49903

urnal of Applied Gerontology

JAG33110.1177/0733464812449903

Article

Hand Hygiene Deficiency

Citations in Nursing
Homes

Journal of Applied Gerontology

2014,Vol 33(1) 2450
The Author(s) 2012
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DOI: 10.1177/0733464812449903
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Nicholas Castle1, Laura Wagner2,

Jamie Ferguson1, and Steven Handler1

Abstract
Hand hygiene (HH) is recognized as an effective way to decrease transmission of
infections. Little research has been conducted surrounding HH in nursing homes
(NHs). In this research, deficiency citations representing potential problems
with HH practices by staff as identified in the certification process conducted
at almost all US NHs were examined. The aims of the study were to identify
potential relationships between these deficiency citations and characteristics of
the NH and characteristics of the NH environment.We used a panel of 148,900
observations with information primarily coming from the 2000 through 2009
Online Survey, Certification, And Reporting data (OSCAR). An average of 9%
of all NHs per year received a deficiency citation for HH. In the multivariate
analyses, for all three caregivers examined (i.e., nurse aides, Licensed Practical
Nurses, and Registered Nurses) low staffing levels were associated with receiving a deficiency citation for HH. Two measures of poor quality (i.e., [1] Quality
of care deficiency citations and [2] J, K, or L deficiency citations, that is deficiency
citations with a high extent of harm and/or more residents affected) were also associated with receiving a deficiency citation for HH. Given the percentage of NHs
receiving deficiency citations for potential problems with HH identified in this
research, more attention should be placed on this issue.
Keywords
citations, infection control, nursing homes (NHs)
Manuscript received: June 08, 2011; final revision received: March 02, 2012; accepted:
April 23, 2012.
1

University of Pittsburgh, Pittsburgh, PA, USA

New York University, New York

Corresponding Author:
Nicholas Castle, University of Pittsburgh, A610 Crabtree Hall, Pittsburgh, PA 15261, USA.
Email: castleN@Pitt.edu
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Castle et al.

25

Introduction
Hand hygiene (HH) is recognized as essential to decreasing transmission of
infections (Centers for Disease Control [CDC], 2002); however, little research
has been conducted surrounding HH in nursing homes (NHs). In this research,
deficiency citations for HH in a nationally representative sample of NHs are
examined. These deficiency citations represent potential problems with HH practices by staff as identified in the certification process conducted at almost all U.S.
NHs. Using a large panel of observations (N=148,900) from 2000 through 2009,
and Generalized Linear Models, the aims of this study were to identify potential
relationships between these deficiency citations and characteristics of the NH
(e.g., staffing levels, quality, ownership) and characteristics of the NH environment (e.g., competition, reimbursement rates).
Prevention and management of infections in NH settings is an important, yet
underexamined, resident safety concern (Rust, Wagner, Hoffman, Rowe, &
Neumann, 2008). Healthcare Associated Infections (HAIs) are the leading cause
of morbidity and mortality in the 1.7 million NH residents with between 1.6 and
3.8 million infections and almost 388,000 deaths occurring annually in this setting (Richards, 2002). Infections are the reason for one fourth of all hospitalizations from long-term care (LTC) facilities (Ahlbrecht, Shearen, Degelau, & Guay,
1999; Richards, 2007). The costs associated with infections in NH settings have
a significant impact on the healthcare system with annual estimates ranging from
US$38 to US$137 million for antimicrobial therapy and US$673 million to US$2
billion for hospitalizations (Barker et al., 1994; Hu, 1990). Furthermore, the
importance of HH in NHs extends beyond just these facilities; as millions of NH
residents every year are transferred to and from acute care settings and can potentially spread pathogens between settings (Mody, 2009).
Although there are a number of ways to decrease transmission of infections
(i.e., vaccinations, skin testing, use of antimicrobials), HH is recognized as one of
the simplest and the most cost effective ways to do so (CDC, 2002; Fendleret al.,
2002; Mody, 2009; Smith, Carusone, & Loeb, 2008). When performed correctly,
HH can reduce HAIs by up to 30% (Boyce & Pittet, 2002). Improving HH practices has also been identified as a patient safety goal by TJC (i.e., The Joint
Commission) and has also been targeted by the World Health Organization
(WHO) as the first global patient safety challenge entitled Clean Care is Safer
Care (Pittet & Donaldson, 2005; WHO, 2009).
Resident infection rates are often associated with HH techniques and use of
appropriate HH techniques have been shown to decrease infection rates among
NH residents (Richards, 2007). Infection control standards and guidelines are
underdeveloped in the NH industry. Regulations stipulate that infection control

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Journal of Applied Gerontology 33(1)

activities should be performed; but, provide few details. NH infection control

specialists (such as infection control nurses) are not mandated. In addition, the
infection control specialists that do exist in NHs often lack training in specialized
areas of microbiology or epidemiology (Otero, 1993).

Background
Prior Literature
As noted above, examining HH in NHs is important; however, little research has
been conducted surrounding HH in NHs (12 publications during the past 9 years).
Our review of these publications is summarized in Table 1. This review shows that
few empirical studies have been conducted specifically in NHs; and, those that
exist have a small sample size and likely poor generalizability. Moreover, few
studies have examined factors of NHs associated with HH practices. Overall, our
knowledge of HH practices in NHs is limited, and as noted by Juthani-Mehta and
Quagliarello (2010), this topic is vastly understudied (p. 935). The study presented here is the first nationally representative examination of HH in NHs and is
the first to present characteristics of the NH and characteristics of the NH environment that may influence HH practices. However, we note that the analyses are
limited to secondary data and include failure to follow HH requirements only as
identified by surveyors as part of the annual inspection through the Centers for
Medicare and Medicaid Services (CMS).

