institutions.
Beattie and Bullock (Note 18) surveyed a number of .
characteristics of 80 nursing homes in St. Louis. They
I
'found non-profit auspices, level of licensure, and large
i
|size associated with good ratings on a scale of milieu qual-
jity. However, they also found that sponsorship, classifi
cation, and size were not independent, since at that time
I
!non-profit facilities were larger and more domicilliary,
while proprietary nursing homes were smaller and rated as
giving more nursing care.
Although they did not try to compare institutions,
Pincus and Wood (19 70) identified four factors by which
[institutions could be analyzed for quality. Based on res-
i
iponses of 263 staff members regarding institutional poli-
I
cies, they found factorial support for the measurement of
, dimensions of public versus private auspices, structured
versus unstructured institutional life, resource rich ver
sus resource poor, and isolation versus integration with
the community.
Gottesman (1970) identified differences even among
52;
I
nursing homes. His sample of 1145 residents resided in 40 '
nursing home facilities and were selected to represent all
facilities in the Greater Detroit area with regard to size,’
I ownership, and source of payment for resident care. Non
profit church related nursing homes were found to contain
higher proportions of residents who were older, white, fe-
,male, residents for relatively longer periods of time, and
'who were somewhat more mentally alert than residents of
other nursing homes. They received roughly equal amounts ,
of medical care as their peers in other facilities, but far
I
more social care. They,engaged in more social activities, i
i
I had visitors more frequently, and closer ties to family
Imembers, but nevertheless regarded the nursing home facili-
!
Ity as their permanent residence.
In proprietary facilities with fewer than two-thirds
! of the residents supported by public funds, residents were ,
'somewhat younger than residents of non-profit facilities,
!more were white, female, had recently been admitted, and
.came from acute care general hospitals. They were likely
I
I
'to need considerable assistance with activities of daily i
1
living but not to be more confused than residents of other
facilities. Similar to residents of non-profit nursing
jhomes, they were likely to have family visits. They re
ceived more medical services, more basip services from non- ,
professional staff, and were more likely to engage in psy-
53i
_ _ J
Ichosocial activities.
The most common type of nursing home was the proprie
tary with high proportions of residents paid for by public
funds. Such facilities were found to serve those under 65 ;
and the younger group among residents over 65. They served
I i
proportionally more men and the residents had fewer commun- :
I
ity contacts and visitors. Of all types of facilities,
these nursing homes were most likely to be available to ex-
imental patients and to residents whose race was not Cauca-
t I
jsian. More of their residents were among the most confused,
:and, on the other hand, more were among the most alert '
!found in all the facilities. They were also likely to be ,
jmore capable of independence in activities of daily living.
Despite apparent greater capacities, these residents en
gaged less often in activities of daily living (e.g. dress
ing, bathing, grooming) and received less assistance with
these activities from staff. They received fewer medical
{services, and engaged in fewer psychosocial activities than
|residents of other types of nursing homes.
I These differences among nursing homes were interpreted
as due to differential recruitment of residents, different
amounts of available resources and varying degrees of family
^involvement (Barney, 1974; Gottesman. and Hutchinson,. 1974 ;
Bourestom and. Gottesman , Note 19; Handschu, Note 20) . The
investigators, view this ..type .of ^proprietary nursing ...home..as^,
54:
contemporary replacement of the almshouse, prison and men-
Ital hospital since it houses a number of socially marginal
Ipersons who are less ill than residents of other types of
;nursing homes.
1 Another study of differences among institutions was
reported by Kosberg and Tobin (19 72) . They examined 214
nursing homes serving the metropolitan Chicago area, using
'public records to relate treatment resources to 36 indepen-
.dent organizational characteristics. They found greater
I concentrations of treatment resources (e.g. nursing and
{professional staff, medical treatment, records and facili-
jties) in large non-urban nursing homes located in areas of
I
,high median income. High resource nursing homes conformed
!
to licensing standards, were accredited, were members of
!nursing home associations, and served only white residents.
They offered several levels of care with rates set accord
ingly . No relationship was found between resources and
I forms of ownership or the background of the owner or admin-
I istrator.
j Linn (19 76) constructed a nursing home rating scale
I covering the broad areas of resident care, administration,
! staffing and physical facilities. The scale, suggested as
! a check list for favorable characteristics of a good nurs-
'ing home or a method of comparing one facility with another
: required a personal inspection of the nursing home and an
55
interview with the nursing home administrator. The 56
nursing homes in Florida which were scored on the Linn
nursing home rating scale differed the most on staffing
; patterns and in the training of the nursing home adminis-
1
trators. Although the scale could be applicable to nursing
homes in other areas of the country, the results obtained
would vary according to state licensure requirements and
community economics.
IE. Proprietary Status of
Nursing Homes
One often encounters the assertion that proprietary
institutions have received too much encouragement to enter
j the long-term care field relative to philanthropic and re-
I
Iligious institutions (Senate Special Committee on Aging,
1974). A common explanation for this phenomenon is
; that government policy, possibly unintentionally, favors
ieconomic considerations over resident care needs (Senate
Special Committee on Aging, 19 74; Senate Committee on
,Government Operations, 1968: Vladeck, 1980).
Two studies , one..undertaken;.Lin Minnesotaiahd.:the
other in Massachusetts, have concluded that no statis
tically significant differences in quality of care ren-
:dered exist between proprietary and non-proprietary insti
tutions (Anderson, et al.. Note 21, Levey, et al.. Note
I
!
; 22) . In a paper read at the 1967 Gerontological Society
meeting, Anderson, Holmberg and Stone reported that
56
I interactional qualities in the administration of a
I facility and the characteristics that the person in charge
i
: brings to the job seem to explain variations in quality of
I
jcare better than do structural variables, including owner-
I
! ship. ^
Anderson et al. (Note 21) further note that of the I
{eight quality variables used in their study— resident per
'room ratio, resident to bathroom ratio, construction of
jfacility, total staff weekly hours per resident, percent of
I
IRNs on nursing staff, variety of services, time spent in
j the facility by physicians per resident, and total percent '
]
; of resident activity participation— significant differences;
between proprietary and non-proprietary facilities were re-
I gistered for only the resident per room ratio and the time
'spent in the facility by physicians per resident.
