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Analysis

Nurse Staffing at Nursing Homes is Lacking

By Jennifer Thew RN  
   July 11, 2019

Nursing homes only met nurse staffing requirements less than 60% of the time, a new analysis finds.

When patients are admitted to a nursing home, it's usually because they're unable to care for themselves at home. While it's a difficult choice, families often make the decision to ensure their loved ones get the care and assistance they need.

But a new analysis of payroll-based staffing data for U.S. nursing homes, uncovered large daily staffing fluctuations, low weekend staffing, and daily staffing levels that often fall well below the expectations of the Centers for Medicare and Medicaid Services.

The study, published in the July issue of Health Affairs, found that when compared to weekday staffing there was a large drop in weekend staffing in all staffing categories, based on CMS' data resource, the Payroll-Based Journal.

In fact, the average weekend staffing time per resident day was just 17 minutes for registered nurses, nine minutes for licensed practical nurses, and 12 minutes for nurses' aides.

Additionally, using PBJ data from more than 15,000 nursing homes, researchers discovered that 54% of facilities met the expected level of staffing less than 20% of the time during the one-year study period. For RN staffing, 91% of facilities met the expected staffing level less than 60% of the time.

CMS does not mandate a staff-to-resident ratio standard for nursing homes, but it does require that an RN must be present for eight hours a day, and an RN or LPN must always be present at a facility.   

To meet a requirement of the Affordable Care Act, CMS has been collecting data from nursing homes since 2016. PBJ data have been used in the federal Five-Star Quality Rating System for Nursing Homes since April 2018.

"Staffing in the nursing home is one of the most tangible and important elements to ensure high quality care," study co-author David Stevenson, PhD, a Health Policy professor at Vanderbilt University Medical Center says in a news release. "Anyone who has ever set foot in a nursing home knows how important it is to have sufficient staffing, something the research literature has affirmed again and again. As soon as these new data became available, researchers and journalists started investigating them, and the government now uses the PBJ data in its quality rating system."

Unlike previous nursing home staffing data that was self-reported by facilities and covered only a narrow window of time around a facility’s annual recertification survey, PBJ data are linked to daily payroll information for several staff categories and cover the entire year.

"We found that the newer payroll data showed lower staffing levels than the previous self-reported data," says co-author David Grabowski, PhD, professor of Health Care Policy at Harvard University. "The lower levels in the PBJ data likely reflect both the fact that they are based on payroll records as opposed to self-report, and also that staffing levels were abnormally high around the time of the inspection. In fact, the PBJ data clearly show this bump, followed by a return to normal after inspectors leave."

Stevens says he hopes families and future nursing home residents become aware of and push back against these staffing practices.

"Hopefully, the general public will gain a broader awareness of the information that is available, not only on staffing but on other aspects of nursing home care," Stevenson says. "The only way nursing homes will change their behavior is if there is value in doing so. Some of that can come through the pressure of regulators, but it also needs to come from incentives in the marketplace, notably from expectations of current and future residents and their families."

Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.


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