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Mandatory Reporting of Nursing Home Deaths: Markers for Mistreatment, Effect on Care Quality, and Generalizability Final Report

NCJ Number
Date Published
November 2008
97 pages

This study collected followup data for a previous study in exploring the potential impact of a 1999 Arkansas law that mandates the reporting of all nursing home deaths to the local coroner.


The study found that from 1999 through 2004, there were 3,174 nursing-home death investigations by the Pulaski County Coroner's Office. Ninety-two cases (2.9 percent of all investigations) were referred to the Attorney General or Office of Long-term Care for suspicion of mistreatment. Factors associated with these referrals were family dissatisfaction with care, being of a racial minority, tube feeding, the presence of a severe pressure sore, or a recent ostomy of some type. The current study found no differences in care-quality indicators between Pulaski County and other Arkansas counties over this time period. The coroner survey contributed to further insight into the attitudes and knowledge base regarding nursing home mistreatment, and it identified some of the significant barriers to generalizing such investigations to other locations. The diagnostic discrepancies identified in the autopsy case series show the importance of autopsies in the nursing home death investigations. Despite the lack of evidence of improvement in nursing home care as a result of the Arkansas law, this study is inconclusive because of the use of retrospective and self-reported data. This study expanded the database and analysis of Pulaski County Coroner's Office investigations, abstracting and analyzing all records from 1999 through 2004. In addition, cases from the Pulaski County Coroner's Office were matched with Minimum Data Set (MDS) data from each resident and facility to identify MDS items associated with higher suspicion for mistreatment. Coroners throughout Arkansas were surveyed to learn more about the potential generalizability of death investigations outside Pulaski County, and a case series of 20 autopsies from Pulaski county added to knowledge about pathologic findings in nursing home decedents. Tables, figures, and study instruments

Date Published: November 1, 2008