Racial Differences in Antidepressant Use in Nursing Facility Residents With Moderate to Severe Cognitive Impairment.

Objective To describe and compare the use of antidepressants between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment. Design This was a secondary data analysis using baseline data from the Function and Behavior Focused Care for Nursing Facility Residents with Dementia randomized control trial. Setting Participants were recruited from 10 urban and two rural nursing facilities from Maryland. Methods Participants had to be 55 years of age or older, English-speaking, reside in long-term care at time of recruitment, and score a 15 or less on the Mini Mental-State Examination. A total of 336 residents participated at baseline. Data were collected by a research evaluator through observation, proxy report from staff caring for the resident the day of testing, and patient charts. Main Outcomes A significant difference of antidepressant use between Black or African descent and White nursing facility residents with moderate to severe cognitive impairment would be noted when controlling for depression, age, gender, functional status, agitation, and number of co-morbidities. Results In adjusted models, Black or African descent residents were less likely to be prescribed antidepressants compared with White residents. Conclusion Racial differences were noted regarding antidepressant use among nursing facility residents with moderate to severe cognitive impairment, but it is unknown if race could impact prescribing practices when indications for use are known. Further research is needed to ascertain if knowing the specific indications for use might contribute to racial disparities with antidepressant prescribing in nursing facility residents with moderate to severe cognitive impairment.

Deficiency Citations on Inappropriate Psychotropics Use Related to Care for Behavioral Symptoms of Dementia.

OBJECTIVES: The Centers for Medicare and Medicaid (CMS) initiated the National Partnership to Improve Dementia Care in Nursing Homes in 2012, which helped decrease antipsychotics use. However, inappropriate use of antipsychotics and other psychotropic medications to control behavioral symptoms associated with dementia persists. Nursing homes (NHs) can be flagged for inappropriate psychotropics use as a deficiency of care citation (F-758 tag). The purpose of this study was to comprehensively explore inappropriate psychotropic medication use deficiency, F-758 citations, in caring for NH residents with dementia. DESIGN: A mixed-methods study was performed. SETTING AND PARTICIPANTS: During the first quarter of 2018 (January-March), 3526 NHs were surveyed, of which 642 received F-758 tags. Of the 642, the sample was confined to the 444 NHs that received the citation for the care of residents with dementia. Information on deficiencies was obtained from 2018 Certification and Survey Provider Enhanced Reporting data. Inspection reports for deficiencies were obtained from Centers for Medicare and Medicaid Nursing Home Compare and ProPublica. METHODS: Quantitative analysis was used to examine the frequency of involved psychotropic medications, scope/severity of F-758 deficiency citations, and reasons for the citations. Reasons for F-758 citations by psychotropic medication categories and scope/severity of the citations were also examined using χ2 tests. Qualitative data analysis was conducted using content analysis with an inductive coding approach to summarize the inspection reports. RESULTS: Antipsychotics were the most involved drug category for F-758 tag citations. The 3 most common reasons for F-758 citations included failure to identify and/or monitor behavioral symptoms (178 NHs), attempt gradual drug reduction (131 NHs), and maintain 14-day limitations on Pro Re Nata (PRN) psychotropic orders (121 NHs). Compared with those with no involvement of antipsychotic drugs, facilities with antipsychotics-related F-758 tags had higher rates of failure to identify/monitor behavioral symptoms (P < .001), attempt gradual drug reduction (P < .001), and provide adequate indications for psychotropics use (P < .001). NHs with F-758 tags related to inappropriate antianxiety medication use had a higher prevalence of failure to maintain 14-day limitation on PRN orders (P < .001) and provide nonpharmacologic interventions (P < .001). CONCLUSIONS AND IMPLICATIONS: This study suggests areas for improvement that could potentially reduce inappropriate psychotropics use. Supporting quality of dementia care workforce and improving cooperation within healthcare staff and professionals are recommended to ensure proper nonpharmacologic and pharmacologic interventions.

Nurse staffing and deficiency of care for inappropriate psychotropic medication use in nursing home residents with dementia.