In a study of nursing home care in Massachusetts,
Levey, Kinloch, Stotsky, Ruchlin and Oppenheim (Note 22)
{noted no significant difference in quality of care by type •
; of ownership, where quality of care was approximated by .
compliance with select characteristics of nine major areas :
nursing service, dietary service, restorative service,
I
j resident activities, physical plant, physician's order book,,
I
nursing notes, resident records, and personal care of the
residents. Costs of care were found to be significantly
I
lower in proprietary than in voluntary facilities. The
57
I evidence of two independent in-depth case studies does not
suffice to refute the contention of lower quality of care
in proprietary institutions. There is a definite need for
I additional research on the issue of ownership and quality
I of service both in the long-term and acute sectors of the
medical care field.
To determine the implications of nursing home owner-
' ship on resident care, Holmberg and Anderson (1968) ana-
, lyzed data obtained from interviews of administrators of
I
I proprietary and non-proprietary nursing home facilities.
,The interviews covered all aspects of nursing home opera-
I
Ition, including staff, costs, programs and resident char-
;acteristics. Findings indicate many similarities between
'the two types of institutions. Although quality of care
was not dependent upon ownership, such factors as training,
philosophical orientation and experience of staff did sig
nificantly affect the care given. This same study also
found that the proportion of residents receiving welfare
support was significantly related to quality of care^ The
: larger the proportion of welfare recipients in a nursing
I home, the lower the quality of care.
Several other studies have investigated the relation
ship between quality of care (variously measured) and
facility ownership. Beattie and Bullock (1964) rated the
social milieu, staff attitudes and other features of eighty
58
jnursing home facilities in St. Louis. They reported that
non-profit homes rated higher than others. Townsend's
(1962) multiple-item index of quality of care revealed that
non-profit facilities rated highest, proprietary facilitiesi
occupied a middle position, and public nursing home facili-
I
I
ties were lowest. i
Levey and others, in a study of 129 Massachusetts
'nursing homes in 1965 and 1969, looked at the relationship
Ibetween quality of care, ownership, and cost. Three types
I
of facilities (non-corporate proprietary, corporate pro-
jprietary and corporate charitable) were rated on a nine
I component aggregate quality of care scale. They found no
; significant relationship between quality of care and facil-
■ity ownership. In both 1965 and 1969, the highest per
I
icapita per diem costs were reported by corporate charitable
facilities, and the lowest by non-corporate proprietary
I
nursing homes. When the authors employed a multiple re
gression technique to explain variation in their 1969 qual
ity of care rating, no significant relationship appeared
'between the dependent variable and ownership. Thus, while
cost was found to be related to quality of care and to
'Ownership, ownership was not related to quality.
I
I Other important distinctions among facilities by type ,
I :
.of ownership have been reported. Holmberg and Anderson j
(1968) observed that residents of non-profit facilities
they studied were slightly older and less impaired mentally
« i
than those in proprietary facilities. The National Health '
Survey's study of nursing homes reports that residents in
proprietary facilities are.in the poorest health and have
I
the shortest mean length of stay compared to residents in
facilities under governmental or non-profit management
i
(Department of Health, Education and Welfare, Note 4).
F, Size of Nursing Homes
! System size has also received much attention as a
{sociological variable in quality (Kasarda, 1974). It is
{widely believed that size has a pervasive influence on the
{internal order of an organization. In nursing homes, in
creasing size may necessitate an increasing commitment of
I
resources to clerical, administrative and other impersonal
activities. This may adversely affect the satisfaction of
!institutionalized residents. Greenwald and Linn (1971) have
suggested that as a nursing home gets larger, activity and
!
communication decline. Curry and Ratliff (1973) argue that
ja person's life satisfaction is likely to be influenced
I
jby certain aspects of his or her current environment. They
Icontend that since smaller facilities generally have a more
I
homelike atmosphere than larger facilities, smaller homes
create fewer disruptions in accustomed living arrangements.
[They suggested that this ought to favor resident satisfac
tion. 1
Studying a sample of Ohio proprietary nursing homes,
_60J
Curry and Ratliff found that the residents of the smaller
facilities had more friends within the home, more monthly
contacts with these friends, and more total monthly con
tacts , despite the fact that the residents of the larger
[homes had more living relatives and friends and had more
contacts with these relatives. This may suggest that
increased sociability developed within the smaller nursing
homes as a result of the closer proximity of residents.
I
i There is little agreement on the appropriate size of
I a nursing home facility. In part, this must depend on
manner of funding, the purpose for which the institution
is intended, and the additional supports that it needs.
IEconomic rather than personal considerations seem to be
I
{given greater weight. In Great Britain there is a marked
I trend to smaller nursing homes having no more.than 75 beds,
{while in the United States, less than 100 beds is consid-
,ered economically unfeasible (Vladeck, 1980).
I Straight numeration of beds may be misleading. Jones
and Sidebotham (1962) pointed out that a large mental hos-
ipital they studied actually consisted of two hospitals, one
;with fast turnover and one with minimal turnover. While
I for administrative purposes a hospital or nursing home may
■be large, for therapeutic purposes it may actually consist
of a number of smaller hospitals which share certain spe
cialized facilities such as general hospital wards.
61|
I Townsend's (1962) study indicated the significance of '
I size as a correlate of quality of care. For the four types
of nursing homes compared (work houses, local authority
institutions, voluntary and proprietary homes) the smallest;
I
had a tendency to achieve a better quality of care than the
largest. The smallest homes exceeded the largest in num- |
.bers of staff, toilet facilities, single and double rooms
provided, more means of occupation and freedom of choice
I to the residents. To summarize Townsend's findings : he
I found two principal items which influence high quality of
{care, voluntary sponsorship of the institution and small
size by number of beds.
