Predicting lawsuits against nursing homes in the United States, 1997-2001

Health Services Research, Dec, 2004 by Christopher E. Johnson, Aram Dobalian, Janet Burkhard, Deborah K. Hedgecock, Jeffrey Harman

Online Survey, Certification, and Reporting (OSCAR) is a database of nursing home licensing survey deficiencies and other structural variables that can be used to analyze the effects of nursing home structure and quality indicators on lawsuit activity. There are concerns related to using OSCAR data (Centers for Medicare and Medicaid Services 2001), but these data have been used to conduct research that examines whether or not nursing homes are meeting minimum quality standards across different health survey variables (Harrington, Zimmerman et al. 2000b). We did not use the "chain" variable in OSCAR because the way that variable is coded included systems that were too small to be considered a chain in this analysis. We hand-corrected all of the OSCAR chain information in our data to reflect nursing homes that were part of nursing home multistate chains or systems.

SPECIFICATION OF THE VARIABLES

Explanatory Variables

The OSCAR data and skilled nursing facility complaint data were used to capture information about the staffing structure, care processes that occurred within the nursing home, and deficiency data from 1997 to 2001. These quality-related variables were specified at the nursing-home level and included:

1. Whether the nursing home met the CMS-recommended, long-stay 2.8 certified nursing assistant (CNA) hour per resident day standard for CNAs, the 1.3 hour per resident day standard for licensed practical nurses (LPN), and the 0.75 hour per resident day standard for registered nurses (RN);

2. Development of new pressure sores within the facility per resident in the home;

3. Total number of deficiencies cited on state licensing survey; and

4. Whether the home was cited for an actual harm severity violation (G or higher) on the state licensing survey.

Many consumer groups and proponents such as the American Association of Retired Persons (AARP) view litigation as the ultimate motivator for higher quality of care within nursing homes (Florida Policy Exchange Center on Aging 2001). This argument rests on the hypothesis that there is a relationship between the quality of care provided by the nursing home and whether or not a nursing home is sued. Nurse staffing levels were shown in a number of studies to impact the quality of care outcomes within long-term care facilities (Bliesmer et al. 1998; Wunderlich, Sloan, and Davis 1996). There are currently no enforced minimum national staffing standards, although many states do mandate that nursing homes staff their facilities at specific levels (Harrington, Kovner et al. 2000a). Abt Associates and CMS made specific recommendations about the resident hours per staff that lead to better outcomes for long-stay residents (Centers for Medicare and Medicaid Services 2001). These long-stay residents are more likely to be involved in litigation activity. We used the weighted threshold staffing ratios that were found related to long-stay quality in nursing homes. Lower staffing levels could mean poorer quality of care for residents and this poorer quality of care may translate into higher numbers of lawsuits. Facility outcomes such as development of preventable pressure sores (U.S. General Accounting Office 1999), the total number of deficiencies cited against a nursing home during state licensing and complaint surveys (Harrington and Carrillo 1999), and the severity of those deficiencies could indicate a poor-quality facility. Nursing home survey deficiencies were found to significantly predict higher numbers of lawsuits in previous work (Johnson et al. 2003).