PURPOSE: Psychotropic medications are used to manage behavioral symptoms of dementia in nursing homes despite limited efficacy and the risk of adverse effects, and may be considered an easier solution for the treatment of behavioral symptoms. However, non-pharmacologic interventions are preferable but are most effective with consistent staffing. To address this, the Centers for Medicare and Medicaid Services implemented additional regulatory scrutiny through F-tag for deficiencies of care, targeting inappropriate psychotropic medication use (F-758 tag). The purpose of this study was to examine associations between nurse staffing levels and the occurrence of deficiency citations for inappropriate psychotropic medication use in residents with dementia symptoms. DESIGN: This was secondary data analysis of a cross-sectional study using CASPER (Certification and Survey Provider Enhanced Reporting) and PBJ (Payroll-Based Journal) data from 14,548 Medicare or Medicaid-certified facilities surveyed between December 1, 2017 and December 31, 2018. METHODS: Staffing measures included nursing hours per resident day and registered nurse skill-mix. Generalized linear mixed models with facilities nested within states, were used to estimate the magnitude of the associations between the occurrence of inappropriate psychotropics use deficiency citations and nurse staffing levels. Covariates included facility location, size, ownership, the presence of dementia special care units, and the proportion of residents with dementia, depression, psychiatric disorders, mental behavioral symptoms, and residents with Medicare/Medicaid. RESULTS: There were 1875 facilities with deficiency citations regarding inappropriate psychotropics use for residents with dementia. When controlling for covariates, facilities with greater hours per resident day for registered nurses (odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.44-0.67), certified nursing assistants (OR = 0.87, 95% CI = 0.77-0.99) and total nurse staff (OR = 0.87, 95% CI = 0.79-0.96) had significantly lower odds of inappropriate psychotropics use deficiency citations. Nursing homes with greater registered nurse skill-mix had significantly lower odds of receiving the deficiency tags (OR = 0.10, 95% CI = 0.04-0.26). CONCLUSION: Citations for inappropriate psychotropic medication use among residents with dementia were less likely to occur in facilities with higher staffing levels for registered nurses, certified nursing assistants, total nurse staff, and greater registered nurse skill-mix. Facilities need to be equipped with adequate nurse staffing levels to facilitate the use of non-pharmacological interventions and reduce inappropriate psychotropic medication use. CLINICAL RELEVANCE: Adequate nursing staffing is associated with fewer deficiencies related to the use of psychotropic medications to treat behavioral symptoms. Nursing home administrators and policymakers need to focus on assuring adequate nurse staffing levels to provide safe and high-quality dementia care.

Comparing residential long-term care regulations between nursing homes and assisted living facilities.

BACKGROUND: Nursing homes (NHs) are federally regulated under uniform standards, whereas assisted living facilities (ALFs) use individual state regulations for staffing, training, and oversight of care quality and safety. PURPOSE: To describe ALF staffing, training, inspection, and enforcement regulations for 50 U.S. states and the District of Columbia, and compare them to NH regulations. Publication of ALF quality and safety outcomes data also was assessed and compared to NHs. METHODS: Regulatory data were compiled from administrative and regulatory data sources, state websites, and regulatory compendia. FINDINGS: NHs followed a standard set of regulations, whereas ALF regulations varied widely. Overall, state ALF regulations were less stringent than NH in all categories. DISCUSSION: As ALF populations and acuity levels increase, staffing, training, nursing presence, and outcomes data requirements are warranted, and could be tailored from NH regulations to protect ALF quality and safety.

CNA Training Requirements and Resident Care Outcomes in Nursing Homes.

Purpose of the Study: To examine the relationship between certified nursing assistant (CNA) training requirements and resident outcomes in U.S. nursing homes (NHs). The number and type of training hours vary by state since many U.S. states have chosen to require additional hours over the federal minimums, presumably to keep pace with the increasing complexity of care. Yet little is known about the impact of the type and amount of training CNAs are required to have on resident outcomes. Design and Methods: Compiled data on 2010 state regulatory requirements for CNA training (clinical, total initial training, in-service, ratio of clinical to didactic hours) were linked to 2010 resident outcomes data from 15,508 NHs. Outcomes included the following NH Compare Quality Indicators (QIs) (Minimum Data Set 3.0): pain, antipsychotic use, falls with injury, depression, weight loss and pressure ulcers. Facility-level QIs were regressed on training indicators using generalized linear models with the Huber-White correction, to account for clustering of NHs within states. Models were stratified by facility size and adjusted for case-mix, ownership status, percentage of Medicaid-certified beds and urban-rural status. Results: A higher ratio of clinical to didactic hours was related to better resident outcomes. NHs in states requiring clinical training hours above federal minimums (i.e., >16hr) had significantly lower odds of adverse outcomes, particularly pain falls with injury, and depression. Total and in-service training hours also were related to outcomes. Implications: Additional training providing clinical experiences may aid in identifying residents at risk. This study provides empirical evidence supporting the importance of increased requirements for CNA training to improve quality of care.