NH Certification and Deficiency Citations

CMS requires NHs to be certified before they can receive reimbursement for
Medicare and/or Medicaid residents. The Medicare and Medicaid programs constitute major payers for care, thus almost all NHs in the United States (i.e., 96%)
participate in this process. As part of this certification process deficiency citations can be issued in specific areas of care (these are often called F-tags). That
is, if NHs do not meet certain minimum health and safety standards, deficiency
citation(s) can be issued. The current certification process is described in detail
by CMS (www.cms.hhs.gov).
The Nursing Home Reform Act (NHRA) is considered to be highly influential
in this regulatory process. The NHRA was included in the Omnibus Budget
Reconciliation Act (OBRA) of 1987 (P.L. 100-203). Of most significance to this
research, the NHRA mandated that NHs were to have a functioning infection control program in place (Goldrick, 1999). The programs were to include surveillance, outbreak investigations, isolation procedures, educational programs for

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27

NHs

Setting
Survey

Type
N

Measure(s)

Outcome(s)

(continued)

749 employees; Compliance and

Need for more handwashing
6 NHs
knowledge of
education to all employees
handwashing based on
and decreasing the number
the CDC guidelines.
of barriers to handwashing.
Rummukainen, Jakobsson, LTC facilities Site visits with 123 facilities
Use of ABHR and ongoing One year after site visits,
Karppi, Kautiainen, &
structured
systematic antimicrobials. use of ABHR increased
Lyytikinen (2009)
survey
and antimicrobials for
prevention of urinary tract
infections decreased.
Aiello, Malinis, Knapp, & NHs
Cross-sectional 392 HCWs; 4 HH; alcohol rub use;
Positive responses to HH
Mody (2009)
survey of
NHs
fingernails; glove use;
practices; appropriate
HCWs
knowledge of CDC HH
glove use and fingernail
guidelines.
characteristics; need for
further education of HH
guidelines.
Rao et al. (2009)
NHs
Cluster
12 NHs; 565
Observed infection control Low compliance rates of
randomized
residents
measures (i.e., HH
HH; improved compliance
trial
facilities; environmental
with safe disposal of
cleanliness; safe disposal
clinical waste.
of clinical waste)
and then introduced
improved infection
control measures to the
intervention group.

Ashraf et al. (2010)

Author(s)

Table 1. HH Studies in LTC Settings.

28

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Setting

Type
N

Measure(s)

LTC facilities Cross-sectional 459 HH

HH monitoring instrument
study
opportunities; to examine HH
2 LTC
compliance.
facilities
Pan et al. (2008)
LTC facility Observationl 308 HH
HH compliance (i.e.,
study
opportunities Handwashing and Glove
Use).
Mackenzie, James, Smith, Mental
Survey
114 staff
Handwashing assistance
Barnard, & Robinson
health care
provided to patients by
(2008)
settings
staff.
for older
people
Richards (2007)
LTC facilities Literature
N/A
Urinary tract
review
infections; respiratory
tract infections;
gastrointestinal
infections; skin infections;
antimicrobial-resistant
infections.
Huang & Wu (2008)
NHs
Intervention
40 NAs
Impact of a training
with self
program in HH for NAs.
reporting

Smith et al. (2008)

Author(s)

Table 1. (continued)

(continued)

An intense training program

improved knowledge and
compliance of HH and
a reduction in resident
infection rates.

Evaluations; infection control

programs; immunization;
antimicrobial prescribing;
HH.

HH compliance low and

comparable to acute care
settings.
Staff do not often assist
patients in handwashing.

Low HH compliance.

Outcome(s)

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29

ECF

Skilled
nursing
LTC
facilities

Fendler et al. (2002)

Goldrick (1999)

Infection rates 275-bed

ECF; 265
employees
Descriptive
136 facilities
study

Self35 NHs
administered
questionnaire

Type

Outcome(s)

Infection control practices; Varying infection control

immunization practices;
guidelines; different
role of Icp and infection definitions of infections;
control activities.
varying immunization
compliance; small number
of full time employed ICP.
Effect of alcohol gel
Alcohol gel sanitizer can
sanitizers on infection
reduce infection rates.
rates.
Infection control programs; Lower infection surveillance
effectiveness of infection and control; low
control activities.
handwashing compliance.

Measure(s)

Note: ABHR = alcohol-based hand rubs; CDC = Centers for Disease Control; ECF = extended care facility; HH=hand hygiene; ICP = infection control practitioner; NA = Nurse Aides; NH=nursing home; LTC = long-term care.

NHs

Setting

Mody, Langa, Saint, &

Bradley (2005)

Author(s)

Table 1. (continued)

