The choice of which nursing home to send a loved one to is among the most wrenching decisions that many Americans face. As the pandemic has shown, the decision can mean the difference between life and death. To guide people through that difficult process, the federal government has created a widely used ratings system that scores thousands of nursing homes based on a variety of objective criteria.
That system, as The New York Times revealed in three investigative stories in 2021, is broken. It often makes nursing homes appear safer and cleaner than they actually are, hiding some of the worst behavior and enabling homes to engage in potentially dangerous practices.
Countless Americans rely on Medicare’s five-star rating system to select nursing homes. During the pandemic, some of the hardest-hit homes boasted top ratings. We wanted to understand why.
In our first report, in March, we revealed that much of the rating system’s underlying data, largely self-reported by nursing homes, is wrong. For example, homes routinely inflated the data about the number of hours worked by nurses and other staff, a key variable in the ratings system. The number of serious accidents involving residents was frequently understated.
We also found that there was little correlation between having a high star rating and doing well when inspectors showed up to examine nursing homes in person. In fact, there was evidence that some nursing homes were getting tipped off to such visits in advance. Nursing homes with terrible track records managed to earn five stars.
In the second installment of the series, we turned our attention to the regular use of powerful – and at times dangerous – antipsychotic drugs to subdue residents. While public health experts have worried for years about the overuse and misuse of such drugs among nursing home residents, the data that the Centers for Medicare & Medicaid Services published on the ratings website suggested that the problem was in retreat.
But the public data only tracked antipsychotic use among residents who did not have a diagnosis – like schizophrenia – that warranted the use of such drugs. We found that many nursing homes appeared to be relying on bogus schizophrenia diagnoses to mask their true use of antipsychotics. A big incentive for the nursing homes to do so was the star-rating system, which penalized homes for using the drugs on undiagnosed residents but allowed them to do so for patients with schizophrenia and certain other conditions.
Our analysis found that the share of nursing home residents with schizophrenia diagnoses had soared 70 percent over the past decade; one in nine nursing home residents had such a diagnosis, compared to about one in 150 in the general population. Roughly one out of every five nursing home residents nationwide received antipsychotics.
In the series’ final article, published in December, we pulled back the curtain on a secretive appeals process that allows nursing homes to keep inspectors’ most damaging findings out of public view, fostering the illusion that recent inspections had given them unblemished marks.
Even when nursing homes lost repeated appeals, we found that some inspection reports still didn’t appear on the ratings website, creating the false impression that the homes had received a clean bill of health.