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For-Profit Nursing Home Residents Show More Signs of Neglect, Study Says


Previous studies have noted a lower quality of care in for-profit nursing homes, but those studies have typically focused on individual clinical effects. A new study looking at a broader list of neglect found that residents in for-profit homes are almost twice as likely to experience adverse health problems from substandard care.

Previous studies have noted a lower quality of care in for-profit nursing homes, but those studies have typically focused on individual clinical effects, like pressure sores. A new study looking at a broader list of neglect found the same association, and the authors called for more oversight, especially as the for-profit nursing home industry grows.

The study, which found that residents in for-profit homes are almost twice as likely to experience adverse health problems as a result of substandard care, was published recently in the journal Gerontology.

Patients included in the study were seen at 5 hospitals in the Chicago area between 2007 and 2011 for issues ranging from mild to severe that could be related to substandard care. The researchers assessed the relationship between residence type—community-dwelling, not-for-profit facility, for-profit facility—and clinical signs of neglect.

Community-dwelling residents live in private homes, often with family members or friends. The study also found that these residents, who need assistance with tasks related to daily living but do not live in a nursing home, had the fewest number of clinical signs of neglect compared with those living in any type of nursing facility.

The study included medical records for 1149 patients aged 60 and older. The researchers used the Clinical Signs of Neglect Scale (CSNS), which was developed by the lead author, Lee Friedman, PhD, associate professor of environmental and occupational health sciences the University of Illinois at Chicago School of Public Health, and his colleagues. The CSNS quantifies health problems related to substandard care and health outcomes among individuals they identified living in private homes, nonprofit nursing homes and for-profit nursing homes. The scale lists about 24 conditions, ranging from constipation and dehydration to more serious issues such as severe bed sores and broken catheter tubes.

Individual clinical signs of neglect like sores or injuries rarely occur by themselves, so past studies that only included those factors likely underestimated the scope of the problem, the researchers said.

"We saw more—and more serious—diagnoses among residents of for-profit facilities that were consistent with severe clinical signs of neglect, including severe dehydration in clients with feeding tubes which should have been managed, clients with stage 3 and 4 bed sores, broken catheters and feeding tubes, and clients whose medication for chronic conditions was not being managed properly," Friedman said in a statement.

Relative to low-functioning community-dwelling patients, the mean difference in CSNS scores was higher among patients residing in not-for-profit facilities by 1.99 (P = .012) and 3.55 (P ≤.001) among patients in for-profit facilities. In a separate model, the mean difference in CSNS scores among patients living in for-profit facilities compared to not-for-profit facilities was 1.90 (P = .035).

Part of the problem, Friedman said, is that administrators in for-profit homes are paid more, and staff at non-for-profit homes are underpaid. Staffing levels at for-profit homes may also be lower.

Neglect can be hard to detect, the authors wrote, but without improved identification and reporting, it will be difficult to protect patients. A typical scenario is that a nursing home patient will be sent to a hospital, where substandard care is not recognized. The patient improves and is returned to the home, only to return again.

The problem is starting to become recognized, though. Kaiser Health News recently reported that, starting this month, Centers for Medicare and Medicaid Services will begin handing out bonuses or penalties to nursing homes based on their hospital readmission rates.

The authors cited several factors that are barriers to improved screening within hospitals:

  • A lack of awareness of the problem
  • Unfamiliarity with the reporting process
  • Fear of lawsuits
  • Lack of institutional protocols for identifying mistreatment
  • Lack of training on related issues
  • Feeling uncomfortable talking about mistreatment because of poor training
  • Potential conflicts of interest when the physician is employed by both the hospital and nursing home

"There needs to be better staffing and training for enforcing these measures. Performance improvement programs and quality assurance and assessment committees, tighter adherence to federal law by Central Management Services that ties Medicare and Medicaid reimbursement with quality of care, and pressure from insurance providers to limit costly outcomes could help reduce the unfortunate diagnoses we saw in our study,” said Friedman.

The issue of oversight is key because, while Americans are aging, there has been a small decline in the quantity of overall nursing home beds, as the number of government and not-for-profit nursing homes has fallen over the past 10 years, the study said.

The study had several limitations, although the authors said the design mitigated some of them. For instance, the referral patterns of patients to hospitals may differ in not-for-profit and for-profit facilities, but the authors said that inclusion criteria were not based on place of residence. In addition, the 5 hospitals have very large catchment areas that cover approximately 10% of all inpatient cases statewide. And since nursing homes are more likely to treat persons with functional limitations, or terminal patients with clinical signs treated as outcomes in this study, the authors included days of follow-up.


Friedman L, Avila S, Friedman D, Meltzer W. Association between type of residence and clinical signs of neglect in older adults. [published online October 9, 2018]. Gerontology. doi: 10.1159/000492029.

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