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Journal of Applied Gerontology 33(1)

both employees and residents, and reporting procedures (Ahlbrecht et al., 1999).
However, details on implementing each of these programs were generally lacking. For example, educational programs for nurse aides are likely highly important for infection control (Juthani-Mehta & Quagliarello, 2010). Nevertheless,
educational programs are considered to be ill-defined and insufficient, and are not
mandated as part of the 75 hrs of training nurse aides receive (Juthani-Mehta &
Quagliarello, 2010).
The staff hand washing after direct resident contact deficiency citation is
examined in this research (i.e., F-Tag 444). Specifically, CMS guidelines state
workers are expected to wash their hands before and after direct resident contact
(for which HH is indicated by acceptable professional practice); performing any
invasive procedure (e.g., fingerstick blood sampling); entering isolation precaution settings; eating or handling food (hand washing with soap and water); assisting a resident with meals; assisting a resident with personal care (e.g., oral care,
bathing); handling peripheral vascular catheters and other invasive devices;
inserting indwelling catheters; assisting a resident with toileting (hand washing
with soap and water); and changing a dressing. In addition, after coming in contact with a residents intact skin (e.g., when taking a pulse or blood pressure, and
lifting a resident); personal use of the toilet (hand washing with soap and water);
contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella, and Clostridium difficile (hand
washing with soap and water); blowing or wiping nose; contact with a residents
mucous membranes and body fluids or excretions; handling soiled or used linens,
dressings, bedpans, catheters and urinals; handling soiled equipment or utensils;
performing personal hygiene (hand washing with soap and water); and, removing
gloves or aprons; and, when hands are visibly soiled (hand washing with soap and
water). Also: when coming on duty and after completing duty (CMS Manual
System, 2009a).
CMS also gives guidelines on recommended techniques for washing hands.
This includes the following: with soap and water include wetting hands first with
clean, running warm water, applying the amount of product recommended by the
manufacturer to hands, and rubbing hands together vigorously for at least 15
seconds covering all surfaces of the hands and fingers; then rinsing hands with
water and drying thoroughly with a disposable towel; and turning off the faucet
on the hand sink with the disposable paper towel (CMS Manual System, 2009a).
In addition, CMS states that except for situations where hand washing is specifically required, antimicrobial agents such as alcohol-based hand rubs (ABHR) are
also appropriate for cleaning hands and can be used for direct resident care.
Recommended techniques for performing HH with an ABHR include applying

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Castle et al.

RESIDENT RISK FACTORS

- Age^

Chronic Diseases^
Indwelling Devices^
Decreased Immunity^
Care Processes (contact with medical
devices and group activities)^

FACILITY RISK FACTORS

Internal Factors
- Nurse aide staffing
- LPN staffing
- RN staffing
- Resident case-mix
- Restraint use
- Psychiatric condition
- Dementia
Organizational Factors
- Quality of care citations
- J, K, or L citations
- Medicaid resident occupancy
- Medicaid resident occupancy X
Medicaid reimbursement rate
- For-profit ownership
- Size
- Chain membership
- Occupancy rate
EXTERNAL RISK FACTORS
- Medicaid reimbursement rate
- Competition
- Elderly in county
- Per capita income

DEATH^
HAND HYGIENE

Deficiency Citation
HAND HYGIENE
(F-tag 444)

HEALTHCARE
ACQUIRED
INFECTIONS^

HOSPITALIZATION^

Figure 1. Conceptual Framework for Examining Deficiency Citations for Hand

Hygiene in Nursing Homes.
Source: Conceptual framework was modified from the work of Mody (2009, p. 411)
Note: RNs = Registered Nurses; LPNs = Licensed Practical Nurses.
^Not examined in the empirical analyses.

product to the palm of one hand and rubbing hands together, covering all surfaces
of hands and fingers, until the hands are dry. In addition, gloves or the use of baby
wipes are not a substitute for HH (CMS Manual System, 2009a).
From 1997 to 2009, an average of approximately 1,000 NHs per year received
a deficiency citation for this F-tag (i.e., F-Tag 444). This was the 24th most frequently used F-tag (from approximately 190 available). This F-tag was examined
in the research presented here, as it was the only deficiency citation available that
specifically addressed hand washing.

Conceptual Framework
This research was guided by the conceptual framework presented in Figure 1
(Mody, 2009). This conceptual framework is proposed as a means of understanding the potential relationships between HH, deficiency citations, and resident
outcomes. It was also used as a means for guiding variable selection for the

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Journal of Applied Gerontology 33(1)

empirical analyses. This conceptual framework consists of resident (e.g., age and
decreased immunity) and facility (e.g., staffing levels and quality) risk factors as
well characteristics of the NH environment (e.g., competition and reimbursement
rates).
NH residents are typically older and more susceptible to acquiring infections,
and this can lead to hospitalizations or even death (Mody et al., 2011). Risk factors associated with NH residents susceptibility to acquiring infections include
malnutrition and functional impairments. In addition, while in the NH, there are
a number of risk factors for residents coming in contact with and/or spreading
infections. These risk factors include care processes such as contact with medical
devices and group activities (i.e., physical therapy, dining facilities, and bathing
areas) (Richards, 2007). Resident risk factors and potential resident outcomes
were initially combined in a conceptual framework by Mody (2009). That is,
based on existing literature, these resident risk factors and HH practices were
proposed to influence healthcare acquired infections, and in turn healthcare
acquired infections were proposed to influence resident outcomes such as death
and hospitalization. In this research, we modify this initial conceptual framework
to include NH internal, organizational, and external factors, as well as the deficiency citation for HH (F-Tag 444). This is shown in Figure 1.
Internal factors are operating characteristics of the facility, such as staffing
levels; organizational factors are characteristics of the facility itself, such as the
number of beds; and external factors are characteristics generally outside of the
influence of the organization, such as competition from other providers. Including
these factors is useful, because many internal, organizational, and external factors
are believed to influence care in NHs.
One often-cited important internal characteristic, for example, is the staffing
level of nurse aides. High nurse aide staffing levels have been shown to be associated with better quality in many prior NH studies (Castle, 2008). One often-cited
important organizational characteristic, for example, is the ownership of the
facility. For-profit facilities are thought to provide lower quality of care than
not-for-profit NHs (Comondore et al., 2009). One often-cited important external
characteristic, for example, is the Medicaid reimbursement rate. High rates have
been shown to be associated with better quality in many prior NH studies (Hyer
et al., 2009). These factors may also be associated with whether or not a facility
receives a deficiency citation for HH.
This conceptual model is used, first because based on data availability the NH
is used as the unit of observation. Thus, an organization-based conceptual
framework was appropriate. Second, a similar conceptual framework was
used previously in NH analyses examining deficiency citations (Castle,
Wagner, Ferguson-Rome, Men, & Handler, 2011; Castle, Wagner, Ferguson,

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Castle et al.