Variation Across U.S. Assisted Living Facilities: Admissions, Resident Care Needs, and Staffing.

PURPOSE: Though more people in the United States currently reside in assisted living facilities (ALFs) than nursing homes, little is known about ALF admission policies, resident care needs, and staffing characteristics. We therefore conducted this study using a nationwide sample of ALFs to examine these factors, along with comparison of ALFs by size. DESIGN: Cross-sectional secondary data analysis using data from the 2010 National Survey of Residential Care Facilities. METHODS: Measures included nine admission policy items, seven items on the proportion of residents with selected conditions or care needs, and six items on staffing characteristics (e.g., access to licensed nurse, aide training). Facilities (n = 2,301) were divided into three categories by size: small, 4 to 10 beds; medium, 11 to 25 beds; and large, 26 or more beds. Analyses took complex sampling design effects into account to project national U.S. estimates. FINDINGS: More than half of ALFs admitted residents with considerable healthcare needs and served populations that required nursing care, such as for transfers, medications, and eating or dressing. Staffing was largely composed of patient care aides, and fewer than half of ALFs had licensed care provider (registered nurse, licensed practical nurse) hours. Smaller facilities tended to have more inclusive admission policies and residents with more complex care needs (more mobility, eating and medication assistance required, short-term memory issues, p < .01) and less access to licensed nurses than larger ALFs (p < .01). CONCLUSIONS: This study suggests ALFs are caring for and admitting residents with considerable care needs, indicating potential overlap with nursing home populations. Despite this finding, ALF regulations lag far behind those in effect for nursing homes. In addition, measurement of care outcomes is critically needed to ensure appropriate ALF care quality. CLINICAL RELEVANCE: As more people choose ALFs, outcome measures for ALFs, which are now unavailable, should be developed to allow for oversight and monitoring of care quality.

Factors associated with eating performance for long-term care residents with moderate-to-severe cognitive impairment.

AIMS: The aim of this study was to examine the association of specific personal and environmental factors with eating performance among long-term care residents with moderate-to-severe cognitive impairment. BACKGROUND: Eating is the one of the most basic and easiest activities of daily living to perform. While multilevel factors can be associated with eating performance, the evidence among those with dementia was insufficient. DESIGN: A secondary analysis of baseline data collected between March and September in 2012 from 199 residents in eight long-term care facilities. METHODS: Eating performance was conceptualized using the single self-care 'feeding' item in the Barthel Index and was scored based on four levels of dependence and assistance required. Binary logistic regression was used to examine the adjusted association of specific factors with eating performance. RESULTS: Almost one-third of the residents needed help with eating. After adjusting the type of facility, number of comorbidities, chair-sitting balance, agitation and depression, compromised eating performance was associated with severe cognitive impairment and low physical capability. CONCLUSION: This study supported the association of eating performance with cognitive impairment and physical capability among long-term care residents with moderate-to-severe cognitive impairment. Targeted interventions should be implemented to reduce the impact of cognitive decline on eating performance and promote physical capability to optimize eating performance. Future work need to use validated multiple-item measures for eating performance and test the association of personal and environmental factors with eating performance among a larger heterogeneous group of long-term care residents to enhance understanding of the factors.

Function Focused Care for Assisted Living Residents With Dementia.

PURPOSE OF THE STUDY: Assisted living (AL) residents with dementia require assistance with activities of daily living, encounter limited opportunities to engage in physical activity, and often exhibit challenging behavioral symptoms. The Function Focused Care Intervention for the Cognitively Impaired (FFC-CI) teaches and motivates direct care workers (DCWs) to engage residents with dementia in activities that optimize function and activity while minimizing behavioral symptoms. The purpose of this study was to test the impact of FFC-CI on function, physical activity, behavior, and falls. DESIGN AND METHODS: A cluster-randomized trial included 96 residents with dementia and 76 DCWs from 4 ALs. Generalized estimating equations were used to evaluate outcomes at 3 and 6 months. RESULTS: There were no treatment by time differences with regard to resident behavior, mood, counts of physical activity based on actigraphy, falls, and function. There were significant increases in physical activity based on kilocalories burned (p = .001), time spent in physical activity based on survey results (p = .001), and time spent in repetitive behaviors, such as wandering (p = .01) among the control group over time. There were no treatment by time differences with regard to DCW beliefs, knowledge, or performance of FFC, except for less decline in job satisfaction among the treatment group (p = .002). Treatment fidelity with regard to delivery and receipt were poor due to high staff attrition in the treatment group (46% vs. 16%) and limited site support. IMPLICATIONS: The findings from this study can be used to adapt future FFC intervention studies to improve treatment fidelity and optimize intervention efficacy.