I As part of a more comprehensive study of the services
I
! offered to and of the characteristics of residents in 80
I
I nursing homes and homes for the aged in metropolitan St.
{Louis area, Beattie and Bullock (1964) used an interviewing
schedule to determine whether a facility had oriented and
I organized its services and personnel in a manner capable of
j adapting to the unique requirements of residents in their
I '
facilities. They found that size and type of setting were
related to their ratings, with the smaller facilities
; receiving a low rank.
! Greenwald and Linn (1971) visited 26 nursing homes and
evaluated them in terms of staffing patterns, physical !
facilities, resident satisfaction, cleanliness, cost, size
62
{and services. After correlating all data, their results
[favored the nursing homes of smaller size and higher aver-
I
age cost. In disagreement with Beattie and Bullock's
1(1964) conclusions, Greenwald and Linn (1971) concluded
I
that enlargement of nursing homes does not lead to improved
or better quality resident care.
I
Size has often been confounded with other dimensions,
as in studies of nursing homes by Beattie and Bullock
(1964), Greenwald and Linn (1971) and Anderson, et al.,
I(Note 21). In the first of these studies, small size was
associated with an institutional milieu which was policy
'rather than resident-oriented, and with negative staff
I
attitudes. Anderson et al. (Note 21) found size to be
{positively correlated with a structural quality criterion
I(residents per bathroom) and with staffing quality criter
ion (variety of staff). Greenwald and Linn (1971) found
small size associated with high costs. In all cases, small
{size was confounded with proprietary or non-professional
I
ownership, and cost per resident day, so that size in and
I
I
|Of itself does not actually emerge from these studies as a
clearly definable influence.
One matter that should be noted is that generally rare
I
services will only be made available when the base is of a
sufficient size to justify them. Most services can be
conceptualized as having a particular place in a hierarchy
63
of need for services. Only when services lower in the
hierarchy are used to their limit will the demand for less
frequently required services develop to justify providing
them. Considerable attention to the relationships among
'location, size, services and transferability among services
has been given by McKeown (1955) .
In recent years, nursing homes have increased in size
of resident population. To a great extent, this increase
j in size can be.attributed to federal policy. The principal
I
{policy requirements that led to the increase in size were
those that specified nursing homes at various levels of
|care should employ certain types of medical staff. The
I ability of a particular nursing home to obtain nurses is,
I
{of course, limited by the nursing home's resources and the
local labor market. In addition, most nursing homes are
'proprietary and must make a profit. Federal requirements
ithat certain types of medical professionals be employed may
decrease the resources available for other staffing, or, at
least, appear to motivate nursing home administrators to
'fill requirements in the most economical way. The most
i
economical way to meet staffing requirements has been to
increase the number of residents in the nursing home. The
{increase in size of nursing homes has favored the develop
ment of nursing home buildings that look like hospitals, a
I
trend intentionally encouraged by policy. This tendency
64
lhas important implications for the social environment of
{these nursing homes.
While large nursing home facilities may be optimal in
a purely economic sense, they may not be in a psychological :
I
{social sense. Largeness breeds an impersonal atmosphere.
I ‘ ■ i
In addition to the factor of impersonality, large facili
ties can only be accommodated in areas of sufficient popu
lation (resident) density.
G. Location of Nursing Homes
I Another set of variables in the study of quality of
I
' 1
care in nursing homes concerns the interaction between the
[institution and the community. In the studies of Lieberman
I
(1969), institutional relatedness to the outside community
was thought to play a role in resident adjustment. Goffman
'(1961) and Gelfand (1968) referred to the permeability of
the institution. Permeability is defined as the access the
community has to the facility and the freedom of the resi
dent to maintain his or her outside contacts. This mutual
I
exchange has been found to be significant for residents'
'social adjustment. Other factors such as proximity to
I
shopping, transportation, family, physical security, wea
ther and topography have been evaluated in relation to the
desirability of community housing for the aged. But these
issues have not often been considered in relation to in
stitutional housing where inexpensive settings are sought
put (Sherman et al., 1968) .
65
I The relationship between institutional location and
j the inmates' original home may have implications for length
I ;
I of stay in the institution for short-term or temporary
I
I residents. As distance between the two locations increases,
I :
and when transportation becomes a problem because of scar-
I
city, cost or time factors, the number of visitors and the
,frequency of visits declines (Brown, 1959; Townsend, 1962),
'contact with pre-institutional life diminishes, length of
1
, stay in the institution can be expected to increase, and
I
I the stage is set for permanent institutionalization.
I While the effect on staff of institutional location
I does not appear to have been examined, it might be expected
I
I that the more interested and knowledgeable professionals
I would be generally less inclined to go to a remote area,
jIf they do go they may be less disposed to stay, unless
some special attention or provision is made which takes
their interests and needs into account.
{ Frequently, the physical location of a particular
I institution is more a matter of the ready availability of
l a building than of planned construction, or of lack of
Iobjection to a particular site than of particular site
I selection for therapeutic reasons (Townsend, 1962). Thus,
I
{large country nursing homes whose upkeep becomes too expen-
!
;sive are offered for sale as appropriate for use as homes
for the aged or as schools. Army hospitals turned over to
66
the public after the war see service again as mental hos
pitals. Halfway houses for the delinquent and ex-mental
patients must often locate away from therapeutically valu
able residential areas because of the protests of the other
j inhabitants. In such cases, the major consideration is not
so much one of what is best for the intended recipients of
services, but what is economically provident for the
supplier and least disturbing to society.
I The location which may be most beneficial to the resi-
Idents of an institution may be the place where they are
I
Imost welcome. Few people willingly seek to live beside
[mental institutions or prisons but this does not seem to
i
Ihold for all institutions. As Brown , (19 59) has pointed
I
{out, there is no move against institutions such as schools
land general hospitals. Certain institutions may be wel
comed as an asset to a community : these might include not
{only schools and hospitals, but also, and particularly in
jareas interested in attracting the elderly, good nursing
(homes.