33

& Handler, 2011). A complete list of the factors used in the analyses and their
definitions are provided in Table 4. Given the large number of factors examined,
and given the paucity of research in this area, this study is presented as an exploratory analysis. Thus, specific hypotheses for the potential relationships between
factors and deficiency citations for HH were not developed.

Method
Secondary data (described below) from 2000 to 2009 are used in the analyses.
These data were combined into a panel consisting of a total of 148,900 NH
observations. Descriptive analyses and multivariate analyses are used to examine
characteristics (i.e., internal, organizational, and external factors) associated with
receiving deficiency citations for HH (F-444).

Data Sources
Deficiency citations are recorded in the Online Survey, Certification, And
Reporting (OSCAR) data. Moreover, the OSCAR also includes aggregate resident information (e.g., number of residents with dementia, with psychiatric
conditions, etc.), staffing information (e.g., number of full-time equivalent (FTE)
nurse aides, etc.), and facility information (e.g., ownership characteristics, bed
size, etc.). Thus, all of the internal and organizational factors examined in this
research came from the OSCAR data.
The OSCAR data are publicly available from CMS (i.e., Centers for Medicare
& Medicaid Services). The OSCAR is the only readily available data source that
represents a national sample of NHs and includes resident, staffing, facility, and
deficiency citation information over time. The reliability of many variables is
well established (such as ownership characteristics; Kash, Hawes, & Phillips,
2007; Kash, Naufal, Corts, & Johnson, 2010); but, this should not be overstated
as no comprehensive psychometric analyses of the data are available, and opinions vary as to the overall reliability of this data (Kash et al., 2007). Details
regarding the variables included in the OSCAR and how the data are collected is
provided by Kash et al. (2007).
A limited number of variables included in the analyses came from the area
resource file (ARF). Specifically, variables used as external factors (i.e., per capita income in the market and the number of elderly in the market). Extensive
details regarding the ARF can be found at www.arfsys.com.
In addition, Medicaid reimbursement levels (a variable used as an external factor) came from primary data collected by the authors. This followed a process
previously used by others (Grabowski, Feng, Intrator, & Mor, 2004). This primary

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Journal of Applied Gerontology 33(1)

data collection included contacting representatives in each state, validating

responses with information from other sources (when available), and adjusting
the Medicaid reimbursement levels using the overall consumer price index (CPI).
Extensive details regarding this data collection methodology is provided by
Grabowski et al. (2004).

Analytic Approach
The OSCAR data for each NH are available on a yearly basis (as the certification process occurs approximately yearly). Moreover, each facility has a
unique ID number. Using these ID numbers, the OSCAR data for each NH
from 2000 through 2009 were combined to create a longitudinal panel data
source. The period 2000 through 2009 was used because these data were available to the authors, and the data were used in a longitudinal panel format that
allows more accurate inference of the included model parameters (Hsiao,
Mountain, & Ho-Illman, 1995). ZIP codes are included in the OSCAR that
were used to identify counties in which NHs were located and match facilities
with the ARF data.
In the baseline year (i.e., 2000) 16,745 NHs were identified. Subsequently,
10% (N=1,855) of these NHs were excluded because they could not be identified
in a subsequent year up to 2009. Thus, combined for the analyses 148,900 NH
observations were used in this analysis (i.e., 14,890 NHs 10 years).

Analyses
Descriptive statistics for the deficiency citation for HH (F-444) are presented.
This includes the percentage of NHs receiving this deficiency citation; this citation as a percentage of all deficiency citations given; and, the rank of this citation
of all deficiency citations used, for each year from 2000 to 2009.
Twelve categories (labeled A through L) are used for each deficiency
citation. These categories vary in scope and severity (i.e., the greater the letter,
the more severe the citation). The severity depends on the extent of harm to the
resident and the scope depends on the number of residents affected (these designations are further defined in Table 2). Using all years of data (2000 through
2009), the percentage and number of NHs receiving each category of the deficiency citation for HH (F-444) is presented.
Descriptive statistics (means and percentages) for the internal, organizational,
and external factors used in the analyses are presented. These are stratified by
NHs receiving a deficiency citation for HH (F-444) in 2000, or not. These
descriptive statistics are provided for the baseline year of 2000 for parsimony.

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Castle et al.

Table 2. Nursing Homes Receiving Deficiency Citationsa for Hand Hygiene (F-tag
444) From 2000 to 2009.
Percentage of
F-Tag 444 Deficiency Rank of F-Tag 444
Nursing Homes
Citations as a
Deficiency Citations
With an F-Tag 444
Percentage of All
of All Deficiency
Deficiency Citation
Citations Given
Citations Given

Year
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
Summary (all years)

7.37
7.38
7.31
8.64
9.06
9.97
10.75
11.56
11.65
11.98
9.06

1.17
1.18
1.40
1.46
1.51
1.54
1.55
1.64
1.67
1.75
1.63

31
32
26
25
23
22
22
20
19
19
24

Note: aA nursing home deficiency citation is defined as a finding that a nursing home failed
to meet one or more federal or state requirements (Department of Health and Human
Services [DHHS], 2004, p. 34).

