top of page

Patient safety in long-term care facilities and the COVID-19 pandemic

Significant parts of the world are growing old. During this century, several regions will experience a marked increase in the proportion of adults over 65 years old. This transition is well underway in the United States as the so-called baby boomers, born between 1946 and 1964, began turning 65 in 2011. It is projected that the US population aged 65 and over will reach 83.7 million by 2050, equivalent to more than 20% of the entire population.1 The US is not unique in this. By 2040, the median age in Japan will be 70, and it is anticipated that Asia, Latin America and the Caribbean will join Europe and North America as having more people older than 60 than children under age 15.

The need for long-term care is growing alongside the rapidly aging population. In 2018, over 14 million Americans needed long-term care services.2 By 2025, it is projected that 1 out of every 5 Americans will be retirement age, and just over half of those individuals will require long-term care.3

Despite unprecedented growth in the long-term care industry, there are serious deficiencies in patient safety and quality of care. In the US, the Office of the Inspector General estimated that 22% of Medicare beneficiaries in skilled nursing facilities, and 46% in long-term care hospitals experienced adverse events.4 Over half of these adverse events were thought to be preventable. Reports also suggest that a large majority of nursing homes fail to meet federal quality standards.5

The most common safety issues in long-term care include pressure ulcers, falls, medication administration errors and nosocomial infection.6 It has been suggested that the high incidence of adverse events in long-term care compared to hospitals is due to lower levels of staff training, lower staff to resident ratios, longer term stays, and a broader scope of care.7

In the US, there have long been attempts to improve the quality of long-term care, beginning with the Nursing Home Reform Act in 1987, which imposed federal standards to bolster inspections and nursing home quality enforcement.8 The 2006 Advancing Excellence in America's Nursing Homes Campaign, which later morphed into the National Nursing Home Quality Improvement Campaign, was another attempt, which promoted nine goals to improve quality in nursing homes.9 In 2013 the Commission on Long-term Care adopted 28 public policy recommendations in service delivery, workforce and financing in long-term care.10 There have also been attempts to measure patient safety in long-term care settings, such as the “Nursing Home Compare” program offered by the Centers for Medicare & Medicaid Services. However, the scores in these systems have been criticized as having a weak and inconsistent relationship between facility metrics and actual performance.11 In the US, improvements have been stymied by a general lack of research focused on quality of care and patient safety in long-term care settings, with a specific lack of studies on the effectiveness of improvement initiatives. The large majority of research has concentrated on hospital-based acute care.12

The COVID-19 pandemic spotlighted the quality and safety of long term care. From the start, nursing homes in the US were centers of outbreaks and excess mortality from COVID-19. Staff and residents of long-term care facilities accounted for 31% of all COVID-19 deaths in the US as of June 20, 2021.13 Data from more than 20 other nations with significant numbers of long-term care facilities show that they accounted for more than a third of COVID-19 deaths, though housing less than 2% of the population14

There is a growing body of research on the quality of care and patient safety issues that arose during the pandemic.1517 It is clear that the pandemic exacerbated existing underlying problems. As stated by one author: “The coronavirus has exposed and amplified a long-standing and larger problem: our failure to value and invest in a safe and effective long-term care system.”18 Anecdotally, resourcing issues during the pandemic made it commonplace for homes and staff to sidestep basic quality and safety guidelines, leading to a worsening of the already sub-standard quality and safety protocols in such settings.

There are notable exceptions. This issue of the Journal includes a commentary from a continuing care retirement community in New York State. Professor Wilcox, a current resident of the facility, was in a unique position to describe how safety can be maintained during a pandemic.19 In a rare achievement, his care home has experienced zero COVID-19 deaths. The solution included imposing conservative control measures and frequent testing of residents and staff, prompt contact tracing, and a big bang adoption of vaccine as soon as it became available. Implementation was aided by participation of the managers, experts, and the residents themselves.

In related work, Micocci and colleagues describe the evaluation of rapid SARS-COV-2 point-of-care testing in a nursing home setting.20 They found that both standard operating procedures and knowledge of contextual factors associated with care homes were needed for safe use of these tests.

