Behind The Nursing Home’s Glossy Brochure

Where are the Staff?

If you have been researching nursing homes, chances are you’ve collected a stack of nicely laid out brochures featuring heartwarming photos of caring staff interacting with well-cared-for residents.

But what is the reality behind that sunny promise? Perhaps not what you would expect. For decades, medical experts have been sounding the alarm on a staffing crisis in nursing homes and other long-term care facilities. Making a serious problem even worse, COVID-19 took an additional and devastating toll on staffing and care as it claimed the lives of over 184,000 residents and staff and resulted in many staff resigning.

But even before COVID-19 shed a harsh spotlight on care and staffing gaps in nursing homes, there was already a chronic staffing problem. Seventy-five percent of nursing homes had inadequate staffing before the pandemic according to one expert. And a June 2021 survey from the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) revealed that 94% of nursing homes reported staff shortages in the wake of COVID-19. Those shortages are not simply statistical; they represent significantly degraded quality and standard of care.

So, what is considered an adequate staffing level? While resident needs differ, a 2001 Centers for Medicare and Medicaid Services (CMS) study determined a minimum standard of 4.1 hours per resident day (hprd) divided among registered nurses (RNs), licensed nurses (LVN/LPN), and certified nursing assistants (CNAs), was required to avoid significant care issues. That standard has since been endorsed by a number of organizations. Federal nursing home staffing requirements state that “[a] nursing facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care.” Beyond sufficient staffing, the law states that “…all services provided or arranged by a facility must be provided by qualified persons using professional standards of quality.”  In other words, having the adequate number of staff is not enough. Nursing home staff must be appropriately trained and licensed/certified. However, the law doesn’t specify a minimum staff-to-patient ratio and leaves the definition of “adequate” to the facility, paving the way to chronic understaffing and less than optimum work conditions. Weekends are a particular issue. While the needs of residents do not change because it is a Saturday or Sunday, there are often large staffing shortfalls on weekends resulting in patient-to-staff ratios twice that of a weekday.

Why do nursing homes have such a hard time attracting and retaining staff? The answer is simple – working in a nursing home is demanding both physically and emotionally, and the pay is low. In fact, according to the U.S. Bureau of Labor Statistics, the median annual wage for certified nursing assistants (CNA) was only $30,850 in May of 2020.

And even when a nursing home successfully hires staff, keeping them is another issue. According to a March 2020 report in Health Affairs looking at 2017 and 2018 data, there was an average turnover rate of more than 140% for registered nurses working in nursing homes and more than 129% for CNAs. And those are the averages. Some facilities had double those numbers. What can you as a consumer do? First, know the facility’s staffing levels (Nursing Home 411 provides useful staffing data by state and facility). Asking specific questions can also reveal important information:

1. Where do you post information on staffing levels?
2. What is your facility staff hours per resident day (hprd)?
3. How do you vet and train employees?
4. What is your turnover rate?
5. How do staff work together with physicians on medical care and needs?
6. Are licensed nursing staff available 24 hours a day (including a registered nurse (RN) for at least 8 hours each day)?

With renewed focus on nursing home staffing in the wake of COVID-19, there is hope these chronic staffing issues will be addressed, resulting in more qualified nurses and higher retention, but that will certainly be sometime down the road. If you feel a loved one’s care has suffered because of low staffing levels or inadequately trained personnel, contacting a knowledgeable medical malpractice attorney can be a good first step in getting relief.