To examine internal, organizational, and external factors of NHs associated

with receiving deficiency citation for HH (F-444) multivariate analyses were
used. Thus, multicollinearity and collinearity levels among the variables using
the variance inflation factor (VIF) test were first measured (SAS Institute, 1999).
The multivariate analyses used consisted of Generalized Linear Models.
Specifically, generalized estimating equations (GEE) with a logit link were used
(Zeger & Liang, 1992). GEE controls for the biases that can occur in data consisting of repeat observations (i.e., in this case, NHs with repeat observations from
2000 to 2009). The logit link was used because the variable of interest was
dichotomous (e.g., deficiency citation F-444 or no deficiency citation). SAS
version 9.13 was used for all statistical analyses.

Results
Results of the Descriptive Analyses
From 2000 to 2009 an average of approximately 9% of all NHs per year received
an HH deficiency citation (F-444; see Table 2). An upward trend is evident, with

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Journal of Applied Gerontology 33(1)

Figure 2. Tercile distribution of deficiency citations for Hand Hygiene (F-444) are
presented. The figure represents the average number of these deficiency citations
given per nursing home in each state.

an average yearly percentage increasing from 7.37% (in 2000) to 11.98% (in
2009). On average, these are the 24th most frequently used deficiency citation
(from 190 available); although, as shown in Table 2, the use of these citations
does vary slightly per year from the 32nd most frequently used (in 2001) to the
19th (in 2008 and 2009). In addition, the use of deficiency citations for HH
(F-444) varies by state. In some states, such as Pennsylvania, an average of 6%
of facilities were given this deficiency citation in 2009; whereas, in other states
such as Michigan, an average of 15% of facilities were given this deficiency
citation in 2009. The tercile distribution of these deficiency citations by state is
shown in Figure 2.
Table 3 shows the percentage of HH deficiency citations (F-444) from 2000 to
2009 given by scope and severity. This shows that almost no NHs received deficiency citations in the most severe categories (i.e., J, K, and L). Most deficiency
citations (i.e., 66.3%) were at the D level (representing potential for more than
minimal harm [severity] and isolated cases [scope]).
Descriptive statistics of the variables used in the analysis for the baseline
period of the year 2000 are presented in Table 4. A total of 1,828 NHs received
this deficiency citation (F-444) in the year 2000. Compared to those NHs that did
not receive a deficiency citation for HH, the bivariate analyses show higher rates
of both more quality of care deficiency citations (addresses how well the facility
renders services provided and supervised by nursing staff) and J, K, or L deficiency citations.

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Castle et al.
Table 3. Scope and Severity Classifications Used for Medicare/Medicaid
Certification Survey Deficiencies and Percentage of Nursing Homes Receiving
Deficiency Citations for Hand Hygiene (F-tag 444) From 2000 to 2009.
Scope
Severity
Potential for minimal harm
Potential for more than minimal harm
Other actual harm
Actual or potential for death/serious injury

Isolated

Pattern

Widespread

A
(NR)

B
(n=241
2%)
E
(n=2,561
29%)
H
(0)
K
(0)

C
(n=43
0.5%)
F
(n=126
1.5%)
I (0)

D
(n=5,843
66%)
G (n=1
0.01%)
J(0)

L
(n=1
0.0%)

Note: Number in parentheses is the number of citations for hand hygiene (F-tag 444) from
2000 to 2009 (total number of these citations = 8,816). Severity is the extent of harm
to the resident. Scope is the number of residents affected (Isolated defined as affecting a
single or very limited number of residents; Pattern defined as affecting more than a very
limited number of residents; Widespread defined as affecting a large portion or all residents). Thus, A deficiency citations are the least problematic and L are the most problematic. For example, an A-level deficiency citation may be given if one nurse aide was observed to not
wash her hands adequately; whereas, a C-level deficiency citation may be given if numerous nurse
aides were observed to not wash her hands adequately. If one nurse aide was observed to not wash
her hands adequately with a resident known to have norovirus a D-level deficiency citation may be
given.
NR, not recorded in the OSCAR.

Results of the Multivariate Analyses

Based on the commonly used threshold value of 0.8, the variables showed no
problems of collinearity and no VIF score exceeded 2.5. Results from the GEE
marginal models with a logit link are shown in Table 5.
For the internal factors all of the staffing level factors were significant at conventional levels (see Table 5). That is, for nurse aides high staffing levels were
associated with low deficiency citations for HH (Adjusted Odds Ratios (AOR) =
0.965; p>=.01); high staffing levels of LPNs were associated with low deficiency
citations for HH (AOR = 0.978; p>=.05); and, high RN staffing levels were associated with low deficiency citations for HH (AOR = 0.976; p>=.01).
For the organizational factors examined (see Table 5), facilities with quality
of care deficiency citations were significantly associated with a high likelihood of
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0.44

0.26

0.12

Dementia

0.09

0.06

0.20

0.12
0.15

0.09

0.12

0.10
0.17

0.13

0.33

0.43

0.10
0.16

0.12

0.07

0.12

0.32

0.20

0.12
0.17

0.26

0.11

0.09

0.14

Standard
Deviation

Mean (or %)

Standard
Deviation

Mean (or %)

Restraint use
Psychiatric condition

Internal factors
Nurse aide staffing (FTEs
per resident)
LPN staffing (FTEs per
resident)
RN staffing (FTEs per
resident)
Resident case-mix (ADL
score)

Variables

Facilities Not Receiving

F-tag 444 Citationsb

Facilities Receiving F-tag

444 Citationsa

(continued)

The score for three ADLs (eating, toileting, and

transferring) constructed by giving a score of 1
for low assistance, 2 for moderate assistance,
and 3 for high need for assistance summed for
each ADL.
Proportion of residents in physical restraints.
Proportion of residents diagnosed with
psychiatric conditions.
Proportion of residents diagnosed with
dementia (defined as an ICD-9 code indicating
a specific dementing illness).