Also in this issue, two different papers demonstrate the importance of communication in securing timely, high-quality care. Hannawa takes the unusual perspective of alpine rescue teams, where aviation and healthcare come together.21 In this context, the crucial interpersonal communication process of sense-making is essentially the same in both industries.

Samuels and colleague demonstrate that CANDOR harm-in-healthcare training can improve empathy and communication skills in healthcare workers.22 Their findings provide evidence for optimism that these skills can be taught.

On a positive note, there has been a growing call to arms to address this quality and safety gap for the elderly. The United Nations General Assembly declared 2021–2030 the “Decade of Healthy Ageing” to bring together stakeholders for a “concerted, catalytic and collaborative action to foster longer and healthier lives”.23 This includes a focus on appropriate and person-centred long-term care. The Joint Commission and several other US organizations, such as the Agency for Healthcare Research and Quality, and the Institute for Healthcare Improvement, have set specific goals and directed projects to address quality and safety in long-term care, such as the AHRQ's front-line personnel training program.24,25

For the moment, the spotlight is being held in place on long-term care facilities by media outlets calling for reform26,27 Similar calls with specific recommendations are coming from organizations focused on the health of aging populations such as the AARP.28 Governments across the world are recognizing the need to understand and improve the industry. For example, the US and Canada have initiated commissions to review and make recommendations on quality and safety in long-term care homes.29,30

Collective action will also be needed from stakeholder groups, which include the government, public agencies, private organizations, and researchers. Broader changes may also be needed. For example, it has been suggested that improvements in safety have been stalled due to the punitive regulatory environment, which discourages open communication and reporting of errors..31 As with other aspects of patient safety, culture change will likely be needed to effect real improvements.

We should not let this crisis go to waste. The failures in long term care facilities exposed by the pandemic underscore the need to do much better. Not only do we need to be prepared for future catastrophic events, we need to be prepared to provide a reasonable quality of care during normal times.

People who make the life-changing decision of moving into a retirement home accept the sacrifices they are making in terms of down-sizing and independence. They should not have to accept inadequate safety.


1.Ortman, JM, Velkoff, VA, Hogan, H. An aging nation: the older population in the United States. U.S. Census Bureau. May 2014. (accessed October 25, 2021).

Google Scholar2.Hado, E, Komisar, H. Fact sheet: long-term services and supports. American Association of Retired Persons Public Policy Institute, August 2019, available at (accessed October 25, 2021).

Google Scholar3.Favreault, M, Dey, J. Long-term services and supports for older Americans: risks and financing research brief, June 30, 2015, available at (accessed October 25, 2021).

Google Scholar4.Levinson, DR Adverse events in long-term care hospitals: National incidence among Medicare beneficiaries. Department of Health and Human Services: Office of Inspector General, November 2018, available at (accessed October 25, 2021).

Google Scholar5.Harrington, C, Garfield, R. Nursing facilities, staffing, residents and facility deficiencies, 2009 through 2015. Kaiser Family Foundation, July 2017, available at (accessed October 25, 2021).

Google Scholar6.Gruneir, A, Mor, V. Nursing home safety: current issues and barriers to improvement. Annu Rev Public Health 2008; 29: 369–382. doi:10.1146/annurev.publhealth.29.020907.090912.

Google Scholar | Crossref | Medline | Bienassis, K, Llena-Nozal, A, Klazinga, N. "The economics of patient safety part III: long-term care: valuing safety for the long haul", OECD Health working papers, 2020, No. 121, OECD Publishing, Paris, (accessed October 25, 2021).

Google Scholar8.H.R. 3545 – Omnibus Budget Reconciliation Act of 1987 . available at (accessed October 25, 2021).

Google Scholar9.Healthcare Quality Improvement Campaign . available at (accessed October 25, 2021).

Google Scholar10.Commission on Long-Term Care Report to the Congress . available at (accessed October 25, 2021). September 30, 2013.

Google Scholar11.Brauner, D, Werner, RM, Shippee, TP, et al.Does nursing home compare reflect patient safety In nursing homes? Health Aff (Millwood) 2018 Nov; 37: 1770–1778. doi: 10.1377/hlthaff.2018.0721. PMID: 30395505; PMCID: PMC6405288.