Leadership education, certification and resident outcomes in US nursing homes: cross-sectional secondary data analysis.

BACKGROUND: Leadership is a key consideration in improving nursing home care quality. Previous research found nursing homes with more credentialed leaders had lower rates of care deficiencies than nursing homes with less credentialed leaders. Evidence that nursing home administrator (NHA) and director of nursing (DON) education and certification is related to resident outcomes is limited. OBJECTIVES: To examine associations of education and certification among NHAs and DONs with resident outcomes. DESIGN: Cross-sectional secondary data analysis. SETTINGS: This study used National Nursing Home Survey data on leadership education and certification and Nursing Home Compare quality outcomes (e.g. pain, catheter use). PARTICIPANTS: 1142 nursing homes in the survey which represented 16628 nursing homes in the US. METHODS: Leadership education and certification were assessed separately for NHAs and DONs. Nursing home resident outcomes were measured using facility-level nursing home quality indicator rates selected from the Minimum Data Set. Facility-level quality indicators were regressed onto leadership variables in models that also held constant facility size and ownership status. RESULTS: Nursing homes led by NHAs with both Master's degrees or higher and certification had significantly better outcomes for pain. Nursing homes led by DONs with Bachelor's degrees or higher plus certification also had significantly lower pain and catheter use. Whereas pressure ulcer rates were higher in facilities led by DONs with more education. CONCLUSIONS: Selected outcomes for nursing home residents might be improved by increasing the education and certification requirements for NHAs and DONs. Additional research is needed to clarify these relationships.

Associations between state regulations, training length, perceived quality and job satisfaction among certified nursing assistants: cross-sectional secondary data analysis.

BACKGROUND: In the U.S., there are federal requirements on how much training and annual continuing education a certified nursing assistant must complete in order to be certified. The requirements are designed to enable them to provide competent and quality care to nursing home residents. Many states also require additional training and continuing education hours as improved nursing home quality indicators have been found to be related to increased training. OBJECTIVES: This study investigated the associations among state level regulations, initial training quality and focus, and job satisfaction in certified nursing assistants. DESIGN: Cross-sectional secondary data analysis. SETTINGS: This study used the National Nursing Home Survey and National Nursing Assistant Survey as well as data on state regulations of certified nursing assistant training. PARTICIPANTS: 2897 certified nursing assistants in 580 nursing homes who were currently working at a nursing home facility, who represented 680,846 certified nursing assistants in US. METHODS: State regulations were related to initial training and job satisfaction among certified nursing assistants using chi square tests and binomial logistic regression models. Analyses were conducted using SAS-callable SUDAAN to correct for complex sampling design effects in the National Nursing Home Survey and National Nursing Assistant Survey. Models were adjusted for personal and facility characteristics. RESULTS: Certified nursing assistants reporting high quality training were more likely to work in states requiring additional initial training hours (p=0.02) and were more satisfied with their jobs (OR=1.51, 95% CI=1.09-2.09) than those with low quality training. In addition, those with more training focused on work life skills were 91% more satisfied (OR=1.91, 95% CI=1.41-2.58) whereas no relationship was found between training focused on basic care skills and job satisfaction (OR=1.36, 95% CI=0.99-1.84). CONCLUSIONS: Certified nursing assistants with additional initial training were more likely to report that their training was of high quality, and this was related to job satisfaction. Job satisfaction was also associated with receiving more training that focused on work life skills. Federal training regulations should reconsider additional hours for certified nursing assistant initial training, and include work life skills as a focus. As job satisfaction has been linked to nursing home turnover, attention to training may improve satisfaction, ultimately reducing staff turnover.

Are nursing home survey deficiencies higher in facilities with greater staff turnover.