FTE RNs per resident.

FTE LPNs per resident.

FTE nurse aides per resident.

Operational Definition of Variable

Table 4. Descriptive Statistics of NHs Receiving and Not Receiving Deficiency Citations for HH (F-tag 444).

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39

74

110
70%*

60%*

82%

Chain member

Occupancy rate

16%

23%

64%

Medicaid resident
occupancy
Size (number of beds)
For-profit ownership

0.46

0.08*

3.09*

2.42

83%

56%

109
65%

63%

0.04

1.59

17%

73

26%

0.38

1.84

Standard
Deviation

Mean (or %)

Standard
Deviation

Mean (or %)

Facilities Not Receiving

F-tag 444 Citationsb

Facilities Receiving F-tag

444 Citationsa

J, K, or L deficiency
citations

Organizational factors
Quality of care deficiency
citations

Variables

Table 4. (continued)

(continued)

Number of beds in the nursing home.

For-profit or not-for-profit (including
government owned) ownership.
Whether member of a nursing home chain or
not.
Percent of beds occupied by residents.

Deficiency citations representing the sum of 19

different deficiency citations (F-tags are: 309,
310, 311, 312, 314, 316, 317, 318, 319, 321, 322,
323, 324, 325, 328, 329, 330, 333, 353). Withinstate rankings (percentiles) used for analyses.
Any deficiency citation at J, K, or L level (see
Table 2). Within-state rankings (percentiles)
used for the analyses.~
Percent of residents with Medicaid as payor.

Operational Definition of Variable

40

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81*

26,503*

Elderly per square mile2

Per capita income (US$)2

6,237

174

2,477

27.14

Standard
Deviation

27,324

146

2,076

132.40

Mean (or %)

7,966

419

2,384

31.62

Standard
Deviation

Facilities Not Receiving

F-tag 444 Citationsb

The state average daily (i.e., per diem) payment

rate for Medicaid residents (US$). The rates
were adjusted to constant 2000 dollars using
the Consumer Price Index (CPI).
Herfindahl Index. Each facilitys percentage share
of beds in the county / squared market shares
of all facilities in the county (0-1). Higher
values indicate a less competitive market.
Average number of elderly per square mile (age
65 and above) in the county.
Average income (US$) for all county residents

Operational Definition of Variable

Note: aN = 1,828 facilities (based on 2000 data); bN = 12,372 facilities (based on 2000 data).
ADL = activities of daily living; FTE = full-time equivalent; HH = hand hygiene; LPNs = Licensed Practical Nurses; LTC = long-term care; NH = nursing homes; RNs = Registered Nurses.
*Difference between receiving deficiency citation for HH and not significant at p<0.001.
1.The unit of analysis for this variable is the state (unless otherwise noted, for all other variables the facility is the unit of analysis).
2.The unit of analysis for this variable is the county.
~Variation in the use of nursing home deficiency citations is known to occur from state to state. Using the percentile distribution of deficiency citations within each state gives to a more consistent comparison of deficiency citations across states.
(A). variables primarily came from the Online Survey, Certification, And Reporting (OSCAR); with elderly in the county and per capita income coming from the Area Resource File (ARF); and, Medicaid reimbursement rates coming from primary data; (B). the figures presented are for the baseline
2000 data. The baseline figures are presented for parsimony.

2,216

125.05*

Mean (or %)

Facilities Receiving F-tag

444 Citationsa

Competition (Herfindahl
Index)d

External factors
Medicaid reimbursement
rate (US$)1

Variables

Table 4. (continued)

41

Castle et al.
Table 5. Multivariate Results of Nursing Homes Receiving and Not Receiving
Deficiency Citations for Hand Hygiene (F-tag 444) From 2000 to 2009.
AOR
Internal factors
Nurse aide staffing
LPN staffing
RN staffing
Resident case-mix (ADL score)
Restraint use
Psychiatric condition
Dementia
Organizational factors
Quality of care citations
J, K, or L citations
Medicaid resident occupancy
Medicaid resident occupancy
Medicaid reimbursement ratea
For-profit ownership
Size
Chain membership
Occupancy rate
External factors
Medicaid reimbursement rate
Competition (Herfindahl
Index)
Elderly in county
Per capita income
Intercept

95% CI

0.965
0.978
0.976
1.007
1.017
1.063
1.031

(0.961
(0.941
(0.938
(1.039
(0.989
(0.992
(1.002

0.983)
0.993)
0.989)
1.111)
1.046)
1.035)
1.062)

**
*
**
***

**

1.137
0.826
0.942
0.980

(1.133
(0.779
(0.927
(0.921

1.142)
0.876)
0.956)
0.997)

***
***
***
*

1.005
1.021
0.935
1.004

(0.945
(0.994
(0.887
(0.975

1.068)
1.049)
0.986)
1.035)

**

0.922
1.013

(0.911
(0.982

0.989)
1.045)

**

0.976
0.993
0.074

(0.942
(0.959
(0.0367

1.018)
1.029)
0.149)

***

Note: N = 148,900 observations.