I
67
IV. RESEARCH METHODOLOGY
A. Sample of Complaints
The complaints against nursing homes which are anal- }
yzed in this study represent a composite picture of the
nursing home complaints reported in many states. The
I selection of the thirty nursing homes whose complaints
[contributed to the composite picture was made on a random
[basis. The thirty nursing homes in the sample had a total |
j
of 29 3 complaints lodcred against them which were investi-
i
jgated and deemed substantiated. The total number of com-
j
'plaints against any one nursing home ranged from zero to
38. The categories of complaint analysis were derived by
grouping the items that the Minnesota Office of Health
Facilities Complaints uses on their complaint intake form.
,A breakdown follows.
I Resident-related complaints. These include : missing
1
{personal funds or belongings; negligent nursing care ; medi
cation abuse ; resident abuse ; inadequate or inappropriate
clothing; improper placement of residents ; infection con-
i
trol; lack of appropriate activities ; grievance mechanism;
■restrictions on right to complain ; restrictions on reli- ,
gious rights ; restrictions on civil liberties ; restrictions ,
on social/community activities ; resident/family not informed
! 68i
Iof condition; religious, racial, sex discrimination; con- i
I fidentiality of records; access to own records; not in-
I formed of rights; denied visitors; visiting hours; mail
1 :
opened; no phone privacy; not treated with dignity/respect;
I
needs less restrictive placement ; kept in facility against
will; unattractive building; language barrier; disruptive
.residents; roommate conflict; not assisted with eating;
'food preferences not surveyed; cold food; unappetizing food;
,little choice of food ; no food snacks available ; unneces- '
jsary confinement to chair, bedroom; inadequate supervision
!
j of resident; unanswered call lights ; kept up tooLlong;
jstaff poorly trained ; dehydration ; not turned ; resident
I
; falling; doctor not called; and improper restraints.
Administrative-related complaints. These include :
compliance with federal/state laws, policies and procedures ;
I
financial problems ; rate increase or private pay problems ;
ethical practices ; licensure ; medical records ; clean in
door air act; safety factors ; disaster or emergency plans ;
I sanitation; storage, food handling techniques; offensive
'odors; inadequate housekeeping; inadequate laundry service
or linen supply ; inadequate or incorrect water temperature ;
unsatisfactory room temperatures; pest control; physical
j
■plan problems ; inadequate staff ; physician's orders not
followed; lack of staff orientation; physician's perfor-
69
formance; improper accident procedures; handicap accessi- '
bility; insufficient supplies ; clothing in poor condition;
medications abuse ; access to money denied; financial
accounting denied ; charged for services not rendered; dou-
ible billing; money not accounted for ; special diet not j
followed; no water available ; lack of food utensils; ;
, '
admission procedures ; bed not held during absence; inade-
!quate care plan; improper transfer procedure; inadequate
I
Jdischarge planning.
t
1B. Use of Complaints as Data
j Several methodological issues must be raised in a
I consideration of nursing home quality assessment using
'the complainant's perspective. Research in the area will
! not be of the highest quality until some of these issues
i are discussed, understood and acknowledged. Reliability,
i referring to whether the results would be identical if
the research were redone, is a basic issue in such studies.
The extent to which complaints against nursing homes
iregistered at the Minnesota Department of Health reflect
the complainant's true feelings about care is another
issue. The possibility or potential of retaliation by
the nursing home against the complainant may cause com-
I
plainant reports to reflect the complainant's true opinions,
inaccurately, either by heightening the urgency of the
situation, or in the opposite extreme, by undermining the
70 !
motivation to complain. Monk and Kaye (Note 2 3) found that
institutional employees are most frequently the recipients '
of whatever complaints nursing home residents make and that|
unknown government representatives, such as those from the ,
Office of Health Facilities Complaints, are rarely the per
sons to whom the resident voices complaints.
Another major methodological concern about perception
'of care is the extent to which complainant's opinions :
I accurately reflect care given or conditions present. Here
I the issue is external validity. It is unfortunately quite
1 difficult to assess whether complainant opinion does re-
I
; fleet quality of care. The only method able to indicate
i the validity of such data is comparison of care perception •
! of the complainant with other approaches to care assess
ment, such as structure, process, outcome and impact mea-
,sures. Although no actual comparisons of complaints and
such care measures have been made, a number of studies
show that investigator-initiated patient satisfaction sur-
,veys and other more objective care measures do not corre-
! late highly. Ehrlich, Morehead and Trussell (Note 24)
found patient evaluation of care to be considerably higher
I than physician ratings of the records of the same care.
: One explanation for the difference between patient
opinions and other measures that was found in Ehrlich, |
I
Morehead and Trussell's study (Note 24) is that physician ■
71
raters may have been more rigid on criteria for care or may
have utilized different criteria for the assessment of care
than patients. In the Ehrlich study, patients were not
jnecessarily wrong in their perceptions. That patient
t
opinion was higher, however, does indicate strongly the
need for both patient, or for the purpose of this study,
complainant opinion as well as other evaluations of the
'care situation in order to provide a complete picture,
j The implication of methodological problems connected
jwith the use of complaints as an index of quality of care
■is not that possible inaccuracies in data should be ig-
!
nored. Distorted complaints may be present, especially
in relation to issues or areas in which some complaints
are more socially acceptable than others, such as the
■allegation of cold food versus the allegation of sexual
abuse. When assessments of quality employing different
devices, such as consumer complaints and health department
licensure and certification inspections, agree about the
'quality of care, the confidence in the validity of each of
’ the individual measures increases. Unfortunately, even
such measures are not infallible checks on validity.
Different aspects of care may be different in quality and
I
'have differential import across evaluators. Without an
absolute measure of quality in nursing homes and across the
health care spectrum as a comparison, a perfect one-step
72 !
ivalidational check on all data will remain unavailable.