Google Scholar | Crossref | Medline12.Institute of Medicine (US) Committee on Improving Quality in Long-Term Care; Wunderlich GS, Kohler PO, editors . Improving the quality of long-term care. Washington (DC): National Academies Press (US), 2001, 3, State of Quality of Long-Term Care. Available from: (accessed October 25, 2021).

Google Scholar13.Chidambaram, P, Garfield, R. Nursing home experienced steeper increase in COVID-19 cases and death in August 2021 then the rest of the country. (accessed October 25, 2021).

Google Scholar14.Mathews, AW, Douglas, J, Kamp, J,et al.Covid-19 stalked nursing homes around the world. Wall Street Journal December 31, 2020; (accessed October 25, 2021).

Google Scholar15.Freidus, A , Shenk D, Wolf C.A rapid qualitative appraisal of the impact of COVID-19 on long-term care communities in the United States: perspectives from area aging staff and advocates. Hum Organ 2020; 79(4): 313-322, available at (accessed October 25, 2021).

Google Scholar16.Freidus, A, Shenk, D. “It spread like a wildfire”: analyzing affect in the aarratives of nursing home staff suring a COVID-19 outbreak. Anthropology & Aging 2020; 41(2): 199–206.

Google Scholar | Crossref17.Berridge, C, Parsey, CM, Ramirez, M, et al. Caring for Washington's older adults in the COVID-19 pandemic: Interviews with organization leaders about the state of social and healthcare services. October 12, 2020, available at (accessed October 25, 2021).

Google Scholar18.Werner, RM, Hoffman, AK, Coe, NB. Long-Term care policy after covid-19 - solving the nursing home crisis. N Engl J Med 2020 Sep 3; 383: 903–905. doi: 10.1056/NEJMp2014811. Epub 2020 May 27. PMID: 32459918.

Google Scholar | Crossref | Medline19.Wilcox, C . Kendal at ithaca beats COVID-19. J Patient Safe Risk Manage 2021 (December); 26(6): 237–239.

Google Scholar20.Micocci, M, Buckle, P, Hayward, G, et al.Point of care testing using rapid automated antigen testing for SARS-COV-2 in care homes – an exploratory safety, usability and diagnostic agreement evaluation. Patient Safe Risk Manage 2021 (December); 26(6): 243–250.

Google Scholar21.Hannawa, A . “We’re on our way:” A message from the mountains. Patient Safe Risk Manage 2021 (December); 26(6): 240–242.

Google Scholar22.Samuels, A, Broom, M, McDonald, T,et al.Improving self-reported empathy and communication skills through harm in healthcare response training. Patient Safe Risk Manage 2021(December); 26(6): 251–260.

Google Scholar23.World Health Organization . Ageing and health, October 4, 2021, available at (accessed October 25, 2021).

Google Scholar24.The Joint Commission . Nursing Care Center National Patient Safety Goals, 2022, available at (accessed October 25, 2021).

Google Scholar25.Agency for Health Research and Quality . Improving patient safety in long term care facilities, July 2012, available at (accessed October 25, 2021).

Google Scholar26.Scott, D . Covid-19 made America's long-term care crisis impossible to ignore. Vox, June 27, 2021, available at; (accessed October 25, 2021).

Google Scholar27.Gleckman, H . Where long-term care reform goes now. Forbes, June 30, 2021, available at; (accessed October 25, 2021).

Google Scholar28.Harrar, S , et al. 10 Steps to reform and improve nursing homes. AARP, January 13, 2021, available at

Google Scholar29.Centers for Medicare and Medicaid Services . CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes. April 30, 2020, available at

Google Scholar30.The Honourable Frank N. Marrocco, et al . Ontario's Long-Term Care COVID-19 Commission, Final Report. April 30, 2021, available at

Google Scholar31.Bonner, AF . Patient safety culture: a review of the nursing home literature and recommendations for practice. Ann Longterm Care 2008 Mar; 16: 18–22. available at


Download PDF • 413KB

13 views0 comments


bottom of page