*Statistically significant at p=0.05 level or better; ** Statistically significant at p=0.01 level or
better; *** Statistically significant at p=0.001 level or better. Analyses also include 49 state and
year dummy variables (not shown). Results reported using generalized estimating equations
(GEE).
FTE = full-time equivalent, ADL = activities of daily living, RNs = Registered Nurses, LPNs =
Licensed Practical Nurses, AOR = Adjusted Odds Ratio; CI = Confidence Interval.
a
Adjusted Odds Ratios were manually calculated by using the mean levels of the variables
(Medicaid reimbursement rate and Medicaid resident occupancy [i.e., a and b] and the
variance/covariance matrix [Ai & Norton, 2003]).

receiving a deficiency citation for HH (AOR = 1.137; p <=.001); however, those

with J, K, or L level deficiency citations were significantly associated with a low
likelihood of receiving a deficiency citation for HH (AOR = 0.826 p <=.001).

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Journal of Applied Gerontology 33(1)

Also, facilities that are members of a chain were significantly associated with a
low likelihood of receiving a deficiency citation for HH (AOR = 0.935 p <=.01).
For the external factors examined (see Table 5), facilities located in states
with higher Medicaid reimbursement rates were significantly associated with a
low likelihood of receiving a deficiency citation for HH (AOR = 0.922; p <=.01).

Discussion
HAIs are the leading cause of morbidity and mortality amongst NH residents.
NH residents are particularly susceptible to HAIs because they are frail, have
multiple chronic comorbidities, and take antibiotics that are often inappropriately
prescribed leading to greater susceptibility of antibiotic-resistant organisms
(Bradley, 2009; Mody et al., 2011). HH can be an extremely influential practice
in infection control management to prevent transmission of infectious disease in
NHs (Mody et al., 2011). The research presented here is significant in that it
gives a nationally representative picture of deficiency citations for HH (i.e., F-tag
444) in NHs. That is, in this study we examined relationships between these
deficiency citations and characteristics of the NH and characteristics of the NH
environment.
Overall, the conceptual framework used seemed appropriate for examining
these deficiency citations. However, we note that the conceptual framework was
modified from the initial work of Mody (2009) and the potential relationships
indicating HH influencing healthcare acquired infections, death and hospitalization were not examined in the research presented here (see Figure 1). The majority of factors included in the conceptual framework and resulting analyses were
significant in the multivariate analyses. This was especially true for the internal
and organizational factors. That is, 5 of the 7 internal factors were statistically
significant (i.e., nurse aide staffing, LPN staffing, RN staffing, resident case-mix,
and dementia) and 5 of the 8 organizational factors (i.e., quality of care citations,
J, K, or L citations, Medicaid resident occupancy, Medicaid resident occupancy
Medicaid reimbursement rate, and chain membership) were statistically significant. The external factors performed less well, with 1 of the 4 factors significant
(i.e., Medicaid reimbursement rate) in the multivariate analyses. Thus, further
modification of these external factors may be warranted in subsequent iterations
and development of this conceptual framework.
With an average of approximately 9% of all NHs per year receiving a HH deficiency citation (see Table 2), our results confirm previous survey-based research
that HH measures are not uniformly used in NHs ( Aiello et al., 2009; Ashraf et al.,
2010). The results show an increasing percentage of NHs with an F-tag 444 deficiency citation and a reduction in rank of F-tag 444 deficiency citations of all

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43

deficiency citations given (see Table 2). Thus, HH deficiency citations are becoming more common over time. We are not able to determine the cause(s) of this
trend. We speculate that one reason may be greater awareness of surveyors to
issues of infection control. A second potential reason may be a more difficult operating environment for NHs. Resident case-mix has increased over time, while revenues have remained flat (Hyer et al., 2009). While providing more care with the
same (or less) resources appropriate infection control may be sacrificed.
The issue of staffing appears very prominent in our findings (see Table 5). For
all three caregivers examined (i.e., nurse aides, LPNs, and RNs) low staffing
levels were associated with receiving a deficiency citation for HH (F-444). With
low staffing levels, these caregivers are likely hurried, and may not have the time
to use appropriate HH techniques. Empirical research has identified inadequate
staffing levels to exist in many NHs (e.g., Hyer, Temple, & Johnson, 2009) and to
be highly associated with quality of care (Castle, 2008; Castle & Ferguson, 2010).
Our findings show one further consequence of low staffing: potential poor HH
practices. We note that other staffing related reasons for poor HH likely exist. For
example, poor HH practices could result from limited time for effective supervision, high turnover, or from less peer support. Given the prominent findings for
staffing identified in this research, it would be worth exploring some of these
other staffing-related factors further.
Given the current inhospitable financial and reimbursement climate in which
NHs operate, staffing levels are unlikely to improve in the near future. Therefore,
HH-specific training may be one answer to improve compliance especially for
nurse aides who provide 80%-90% of resident care (Beck, Ortigara, Mercer, &
Shue, 1999). However, studies show that HH training in LTC facilities may be
inadequate (Leinbach & English, 1995). To enhance HH training, facilities could
do more to educate staff that contaminated hands are one of the most common
ways to transmit infections, provide 1:1 coaching on how to wash hands appropriately, describe the pros and cons of handwashing vs. alcohol-based hand sanitizer products, and the need for handwashing (rather than the use of alcohol-based
hand sanitizer products) when hands are soiled or there may be the presence of C.
difficile infection for example.
Still, potential training and education solutions to address this deficiency citation necessitate that we further understand why staff are not washing their hands as
frequently as the guidelines recommend. It could be that the underlying behavior is
influenced by the culture or attitudes of staff. Or it could be that staff does not have
sufficient access to alcohol gel (for example). Training and education approaches
should be informed by a more detailed understanding of reasons for poor HH.
Institutional policies and procedures could be developed to routinize HH as a
required process for all staff, followed by internal quality improvement audits