Complaints themselves are unreliable as a sole indi
cator of quality of care in a given facility. For example,
!the volume of complaints may be related to the nature of
!the Office of Health Facilities Complaints as much as to
quality of care factors. Furthermore, there is no guaran
tee that all problems or even the worst problems are being
I
jreported, so a low incidence of complaint does not neces-
Isarily indicate a facility offering high quality care. In
i
laddition, it is impossible to obtain a statistically
; accurate statement about complaints of the nursing home
;population as a whole since there is no way of knowing how
jmany and what types of problems are not reported. The
'analysis of nursing home residents' complaints against a
nursing home as an index of quality of care has proven to
be a complex idea for various reasons, not the least of
which is that there is no single agreed upon definition
of quality.
C. Hypotheses and Assumptions
Keeping this hypothetical framework in mind, four
Ihypotheses were proposed at the outset of the study. The
I
|first is that as the size of the nursing home increases, it
I
jwill receive a higher frequency of complaints. The second
is that nursing homes wth a proprietary status will have a
higher frequency of complaints. The third is that nursing
73 :
homes with more than one available level of care will
I have a lower frequency of complaints than those facilities
! offering just one level of care. The fourth hypothesis is
j that nursing homes located in an urban setting will have
I
a higher frequency of complaints than those located in a !
suburban setting. !
I
The hypotheses suggest the importance of analogous
! explanations from the literature on nursing home quality
,of care. Curry and Ratliff (1973) state that as size of
I
jthe institution increases, the size of the staff does not
j increase in proportion to the number of residents, and less
I personal accommodations can be made between residents and
! staff members. Non-profit nursing homes have been shown
I
! to serve a more socially advantaged population who have
community persons actively interested in them (Gottesman,
I Note 25) and the amount of contact a resident's significant
others has with the facility directly influences the quali
ty of services he or she receives (Gottesman, 1970).
Kosberg and Tobin (1972) found that nursing homes offering
more than one level of care had higher Resource Scores than
did those homes offering just one level of care. They
'later stated that nursing homes which were rich in treat-
I
I
; ment resources were expensive facilities. Kart and Manard
(1976) found that upper class identification implies
greater resources, which in turn implies a higher quality
1
! 74
of care, and Levey et al. (19 73) reported that quality of
care is higher in facilities that cost more money. It
must be reiterated that there is extremely high potential
for overlap among these explanatory variables and frame-
jworks. In any single nursing home, for example, two or
more of these hypotheses might accurately explain the
quality of care etiology.
! The underlying question in this study is whether com
plaints against nursing homes are better, as good.as, or
worse than regulatory violations as an index of inadequate
jor deficient nursing homes. In order to determine this,
I it was necessary to test the usefulness of regulatory sur-
; veys. Because of the limited scope of this study, it was
I impossible to gather all the regulatory licensure and cer-
Itification data on the thirty nursing homes that would be
irequired for an extensive examination and analysis of the
Irelationship of these data to complaint data. Instead,
jthe data gathered for this study related only to complaints:
|resident-related complaints were used as a general measure-
^ment of quality of life data and administrative-related
i
(Complaints were used as a general measurement of regula
tory survey data.
I The methodology and analysis in this study involve two
!major assumptions. The first is that administrative-
related complaints are a surrogate for regulatory survey
data and the second is that resident-related complaints are
!
I 75
[a surrogate for quality of life data. The problem, even
I after testing and analyzing the two categories of com-
I
jplaints, is that there is still no indication of where the
deficient or inadequate nursing homes are to be found.
! I
The variables chosen for analysis in this study--size,;
I I
I
level of care, geographical location, and proprietary sta- ;
tus— were thus used as a basis for analysis. The review
of the literature indicated that these four variables
iClearly have some relationship to the notion of quality
jof service in a nursing home. The question then becomes
Iwhether the variables correlate more strongly with admin-
jistrative-related complaints (regulatory survey data) or
jwith resident-related complaints (quality of life data).
! If the variables do not correlate with either cate
gory of complaints, they it can be assumed that both
'quality of life complaints and regulatory survey data are
not particularly useful for determining deficient or in
adequate nursing homes. If one or all of the variables
correlate with either or both categories of complaints,
then there would be added reason for further perpetuation
.and use of the existing system in the determination of the
Equality of life in a nursing home.
i
i D. The Minnesota System for
Receiving Complaints
The starting point of this thesis is Minnesota's five
year old system for dealing with the complaints of nursing
76
^^home residents against nursing homes. This system repre
sents a machinery of arbitration between the consumers and
providers of a professional service financed largely by
public monies. The study of information provided by this
jsystem is intended to draw attention to the wider issue
I
of professional accountability, which is limited neither
I
to medicine nor to complaints against nursing homes.
I
I In 1976, the Office of Health Facilities Complaints
. (OHFC) was established within the Minnesota Department of
Health to investigate any health-related action or failure
to act by a nursing home in Minnesota. OHFC is mandated
by Minnesota law to receive, investigate and act upon com-
'plaints from anyone, anonymous or identified, regarding
'services provided by Minnesota health care facilities.
IThrough Minnesota law it also has the authority to review
a resident's records, medical and social, and, if neces
sary, to issue Health Department licensure correction or-
jders and monetary assessments.
* The Office of Health Facilities Complaints is staffed
|by a team of investigators, and has a collect phone number
ithat can be called from anywhere in the state. Once a
Idecision is made regarding a complaint, the case is filed
junder the name of the nursing home. These complaint files
are open for public inspection, with the name of the com
plainant marked out to respect confidentiality. It is
these files, along with the OHFC annual report to the
L
77
(legislature, that serve as the source for complaint data
analyzed in this report.
The number of people who have contacted OHFC in the
jfive years of its existence is not known. The number who
I
.persist and qualify to the point where their complaints get
tabulated and thus included in the official statistics
published yearly by this agency is roughly 900 a year.
‘Slightly over 85% of these complaints are concerned with
jnursing home care, as distinct from hospital and other
jkinds of health facility concerns.
j In form, the OHFC complaints procedure is an adjudi-
jcation of a dispute between a resident or concerned other,
,and a long-term care facility. It is in no sense a method
of inquiry into the efficiency, humanity or competence of
.the long-term care system.
