Brief Report| Volume 22, ISSUE 10, P2196-2200, October 2021

The Association of Nursing Home Characteristics and Quality with Adverse Events After a Hospitalization



      We previously found high rates of adverse events (AEs) for long-stay nursing home residents who return to the facility after a hospitalization. Further evidence about the association of AEs with aspects of the facilities and their quality may support quality improvement efforts directed at reducing risk.


      Prospective cohort analysis.

      Setting and Participants

      32 nursing homes in the New England states. A total of 555 long-stay residents contributed 762 returns from hospitalizations.


      We measured the association between AEs developing in the 45 days following discharge back to long-term care and characteristics of the nursing homes including bed size, ownership, 5-star quality ratings, registered nurse and nursing assistant hours, and the individual Centers for Medicare & Medicaid Services (CMS) quality indicators. We constructed Cox proportional hazards models controlling for individual resident characteristics that were previously found associated with AEs.


      We found no association of AEs with most nursing home characteristics, including 5-star quality ratings and the composite quality score. Associations with individual quality indicators were inconsistent and frequently not monotonic. Several individual quality indicators were associated with AEs; the highest tertile of percentage of residents with depression (4%-25%) had a hazard ratio (HR) of 1.65 [95% confidence interval (CI) 1.16, 2.35] and the highest tertile of the percentage taking antipsychotic medications (18%-35%) had an HR of 1.58 (CI 1.13, 2.21). The percentage of residents needing increased assistance with activities of daily living was statistically significant but not monotonic; the middle tertile (13% to <20%) had an HR of 1.69 (CI 1.16, 2.47).

      Conclusions and Implications

      AEs occurring during transitions between nursing homes and hospitals are not explained by the characteristics of the facilities or summary quality scores. Development of risk reduction approaches requires assessment of processes and quality beyond the current quality measures.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of the American Medical Directors Association
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Kapoor A.
        • Field T.
        • Handler S.
        • et al.
        Adverse events in long-term care residents transitioning from hospital back to nursing home.
        JAMA Intern Med. 2019; 179: 1254-1261
        • Kapoor A.
        • Field T.
        • Handler S.
        • et al.
        Characteristics of long-term care residents that predict adverse events after hospitalization.
        J Am Geriatr Soc. 2020; 68: 2551-2557
        • Centers for Medicare & Medicaid Services
        Nursing Home Compare Five-Star Quality Rating.
        (Available at:)
        • Agency for Healthcare Research and Quality
        Adverse events, near misses, and errors.
        (Available at:)
        • Aparasu R.R.
        • Chatterjee S.
        • Mehta S.
        • Chen H.
        Risk of death in dual-eligible nursing home residents using typical or atypical antipsychotic agents.
        Med Care. 2012; 50: 961-969
        • Levinson D.R.
        Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries.
        Office of Inspector General, Department of Health and Human Services, Washington, DC2014
        • Adler L.M.J.
        • Federico F.
        IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events.
        Institute for Healthcare Improvement, Cambridge, MA2015
        • Brennan T.A.
        • Leape L.L.
        • Laird N.M.
        • et al.
        Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I.
        N Engl J Med. 1991; 324: 370-376
        • Centers for Medicare & Medicaid Services
        National nursing home quality care collaborative.
        (Available at:)
        • Molenberghs G.
        • Verbeke G.
        Models for Discrete Longitudinal Data.
        Springer Science+Business Media, Inc, New York, NY2005
        • Little R.J.
        • Rubin D.B.
        Statistical Analysis With Missing Data.
        2nd ed. John Wiley & Sons, New York, NY2002
        • Raghunathan T.
        • Berglund P.A.
        • Solenberger P.W.
        Multiple Imputation in Practice With Examples Using IVEware.
        Chapman and Hall/CRC, New York, NY2018
        • Chiu Y.
        • Bero L.
        • Hessol N.A.
        • et al.
        A literature review of clinical outcomes associated with antipsychotic medication use in North American nursing home residents.
        Health Policy. 2015; 119: 802-813
        • Ray W.A.
        • Chung C.P.
        • Murray K.T.
        • et al.
        Atypical antipsychotic drugs and the risk of sudden cardiac death.
        N Engl J Med. 2009; 360: 225-235
        • Centers for Medicare & Medicaid Services
        National partnership to improve dementia care in nursing homes: Antipsychotic medication use data report.
        (Available at:) (Accessed April 2019)
        • Doupe M.
        • Brownell M.
        • St John P.
        • et al.
        Nursing home adverse events: Further insight into highest risk periods.
        J Am Med Dir Assoc. 2011; 12: 467-474
        • Andersson A.
        • Frank C.
        • Willman A.M.
        • et al.
        Factors contributing to serious adverse events in nursing homes.
        J Clin Nurs. 2018; 27: e354-e362
        • van Gaal B.G.
        • Schoonhoven L.
        • Mintjes J.A.
        • et al.
        Fewer adverse events as a result of the SAFE or SORRY? Programme in hospitals and nursing homes. Part I: Primary outcome of a cluster randomised trial.
        Int J Nurs Stud. 2011; 48: 1040-1048
        • Quach E.D.
        • Kazis L.E.
        • Zhao S.
        • et al.
        Safety climate associated with adverse events in nursing homes: A national VA study.
        J Am Med Dir Assoc. 2021; 22: 388-392
        • Neuman M.D.
        • Wirtalla C.
        • Werner R.M.
        Association between skilled nursing facility quality indicators and hospital readmissions.
        JAMA. 2014; 312: 1542-1551
        • Ryskina K.L.
        • Konetzka R.T.
        • Werner R.M.
        Association between 5-star nursing home report card ratings and potentially preventable hospitalizations.
        Inquiry. 2018; 55 (46958018787323)
        • Xu D.
        • Kane R.
        • Arling G.
        Relationship between nursing home quality indicators and potentially preventable hospitalisation.
        BMJ Qual Saf. 2019; 28: 524-533
        • Abrams H.R.
        • Loomer L.
        • Gandhi A.
        • Grabowski D.C.
        Characteristics of U.S. Nursing Homes with COVID-19 cases.
        J Am Geriatr Soc. 2020; 68: 1653-1656
        • Chatterjee P.
        • Kelly S.
        • Qi M.
        • Werner R.M.
        Characteristics and quality of US nursing homes reporting cases of coronavirus disease 2019 (COVID-19).
        JAMA Netw Open. 2020; 3: e2016930
        • He M.
        • Li Y.
        • Fang F.
        Is there a link between nursing home reported quality and COVID-19 cases? Evidence from California skilled nursing facilities.
        J Am Med Dir Assoc. 2020; 21: 905-908
        • Li Y.
        • Temkin-Greener H.
        • Shan G.
        • Cai X.
        COVID-19 infections and deaths among Connecticut nursing home residents: Facility correlates.
        J Am Geriatr Soc. 2020; 68: 1899-1906
        • Katz P.R.
        • Karuza J.
        • Lima J.
        • Intrator O.
        Nursing home medical staff organization: Correlates with quality indicators.
        J Am Med Dir Assoc. 2011; 12: 655-659