OBJECTIVES: To examine CNA and licensed nurse (RN+LPN/LVN) turnover in relation to numbers of deficiencies in nursing homes. DESIGN: A secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies. SETTING: The 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States. PARTICIPANTS: This study focused on the 1151 NNHS facilities with complete deficiency data. MEASUREMENTS: Turnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models. RESULTS: High CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10-2.13), Resident Behavior (OR 1.42, 95% CI 1.03-1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12-2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50-2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25-2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies. CONCLUSION: Turnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies.

Turnover, staffing, skill mix, and resident outcomes in a national sample of US nursing homes.

OBJECTIVES: The authors examined the relationship of staff turnover to selected nursing home quality outcomes, in the context of staffing and skill mix. BACKGROUND: Staff turnover is a serious concern in nursing homes as it has been found to adversely affect care. When employee turnover is minimized, better care quality is more likely in nursing homes. METHODS: Data from the National Nursing Home Survey, a nationally representative sample of US nursing homes, were linked to Nursing Home Compare quality outcomes and analyzed using logistic regression. RESULTS: Nursing homes with high certified nursing assistant turnover had significantly higher odds of pressure ulcers, pain, and urinary tract infections even after controlling for staffing, skill mix, bed size, and ownership. Nurse turnover was associated with twice the odds of pressure ulcers, although this was attenuated when staffing was controlled. CONCLUSIONS: This study suggests turnover may be more important in explaining nursing home (NH) outcomes than staffing and skill mix and should therefore be given greater emphasis.

The relationship between nursing staff levels, skill mix, and deficiencies in Maryland nursing homes.

The objective of this data analysis was to explore whether nurse staffing levels and skill mix influenced the number and severity of nursing home deficiencies in Maryland nursing homes. Nursing staff levels and skill mix in relation to quality outcomes in nursing homes have been explored with inconsistent results. Two multiple regression analyses were done to explore factors influencing deficiencies and the severity of the deficiencies found during the annual survey process. The factors influencing the number of deficiencies were the number of nursing home beds (ß = .29), nursing assistant hours per patient-day (ß = -.206), and the location of the nursing home (ß = -.138). The only factor influencing the severity of the deficiencies was RN hours per patient-day (ß = -.199). In conclusion, it was determined that RN staffing, although not associated with the number of deficiencies, is associated with deficiency severity.

Job satisfaction of nursing assistants.

OBJECTIVE: This secondary data analysis explored factors influencing job satisfaction in a sample of nursing assistants employed in Maryland skilled nursing facilities. BACKGROUND: Multiple factors have been shown to affect job satisfaction and turnover in nursing assistants (NAs), but the problem of turnover persists in skilled nursing facility environments affecting quality of care. METHODS: An existing data set of 556 nursing assistants from 12 Maryland skilled nursing facilities was used. To explore factors found to influence job satisfaction from other studies, a multiple regression analysis was performed. RESULTS: Nine dependent variables previously shown to affect job satisfaction were used. Of these variables, only years of experience (ß = .230) and performance of restorative care (ß = .095) were found to be positively associated with job satisfaction. Self-esteem (ß = -.094) was found to be negatively associated with job satisfaction. CONCLUSION: Only length of experience and exemplary care as evidenced by the performance of restorative care were associated with job satisfaction. These results mirror results found in other studies. Self-esteem was negatively associated with job satisfaction in this population, a finding needing further study.

Advanced nursing assistant education program.

BACKGROUND: Nursing assistants provide 90% of the care to the elderly residents of nursing homes, but are the least educated direct-care employees. Supervisory workers believe that nursing assistants require additional training to meet the increasingly complex needs of nursing home residents. METHODS: A day-long training program for experienced nursing assistants was provided to supplement their basic education. Using a pre- and posttest design, the effectiveness of the program for knowledge acquisition and application was tested. Future education needs were identified through a gap analysis. RESULTS: There was a significant improvement in knowledge for nursing assistants attending the program. The attendees expressed interest in receiving additional education on dementia and infection control. All attendees identified a problem unique to their facility and were able to plan a detailed intervention and develop outcome measures for that plan. CONCLUSIONS: Nursing assistants enrolled in this advanced training program expressed a desire for additional education to help them advance their caregiving skills. Advanced education is one method to increase job satisfaction among nursing assistants that can improve the quality of care for nursing home residents.