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Journal of Applied Gerontology 33(1)

(similar to state surveyor audits) to determine HH compliance. It has also been

recognized that healthcare workers should receive feedback to ensure proper HH
practices (Ahlbrecht et al., 1999). We speculate that a lack of such feedback may
also be reflected in the findings. That is, with low staffing levels of RNs in a
leadership position (who would typically provide this feedback), this process
may be weak or nonexistent.
Our findings also show that receiving a deficiency citation for HH (F-444) is
associated with poor quality in general (i.e., with quality of care deficiency citations). This may be due to the notion that HH practices and quality of care are
influenced by similar operating and environmental conditions. Nevertheless, HH
deficiency citations are associated with lower levels of the worst lapses in quality
of care deficiency citations (i.e., J, K, and L deficiency citations, which represent
deficiency citations with a high extent of harm and/or more residents affected).
These contradictory findings should be investigated further. We speculate that
this may reflect the known orthogonality of quality indicators. That is, NHs often
perform poorly in one area at the same time as they perform better in a different
area (Castle & Ferguson, 2010).
The findings show that states with lower Medicaid reimbursement rates had
higher rates of deficiency citations for HH. Low Medicaid reimbursement rates
are also a characteristic of the NH industry (Grabowski et al., 2004). These low
rates are associated with many negative NH outcomes such as high staff turnover
and poor quality of care (Grabowski et al., 2004). That is, Medicaid reimbursement rates can influence the operation of NHs.
Presumably, the HH lapses resulting in deficiency citations by surveyors represent observed cases of problems, and not lapses of reporting and documentation
problems (which is a criticism of many other deficiency citations). As such, the
use of deficiency citations for HH (similar to citations given for other observed
problems such as medication errors; F-329) likely underestimate the potential
HH problems in NHs. One would assume that staff would be following clinical
care protocols (including HH) when surveyors are observing care. Thus, the
potential problems with HH are likely much larger than we report here.
Interventions to improve HH need to be multifactorial in nature since multimodal interventions are more effective at improving HH compliance rates over
single employed approaches. The multifactorial approach should include three
areas improving knowledge of HH through education (Laustsen, Bibby, Kristensen,
Mller, & Thulstrup, 2009); reinforcing behavior through quality improvement
activities (Pittet et al., 2000); motivating the HH behavior through introducing
products such as personal bottles or wall mountedalcohol hand rubs; changing
the culture through increasing administrative support; and using reminders (Pittet
et al., 2000).

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45

Limitations and Suggestions for Future Research

One limitation of examining deficiency citations for HH is that they do not
necessarily represent actual resident outcomes. The literature would suggest that
when caregivers have poor HH practices this is detrimental to residents, but this
cannot be substantiated in our analysis. Future research examining the influence
of HH practices on resident outcomes is needed. Other sources of data could be
used for such analyses, including the minimum data set (MDS), which provides
a somewhat comprehensive evaluation of each resident (Castle & Ferguson,
2010).
From the information available in the OSCAR, it is not possible to present a
more fine-grained analysis of specific breakdowns in HH requirements. That is,
if the errors occur with specific residents or at specific locations. A more finegrained analysis of some of the differences that exist between states may also be
useful. As shown in Figure 2, considerable differences exist between states.
These may be associated with specific state incentives or policies that could be
further investigated.
Some of these more fine-grained analyses would also seem warranted given
the recent changes in F-tags. In late 2009, F-tags 441, 442, 443, 444, and 445
were all collapsed in F-441 (CMS, 2009b). This enables aggregate infection
control deficiency citations to be examined; but, is limited in that it is no longer
possible to examine specific components of infection control, such as HH.

Conclusions
As noted above, deficiency citations have several limitations when investigating
HH. However, no prior research has presented a longitudinal analysis of a
national sample of NHs examining these deficiency citations. With HH deficiency citations increasing over time and with an average of approximately 9%
of all NHs per year receiving an HH deficiency citation, our findings provide
tentative evidence that HH may be a problem in NHs. By examining relationships between these deficiency citations and characteristics of the NH and characteristics of the NH environment, we identify many of these factors (such as
staffing) to be potentially important. This research may foster more interest in
further elaborating influential determinants in this area of care; with the important objective of improving resident care and resident outcomes.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

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Journal of Applied Gerontology 33(1)

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Nicholas Castle is a professor with the University of Pittsburgh in the Department of
Health Policy & Management. His research examines the quality of nursing homes.
Previous research initiatives include examining staffing levels, staff turnover, top
management, resident satisfaction, and safety culture. Dr. Castle is a Fellow of the
Gerontological Society of America.
Laura Wagner is an assistant professor with the New York University College of
Nursing in the Hartford Institute for Geriatric Nursing. Her research examines
improving patient safety care processes in nursing homes. Previous research has
focused on physical restraint and siderail reduction, improving adverse event reporting and disclosure, and safety culture assessment.

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Journal of Applied Gerontology 33(1)

Jamie C. Ferguson-Rome is a project director with the University of Pittsburgh in

the Department of Health Policy and Management. Her work includes safety and
quality of care in nursing homes and assisted living facilities and the age-friendliness
of communities. She can be reached at jamief@pitt.edu.
Steven Handler is an assistant Professor with the University of Pittsburgh in the
Department of Biomedical Informatics and Division of Geriatric Medicine. His
research focuses on the development, implementation, and assessment of clinical
decision support systems to improve medication and patient safety primarily in the
nursing home setting.

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