State and federal regulations governing nursing homes
help to define the gateway for complaints filed with OHFC
land the staff of OHFC serve as the gatekeepers. It is they
'who receive and investigate the complaints. The importance
|of their role is all the greater because of the basic
I
ambiguity of the concept of a complaint. At what stage
does a grumble or a grouse become a complaint? And how do
initially rather ill-defined charges become crystallized
as specific allegations of breach of service? At the first
stage, when the complaint may either be verbal or phrased
78
ambiguously, the OHFC staff has considerable freedom of
interpretation. They may choose to try to clear the matter
up themselves, by discussion or elucidation. They may, as
iallowed by law, refer or forward complaints to be dealt
I
with by another agency.
I
From June 1978 to May 1979, a total of 131 Minnesota
I
.nursing homes were found to be in breach of state regula-
'tions as illustrated by an investigated complaint deemed
I substantiated. A complaint is considered substantiated if '
I I
I the investigator can verify that at least one of the
> 1
‘alleged problems does exist or did occur. Many complaints
Iby their nature are time-limited rather than recurring
I situations and are difficult to determine conclusively as
substantiated or unsubstantiated. The figures above repre- '
! sent a conviction rate of 4 5.9% of the cases in which there
.was any kind of an investigation. Out of these 131 long
term care facilities, 521 correction orders were issued,
land 18 were issued monetary assessments, which ranged from
j$250.00 to $2250.00. The total amount of assessment lodged
jagainst all facilities in this period was $9300.00.
I
OHFC relies upon the Minnesota nursing home licensing .
regulations promulgated by the State Department of Health
las guidelines for its inspections and enforcement. The
state law under which OHFC operates does not place any
restrictions on the complaint jurisdictive purvue, and only
79|
‘outlines the procedures for referral. The federal certi-
!fication regulations that govern the large majority of
Minnesota's long-term care facilities are left to the
Ilicensing and certification surveyors to enforce, housed
I
in another division of the State Department of Health.
80
: V. RESEARCH FINDINGS
I
The process of summarizing findings from preliminary
study data requires the exercise of great care to avoid
making general statements about analyses of data which are,
I at best, tentative. Thus, most of the following discussion
I should be interpreted as suggestive rather than definitive.
I The degree to which these conclusions are actually conclu-
I
Isive will be unknown until a much larger validation study
I is conducted.
The analyses of the complaints against nursing homes
data are presented below. The analyses, which are princi-
'pally descriptive, include information that characterizes
the complaints and the nursing homes. The thirty nursing
: homes about which complaint data were gathered were
analyzed in relation to four variables— size, proprietary
status, geographical location and level of care provided.
The distribution of the sample in these variable cate
gories is shown in Table 1.
81
Table 1
Sample Size by Variable Category
Total
Variable
Size
10-69 beds
70-129 beds
130-189 beds
190-249 beds
250+ beds
Proprietary
Proprietary
Non-profit
Total
Geographic Location
Urban
Suburban
Total
Level of Care Provided
Skilled Only
Intermediate Only
Both
Total
Sample Size
3
9
13
3
2
30
19
11
30
18
12
30
5
4
21
30
A. Sample of Nursing Homes
The nursing homes ranged in size or number of beds
from 21 to 300, with the average number of beds at 241.
The typical nursing home in this sample was located in
I
lan urban area, was operated for profit, had both skilled
and intermediate levels of care available, and had an
'average of 141 beds.
The total number of beds in each facility was divided
by the total number of complaints against each nursing
Ihome to determine the frequency of complaints per bed.
IThis frequency is shown in Table 2 in relation to each
of the four variables. As can be seen from this table,
jthe highest frequency of complaints was found in nursing
home facilities that had 10-69 beds, were proprietary,
located in an urban area and only provided skilled level
I
of care.
In Table 2, the number of total complaints is then
: separated into two descriptive categories of resident-
I
^related and administrative-related complaints. These
categories are analyzed by frequency per bed and corre
lated to the four variables.
83
Table 2
Average Frequency of Complaints per Bed by Variables
i Variable
I
: size
10-69 beds
70-129 beds
' 130-189 beds
190-249 beds
: 250+ beds
I Proprietary
i Proprietary
I Non-profit
1
I
: Geographical
Location
1 Urban
! Suburban
Level of Care
j Provided
i Skilled Only
\ Intermediate
: Only
Both
Administra- Resident-
tive Related Related
Complaints Complaints
29
39
67
150
80
38
109
55
60
47
83
65
10
31
65
81
169
44
82
56
61
21
74
63
All
Complaints
7
16
32
51
43
16
44
28
24
13
39
27
84,
One of the major questions that arose in the method
ology chapter of this study is whether quality of life data ;
are better, the same or worse than regulatory survey data
in determining where the deficient, substandard or inade-
iquate nursing homes are to be found. For the purposes of
1
this study, resident-related complaints were to be synon- ,
I '
ymous with quality of life data and administrative-related ,
^complaints were to be a surrogate for actual licensure
jand certification survey data. Thus it is important to !
[examine the similarities and differences between the data
i :
[in Table 2 to establish an answer to this question.
I
| B. Variables. iStudied
I In relation to the variable of size as portrayed in
jlable 2, both the resident-related and administrative-
related complaint frequencies are highest for the smallest
number of beds, 10-69 beds. This means that for both
I
jcategories of complaints, the smallest nursing home had
[the highest number of both kinds of complaints.
I For the variable relating to proprietary status, the
■resident-related complaints and the administrative-related '
I
complaints have a much greater frequency of complaints than
Ido non-profit facilities. The two categories of complaints
are also in agreement that urban loncr-term care facilities
have more complaints lodged against them than suburban '
facilities. For the final variable under analysis, level
85
of care provided, again the data for the two types of com- '
plaints are similar in revealing that nursing homes offer
ing only skilled care receive the highest frequency of
complaints.
