Other Problems with Arizona Nursing Home “Quality Ratings”: Part 2

This is the second in a series of posts on problems with the “quality rating” system used by the Arizona Department of Health Services [ADHS]. Today’s topic: How most medication errors were ignored in the revisions that watered down the “quality rating” standards in 2003.

The previous post mentioned a nursing home that received an “A” quality rating even though it had violated nineteen federal and state regulations. One of those violations was a medication error rate greater than 5% (the actual error rate, as determined by ADHS, was actually 9.5%).

Prior to 2003, a facility would lose points on its quality rating for “significant medication errors that may adversely affect the resident’s health, safety, and well-being” (emphasis added). After the standards were revised in 2003, a facility loses points only for “significant medication errors that resulted in actual harm” (emphasis added).

A bit of background to make the significance of this change a little clearer.

Federal and state regulations require nursing homes to keep their medication error rates below 5%. See 42 C.F.R. § 483.25(m)(1); Ariz. Admin. Code R9-10-911(B)(3). “Medication errors” include failing to give an ordered medication, giving a medication that was not ordered, administering the wrong dosage, and giving an ordered medication at the wrong time or by an incorrect method of administration (e.g., intravenously instead of intramuscularly, or vice versa).

A “medication error” need not cause harm, or even create a risk of harm, and the regulations reflect that by allowing a facility to make a few medication errors without penalty--the facility just has to get it right at least 95% of the time.

That’s not true with a “significant medication error,” which is a medication error that “endangers the health or safety of a resident,” see Ariz. Admin. Code R9-10-101(87) (until 2003, the Arizona regulations mirrored the federal definition of a “significant medication error” as one “which causes the resident severe discomfort or jeopardizes a resident’s health and safety,” but the “severe discomfort” part of the definition was junked at the same time the quality rating standards were revised).

Unlike “medication errors,” federal and state regulations do not allow a 5% error rate for a “significant medication errors.” Instead, federal and state regulations require that residents be totally free from significant medication errors. See 42 C.F.R. § 483.25(m)(2); Ariz. Admin. Code R9-10-906(B)(14). This zero-tolerance rule makes sense because any “significant medication error” could--though not necessarily--have serious consequences for the resident’s health and safety.

Prior to the 2003 revision of the ADHS quality rating system, only a “significant medication error”--one that jeopardized a resident’s health and safety, even if it did not cause any actual harm--could affect the facility’s quality rating. Now, however, a facility can violate both sets of regulations by having a medication error rate above 5% and having a significant medication error that endangered a resident’s health or safety without any effect on the facility’s quality rating.

Under the current standard, the facility loses points only if someone actually becomes ill or dies from a significant medication error. Even then, the penalty is only five points on the 100-point rating scale--not enough, by itself, to drop the facility a full letter grade.

While it might make sense to penalize a nursing home only five points simply for having a medication error rate above 5% or a significant medication error that did not cause actual harm, knocking off only five points for errors that do cause illness or death seems rather lenient, especially in light of the scope and severity of the problem. In Preventing Medication Errors (2007), the Institute of Medicine of the National Academies estimates:

Between 350,000 and 1.9 million ADEs [adverse drug events] occur each year among the 1.6 million U.S. nursing home residents, about 40-50 percent of which are preventable. Of the estimated 20,000-86,000 fatal or life-threatening ADEs, about 70-80 percent are preventable.

Eliminating medication errors--whether “significant” or not--should be a priority for nursing homes and regulators alike. But the current quality rating system does not provide much incentive for nursing homes to address the problem of medication errors.

After the 2003 revisions, a facility loses five points only in the unlikely event that (1) evidence of actual harm (2) from a significant medication error (3) is discovered by ADHS (4) while ADHS is conducting a relicensure survey (as mentioned in a previous post, the quality rating scores are based only on deficiencies cited during the facility’s license renewal survey, not the cumulative total of deficiencies cited on all interim complaint investigations).

Thus, a “quality rating” of “A” is no indication that a nursing home is free from significant medication errors--or other serious problems--that could seriously harm a vulnerable nursing home resident. This is one reason why the ADHS “quality rating” is worthless for choosing a nursing home for a family member.

I’ll continue to post more on this topic next week. As always, your comments are welcome. For more information, see our website: http://solomonrelihan.com/