Background

For many years, the patient safety field focused on improving safety in hospital and ambulatory care settings. More recently, greater focus has been placed on nursing homes and other long-term care organizations, primarily because of the devastating impact of the COVID-19 pandemic on nursing homes. Long-term care settings include skilled nursing facilities (SNFs), inpatient rehabilitation facilities, and long-term acute care hospitals all providing medical and nursing care to patients who are discharged from the hospital and need ongoing 24-hour post-acute rehabilitation and nursing care. Additionally, assisted living facilities, residential care for the elderly, and congregate living or adult care facilities are considered part of the long-term care continuum. Although this group of organizations are not considered health care facilities, they do provide some basic nursing assistant level care such as help with taking medications and activities of daily living.

Patients requiring care in long-term care facilities are disproportionately older with more chronic illness and co-morbid conditions compared with the general older adult population. From 2015 through 2023, there was about a 12% reduction in residents living in Medicare certified SNFs from 1.37 million residents down to 1.2 million. One of the reasons for the lower numbers is due to the almost 200,000 people who died of COVID-19 in nursing homes during the pandemic. (A PSNet primer summarized the prevalence and challenges that resulted in the enormous number of COVID-19 resident deaths.) Additionally, there were many staff deaths during the pandemic, so post-pandemic staffing levels have restricted admissions. There has also been a growing trend for older adults to age in place in their homes, so they have declined to enter into nursing homes, opting instead for an in-home caregiver or residential care settings. And, while there has been a significant decline in nursing home admissions, health care utilization after entering long-term care continues to be high with about half of all Medicare SNF residents requiring a hospitalization in their last year of life.

Nursing homes admit long-term care patients but also admit patients that are discharged from the hospital, known as post-acute patients. Over the past decade, post-acute patients represent an increasing proportion of the overall SNF patient population, and these patients—who are often medically complex and frail—may challenge the ability of SNFs to provide safe care. As a result of all these factors, the safety field has started to prioritize addressing safety issues faced by patients and residents in long-term care settings. Community-based residential care facilities also provide supervised services but are not licensed to provide nursing care; however, a growing number of these facilities are seeking waivers to provide some limited nursing care.

Each type of long-term care setting provides different services and is suitable for different types of patients. This first group provide medical and 24-hour nursing services along with varying levels of rehabilitation:

• Long-term acute care hospitals (LTACHs) care for medically complex patients expected to require care for weeks to months. These patients are often chronically or critically ill, most commonly recovering from a hospitalization that included an intensive care unit stay. These facilities provide services very similar to acute care hospitals, including the ability to care for patients requiring mechanical ventilation, complex wound care, or hemodialysis. The facilities may be freestanding or attached to an acute hospital, and they are subject to the same licensing and credentialing requirements as traditional hospitals. Patients at long-term acute care hospitals generally require daily evaluation by a physician.
• Inpatient rehabilitation facilities (IRFs) care for patients recovering from surgery, trauma, or an acute illness. They provide intensive rehabilitation—patients must be able to tolerate 3 hours of physical or occupational therapy daily—with the goal of restoring patients to their premorbid functional status. Care is overseen by a multidisciplinary team that includes a physician, typically a specialist in rehabilitation medicine.
• Skilled nursing facilities (SNFs) provide care to two levels of patients or residents. Post-acute or short stay patients are expected to stay a few days to weeks and then be discharged home, while those who are medically stable but continue to need 24-hour nursing care are considered long stay residents. In general, SNF patients do not require daily evaluation by a physician but do require services such as intensive nursing, physical therapy, or wound care.

This group of facilities are part of home and community-based long-term care services and do not provide medical or nursing care routinely:

• Assisted Living Facilities (ALFs) are facilities that provide an independent, but supervised living environment. Residents may live in an apartment, but the ALF provides core services such as housekeeping, laundry, and meal services. Some of these residents can obtain basic nursing care such as vital signs, assistance with medications, weights, and simple dressing changes for an additional charge. These facilities do not have 24-hour nursing care but they have staff on site 24 hours per day.
• Residential Care Facilities for the Elderly (RCFE) are homes for individuals that require assistance with most activities of daily living (bathing, dressing, walking, eating, etc.). Residents may have dementia or have suffered a stroke or otherwise need this level of care but are able to make simple decisions for themselves. Some of these facilities may have a waiver for basic nursing assistant level services.
• Adult Care or Board and Care Homes typically provide housing for adults 18-64 who may be developmentally disabled or have paraplegia or other conditions that prevent them from living independently. Some of these facilities may have a waiver for basic nursing assistant level services.

Safety Concerns in Long-term Care

Preventable adverse events are common in long-term care. A 2014 report by the OIG found that 22% of Medicare beneficiaries in SNFs experienced an adverse event (delirium, falls, pressure injuries) during their stay, half of which were preventable. More than half of the patients who experienced an adverse event at a SNF required hospitalization. Adverse drug events were the most common type of adverse event in the 2014 OIG study as well as in other studies of long-term care populations. A separate 2016 OIG report found an even higher incidence of adverse events at rehabilitation facilities.