I This indicates that resident-related complaints and
I
administrative-related complaints consistently show the j
same variables affecting the frequency of complaints. It ;
;is first important to acknowledge that the results obtained ■
{from both kinds of complaints do not vary demonstrably from
I
jone another. This tells us that for the scope of this
jstudy, resident-related complaints are the same as adminis-
itrative-related complaints, or, in other words, quality of
care data tells us the same information as regulatory sur-
j
vey data. Both sets of data reveal that greater numbers
lof complaints are associated with proprietary nursing homes,
I
an urban location, in facilities offering only skilled care
and having 10-69 beds.
Table 2 also provides an answer to the question of the
relationship between the frequency of quality of care
(resident-related) complaints and the size, proprietary
I I
[status, geographical location and levels of care available
lin a nursing home in the sample. The frequency of resident-
^related complaints increases as size decreases, increases
I
with proprietary status, with an urban location and with
skilled care. Table 2 indicates the same correlations for
administrative-related complaints.
i . 86j
An overall summary of the findings of this study re
veals that in relation to proprietary status, geographical
location, level of care available and size of a nursing
home, quality of care data and regulatory survey data are ,
i ' '
practically identical. Both sets of data, in the form of
complaints lodged against nursing homes, indicate a posi- i
tive relationship between high frequency of complaints and
proprietary status, skilled level of care and small facili
ties. Geographical location was not found to impact great- '
;ly on complaint frequency.
8r
VI. CONCLUSIONS, IMPLICATIONS, RECOMMENDATIONS
I
Quality is excellence in kind. An examination of
I I
institutional quality from a strictly economic point of '
view, with institutional profit defined as the primary
'objective, would be quite different from.the analysis that .
I *
jis presented in this study. The perspective on quality !
[adopted here concerns quality of life in the institution ■
|as experienced by the residents. In other words, the con- '
I I
jCern is with how well nursing homes meet resident-oriented j
goals. This study begins to explore the subject of quality
i
!by means of the analysis of residents' complaints.
1 The nursing home scandals of the 19 50's through the
1970's gave the industry a shady and tawdry image. Such
/
exposes on the industry of that era as Tender Loving Greed
i(Mendelson, 1974) and the New York State 1976 Moreland
iCommission document outlandish profits accompanied by out-
Irageous care. The industry now claims that such scandals
[have virtually ceased, that the many reputable owners and
[administrators were tarnished by a few unscrupulous owners
and chains. But while most nursing homes have improved
considerably, major problems linger.
88 '
I a . Implications for Quality
of Life in Nursing Homes
It is difficult to adhere to any unidimensional scale
in the determination of the quality of life in nursing
homes. This is so because among dependent and frail per-.
I
‘ sons, who are the major inhabitants of nursing homes in this
'country, some forms of verbal or emotional neglect or even
|rudeness.may be just as damaging as physical violence. It .
is important to stress the belief, which stems from research
on the elderly, that in comparison to any other group, the
aged are as sensitive, if not more sensitive, to their en- ,
vironment. Rendered vulnerable by poor physical condition,
, continual crises, prejudice, and isolation, the aged are
easily victimized by uncongenial environments. There is
reason to believe that the aged, like the rest of us, at
[any level of competence, will respond if helped to play an
active participating role in their own life and care.
Townsend (1962) suggests that at the interpersonal
level each person needs to be helped to maintain himself or
herself as far as possible as a responsible individual.
Since institutions require that numbers of persons live
together, these persons should be encouraged to aid and
support each other. At the administrative level, since the
institution ostensibly exists for the support of the resi
dents, they should be encouraged to voice their opinions,
have a hand in running the institution, and be responsible
; 89 I
; for their suggestions and action in this regard (Harel and
I
^Kahana, Note 26).
It will be necessary to conduct many more investiga
tions in order to adequately define, predict, and measure
,the quality of life in our nation's long-term care facili-
I
ties. The present study has revealed as a preliminary step
to the development of a quality assessment tool, that nurs
ing home quality of life data indicate the same character-
.istics of substandard nursing homes as regulatory survey
jdata. This is not to suggest that complaint data are un
necessary in light of the availability of licensure survey
[reports. Rather, complaint data can be used as part of the
■total description of care in a nursing home facility.
I
! The system for receipt, investigation and resolution
I
; of complaints against nursing homes was created with the
intention of responsiveness to consumer concerns. It is
evident that consumers are making use of this system; com-
Iplaints are being lodged, investigated and verified. This
I
jstudy reveals that data concerning the pattern and fre
quency of such complaints correlate with the findings about
■deficient facilities from governmental regulatory surveys.
We know where the inadequate, deficient and substan
dard nursing homes are to be found. We must focus our
response on enforcement and sanction strategies to use that
knowledge and assure that the utmost in quality is afforded
90!
J
I to residents in nursing homes. Nursing homes are, for
I
[most, the last stop before death, but we must remember that
j these institutions also are the last stand for the living.
I
!
B. Recommendations for Policy
* and Program Development
In terms of specific policy recommendations at this
! early stage, the following are suggested.
, First, to improve the quality of nursing home resi-
Idents' lives, the goals of nursing homes must be directed
I
I toward fulfilling resident expectations. It is understood
j that this is not a completely realistic goal. It would be
[quite difficult to satisfy the expectations of any group
I of individuals. Ignoring this facet of life, however, will
I
I not improve the life of the institutionalized elderly.
[Quality of life goals are at least as realistic as health
maintenance goals and a reassessment of the priority of
health maintenance versus quality of life in nursing homes
is certainly in order.
Policy makers must recognize that aging is a normal
process and that the elderly, like all people, have a
!
variety of needs, concerns and interests. These needs,
!
[concerns and interests should receive the same commitment
I that health maintenance has received. To better the qual
ity of life— not just the quality of care— should be a
; primary goal of the nursing home industry and the policy
makers who affect that industry.
