Opposition to Nursing Home Abuse Icon Grows as Group Warns of ‘Unintended Consequences’

The long-term and post-acute care industry’s reaction to a new federal abuse warning icon for nursing homes was swift and negative when the plan was first announced last month — and now another voice has entered the fray to claim that the icons may actually do more harm than good.

Leaders from AMDA, the Society for Post-Acute and Long-Term Care Medicine, late last week characterized the icon as a misguided approach toward improving nursing home safety.

“We truly believe that this approach will have unintended consequences, and in fact be counterproductive to achieving the high-quality patient outcomes for which we strive,” AMDA president Arif Nazir and executive director Christopher Laxton wrote in a Friday letter to Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma. “It will also be clearly detrimental to the motivation and engagement of thousands of very hard-working front-line staff members.”


CMS in October announced a plan to include on its Nursing Home Compare website a special icon — a red circle with an open palm — next to the names of facilities with a history of abuse or neglect citations.

“With today’s action, the Trump administration is putting critical information at consumers’ fingertips, empowering them and incentivizing nursing homes to compete on cost and quality,” Verma said in a statement announcing the initiative.

Industry advocates quickly seized on the image as overly punitive, implying that the icon was similar to a stop sign that would lead consumers to automatically disqualify such facilities — even if the abuse or neglect claim was far in the past, or had been quickly remedied.


“The red hand is dumb,” Clifton Porter, senior vice president for government relations at the American Health Care Association, said earlier this year. “The red hand says ‘Don’t go there.’ The red hand is punitive; the red hand is not about transparency. The red hand is about piling on a consequence in a back-door kind of way. It’s insulting to me. I’m sure more insulting to you … It’s misleading, and I’m fine with being on the record saying that.”

So far, slightly under 5% of the nation’s more than 15,000 nursing homes have received the icon, according to an analysis from third-party analytics firm StarPRO — a figure that matched CMS projections. Despite the low number, StarPRO managing director Colleen Muncy predicted that the icon could soon have a financial impact on the space, as lenders, operators, and referral partners start incorporating the warning into their own business decisions.

“If they refer less patients, less of the better referrals, then that’s going to have an impact on revenue, so I think it’s a very harsh symbol,” Muncy said. “When you have a new operator who takes over, they’re going to have to live with that symbol.”

AMDA’s objection to the icon, meanwhile, centered on its lack of basis in scientific evidence, as well as its potential to create an atmosphere of distrust and secrecy at individual nursing facilities.

“A fundamental principle in the field of patient safety is the establishment of a blame-free environment, in which individuals and organizations work systematically to report all errors and near misses without fear of reprimand or punishment,” Nazir and Laxton wrote.

But the icon specifically assigns blame, they argue, and as such could discourage frontline caregivers from reporting incidents due to a fear of being responsible for earning an icon for their facility. AMDA specifically pointed to the now-defunct pain measure on Nursing Home Compare, in which facilities that underreported data appeared to have better outcomes than those that provided complete information.

“If we truly wish to root out abuse and neglect, the appropriate approach would be to encourage reporting by facilities and health care personnel,” the leaders wrote. “In other words, we should seek to increase reporting of abuse and neglect. In doing so, we will learn from our mistakes, not perpetuate them.”

Like Muncy, the AMDA team also raised the specter of the abuse icon potentially causing difficulties for referral partners, giving the hypothetical of an accountable care organization (ACO) faced with a SNF that received the icon despite a long-standing history of quality care and performance.

“The ACO is now forced to consider suddenly pulling the facility out of their post-acute network and using otherwise lower-quality facilities, which in turn negatively impacts many patients (instead of just one) as well as the fiscal integrity of the ACO,” Nazir and Laxton wrote.

For those reasons, AMDA suggested that CMS scrap the program altogether.

“Abuse and neglect in nursing homes is never acceptable. Bringing it to light through reporting needs to be encouraged,” they wrote. “We therefore urge CMS to rescind its decision to use the red hand icon, a damaging and punitive strategy that violates patient safety principles and is likely to reduce reporting rather than prevent abuse and neglect.”

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