Subsequent OIG reports have also found many patient safety problems and adverse events including well documented problems, such as medication errors, health care–associated infections, and overuse of antipsychotic medications. While patient complexity explains some of these events, it is also worth noting that computerized provider order entry (CPOE) and other medication safety strategies have not been implemented as widely in SNFs as in hospitals. A WebM&M commentary highlights falls that occur in SNF patients in more detail and gives evidence-based recommendations for preventing these harms.

The COVID-19 Pandemic

During the COVID-19 pandemic (2019-2022), several patient safety issues were revealed, particularly around the weakness in nursing home infection control and prevention programs. According to AARP, since the beginning of the pandemic and as of mid-February 2024, there have been over 2 million resident cases of COVID-19 and almost 200,000 resident deaths. Strikingly, there have been almost as many staff COVID-19 cases (1.9 million), but fortunately, far fewer staff deaths. Winter of 2024 saw the biggest surge of COVID-19 cases since the end of the pandemic, despite several safeguards and prevention programs put in place by the federal government including:

• Free vaccinations for residents and staff
• Requirement for all SNFs to have trained infection preventionists
• AHRQ infection control training
• Detailed instructions, policies and procedure guidelines, and other training materials

The ongoing infection control challenges is one piece of evidence of how difficult it is to improve patient safety in nursing homes. Issues such as chronic understaffing, inadequate training, low wages, and the lack of a patient safety culture continue to plague nursing homes.

Improving Patient Safety in LTC

In September of 2023, the Biden-Harris administration initiated steps to improve patient safety in nursing homes that included raising wages for some direct care staff, required registered nurse to be on staff 24/7 (prior requirements was only on day shift), improve overall staffing standards, and increasing nursing home accountability. In fact, several recommendations came from intense focus on nursing homes by CMS, AHRQ, the OIG in 2021 and 2023 as well as the Coronavirus Commission on Safety and Quality in Nursing Homes that are continuing to be implemented.

Establishing a robust culture of safety is essential for minimizing patient harm. Unfortunately, safety culture in many long-term care facilities is poorer than that found in hospitals and ambulatory clinics. The AHRQ Surveys on Patient Safety Culture™ (SOPS®) Nursing Home Survey is used to assess safety culture in nursing home settings The most recent data (2023) indicates some ongoing improvement in long-term care safety culture, but respondents identified several areas for improvement including comfort with speaking up about safety concerns and ensuring sufficient staffing.

Current Context

Improving safety in long-term care facilities requires research into the safety problems faced by patients, education, patient safety training for health care providers in long-term care settings, system-level interventions to enhance care coordination, and greater incentives for long-term care facilities to prioritize patient safety. Most recently, the federal government took steps to focus greater attention on nursing home ownership by private equity firms, which have been associated with poor quality and patient safety outcomes.

The federal government is leading other efforts to improve the safety and quality of care at long-term care facilities. The Center for Medicare and Medicaid Services (CMS) Care Compare website allows patients and providers to compare long-term care and home and community-based facilities on various quality metrics, including measures of patient safety (such as the proportion of patients who experience a health care–associated infection, pressure injuries, and falls).

CMS has also implemented minimum staffing standards for long-term care facilities' conditions of participation in the Medicare and Medicaid programs, which explicitly emphasize a focus on ensuring the quality of care for long-term care facility residents.

AHRQ is funding research to examine the epidemiology of adverse events in long-term care settings and identify effective preventive strategies. AHRQ has also developed a number of resources to examine and address safety in long-term care, including recent programs in response to the COVID-19 pandemic such as, an infection control and prevention training programs for staff and the AHRQ ECHO National Nursing home Action Network.

The Joint Commission offers accreditation programs for nursing care centers that provide post-acute care services, including SNFs and most inpatient rehabilitation facilities. The accreditation process emphasizes the importance of patient safety and efforts to prevent hospital admissions among long-term care patients. The Joint Commission National Patient Safety Goals for nursing care centers were updated in 2024. These require SNFs to have measures in place to prevent specific clinical harms (such as falls, pressure ulcers, and health care–associated infections) and to improve medication management. Long-term acute care hospitals and inpatient rehabilitation facilities are accredited in the same fashion as acute care hospitals, and they are subject to the same National Patient Safety Goals (which were also updated in 2024).

While these efforts are all important, fundamental health care system issues such as adequate staffing, improved safety culture, and enhanced training must be addressed to improve safety in long-term care. As mentioned, the COVID-19 pandemic unveiled numerous issues related to nursing home care. Subsequent studies have identified a multitude of longstanding and ongoing challenges including poor safety culture. CMS efforts to incentivize nursing homes through value-based payment structures such as the Patient Driven Payment Model (PDPM), which is a way of classifying nursing home patients and residents based on the level and intensity of care needed, are still gathering data as to their effectiveness. It is yet to be seen whether the PDPM model or other incentives mentioned will positively impact patient safety in nursing homes.

Originally published in January 2019 by researchers at the University of California, San Francisco. Updated in April 2024 by Deb Bakerjian, PhD, RN, APRN, FAANP, FGSA, FAAN. PSNet primers are regularly reviewed and updated to ensure that they reflect current research and practice in the patient safety field.