91
I
Second, to improve the quality of nursing home resi
dents' lives,the existing system of surveying and regulat
ing nursing homes must be more stringently enforced. The
results of this study reveal that complaint data is equally
;as likely as survey data to indicate a substandard or in
adequately operating long-term care facility. Every state
,has the mechanism and structure in place to identify such
'facilities but the abuses and scandals connected with nurs-
Iing homes continue. Abuses continue to occur, it seems, '
[because not enough is done with the data obtained from the
I ' i
Icomplainant or survey reports. Occasionally nursing homes !
1
are fined or reprimanded or placed on probationary status
!with the regulatory or reimbursement authorities in a state.
i :
Nevertheless, the existence of swift, strong and fair
;enforcement actions to chastise the few unscrupulous owners,
operators and staff of substandard nursing homes still is
not a reality. Emphasis on strengthening and improving the
enforcement aspect of the nursing home regulatory system
should be a primary consideration for policy makers.
Third, to improve the quality of nursing home resi-.
dents' lives, the variables affecting the existence of
quality in such institutions must be examined further. It
I is imperative that, consumers.seeking, nursing .home care.be
given access to all_ information concerning. . the assessment :
of such care. Traditionally, there has been difficulty in
92!
obtaining copies of regulatory survey reports on a parti
cular nursing home and consumers have been forced into
making uninformed decisions. Complaint data on a particu- !
jlar facility might also be inaccessible. If it is possible ;
I to ascertain probable quality of an institution by means of
I j
examining its identifiable characteristics, then consumer
I
knowledge and opportunity for choice would be greatly en-
jhanced. It seems apparent from this study that such iden-
Itifiable characteristics might be agreed upon by experts
I
1 in the field if enough attention were paid to the need for
1
jsuch easily understood data.
I
,C. Recommendations for Research
I
I This study has only begun to examine the complex rela-
!tionship between the existence of quality and life in a
Ilong-term care facility. Some potential areas for future
; research include the following.
First, one of the foundations of science is that
true scientific knowledge can be tested and such discovery
can be replicated. The validity of any single scientific
I
! Study should be tested and the findings verified. Analysis
about complaints and regulatory data from a scientifically
'determined sample of nursing homes would permit some
[assurance of the validity, generalizability and reliability
of the current findings.
Second, comparisons of the frequency of nursing home
complaints and variables other than the four analyzed in
9 3 I
this study would provide an understanding of the effect of
other characteristics of the nursing home.
j Third, formulating public policies for high quality
nursing home care and then enforcing them depend on the
extent to which quality can be defined and measured. In
particular, accurate and efficient measures of quality of
life in a nursing home or institutional setting must be
developed, tested and utilized as one facet of the regu-
1
ilatory system.
|D. Conclusion
i
j Problems facing elderly nursing home residents and
jshortcomings of the programs serving them are major issues
‘which face the elderly population but upgrading the qual- >
i
!ity of care provided in nursing homes is not a high prior-
'ity for policy makers. The nursing home industry has a
poor track record. Abuses and questionable practices are
frequently uncovered and major tragedies occasionally
explode in newspapers, but rarely culminate in solutions
'benefiting the long-range care of the resident.
The scandals continue, yet federal, state and local
governments are making decisions to terminate Medicaid
coverage of critically needed therapies in nursing homes,
place caps on the personal needs allowance for nursing home
residents and to implement ceilings on Medicaid expendi
tures. In Minnesota, the annual unannounced inspection of
94 I
nursing homes was changed to a bi-annual inspection and
there was discussion of allowing the nursing homes to con
duct evaluations of themselves in lieu of the annual health
department inspection. The federal government has under
: consideration the loosening of regulations governing nurs- |
I ' !
ing homes. '
It is doubly important, in the current political and
'economic climate of restraint and cutbacks that the amount
; of dollars and energies available for assuring quality
I nursing home, care is used in the best possible fashion for ^
I the greatest good. The nursing home industry often points ■
I to the fact that the long-term care sector is the most
I heavily regulated part of the health care system. Further,
ithe industry claims that inflexible and confining regula
tions prohibit the exercising of creativity that is neces-
i
Isary in the provision of care. The consumer groups, who
represent the nursing home residents, their families and
ifriends, claim that it is the proprietary nature of the
i
! industry, the dependence of the residents and the use of
I
I public monies as the chief source of payment of care that
; require more stringent governmental regulations and en-
; forcement.
i
; The difficulty arises in agreeing on the operational
1 _ !
definition of quality and achieving a consensus on where
the most deficient nursing homes are to be found. Federal
95
and state governments have traditionally relied on regula
tions or standards aginst which conditions in nursing homes
are compared. Governments and regulators respond to the
problem of poor nursing home care on the basis of viola®
Itions of pre-determined standards. These standards repre- ,
,sent an attempt to quantify a situation of overwhelming
complexity ; the more engineering content there is to an
I
jactivity, the easier it is to determine regulatory stan-
I
jdards, the greater the dynamics of social interaction in
Ithe activity, the harder it is to determine such standards
(Vladeck, 1980).
1 Given the enormous variation in quality among nursing
Ihomes, it would make sense to devote most of the inspection
[effort to the most inadequate facilities and to check the
I
ibetter ones more sporadically. However, government regu-
;latory offices generally have not relied on the receipt of
complaints as a trigger to initiate a more formal survey
investigation. The state Long Term Care Ombudsman Program,
[established in every state to receive, investigate and
1
'resolve complaints against nursing homes, does not regular- ■
*ly participate in the regulation of nursing homes. Although
it is required by law to report complaint-related findings
to the nursing home licensure agency in the state, often
there is little further contact.
The certainty is that public financing of nursing home
96
care will be closely examined for waste. The probability
Iexists that regardless of how fractured or inefficient the
present methods of assuring quality of nursing home care, ‘
resources for such a task will be diminished in the coming
years. It is necessary to maximize minimal resources. One
I
way to accomplish this is to redirect the bulk of the avail
able resources to those nursing homes most deficient in
quality.
971
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Hart, Meredith Anne
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The use of complaints against nursing homes as an index of quality care
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