The Register Citizen (Torrington, CT)
Staffing, culture challenge nursing home care
Connecticut this year took the unusual step of issuing a consent order requiring a New Haven nursing home to hire an independent nurse consultant and implement minimum staffing ratios after inspections at the facility uncovered numerous lapses in care and safety violations.
The order, agreed to in April by the Advanced Center for Nursing and Rehabilitation and the state Department of Public Health, tasked the independent nurse consultant with assessing staff’s ability to do their jobs and evaluating how care is delivered. The minimum staffing ratios ordered are 30 patients to one licensed nurse on all shifts, on most units; 10 patients to one nurse’s aide on the first shift; 12 patients to one nurse’s aide on the second shift and 20 patients to one nurse’s aide on the third shift.
Officials at the facility didn’t return calls seeking comment.
“Most of the bad outcomes are the result of insufficient staffing.”
Toby S. Edelman, senior policy attorney, Center for Medicare
It isn’t often that DPH mandates staffing or requires nursing homes to hire consultants, but the order reflects a broader emerging problem affecting the care provided at many nursing homes: insufficient staffing levels and caregivers who lack training.
“It’s an enormous problem,” said Toby S. Edelman, senior policy attorney at the Center for Medicare Advocacy, based in Washington, D.C. “Most of the bad outcomes are the result of insufficient staffing and insufficiently trained staff. It’s pretty much a universal problem.”
In Connecticut, there have been multiple times in recent years when nursing home residents have been injured in incidents when no or too few staff members were present.
Between 2015 and 2018, Connecticut nursing homes were cited by the state for 247 incidents involving lapses in care. Twenty-five of those cases involved incidents in which citations noted that two staff members were required to assist or move a resident and only one was used, according to a C-HIT analysis of DPH citations signed and finalized. Of those 25 incidents, 17 occurred between 2017 and this year.
The largest share of incidents — 65 — involved falls, which resulted in severe bruising and/or broken bones, between 2015 and 2018. Facilities were cited 37 times for residents suffering pressure ulcers caused by not following doctor’s care orders, or neglect; 31 times for causing general harm to patients; and 29 times for medication errors, some life-threatening.
Nursing homes are entrusted with caring for their elderly residents who are among the frailest and sickest members of the population, and who many times reside in facilities for long stretches of time or for the final years of their lives. Advocates say any lapse in care is one too many.
The occupancy rate at nursing homes has remained constant at an average rate of 87 percent in 2017 and the previous two years, according to the September 2017 state census report.
The state’s Public Health Code requires a level of licensed personnel and aides depending on the number of residents. For example, if a nursing home has 100 residents, a minimum of 140 hours of licensed care and aides are required from 7 a.m. to 9 p.m. and 50 hours of licensed care and aides are required from 9 p.m. to 7 a.m., according to DPH.
There’s no definitive way to gauge the number of staff members that corresponds with those requirements, since each facility is different and caregivers may work different hours depending on whether they are full- or part-time, said DPH spokeswoman Maura Downes.
Edelman said in some cases, staff members aren’t completing their assigned tasks — not because they don’t want to, but because there often isn’t enough staff to do everything.
But generally, Connecticut nursing homes are adequately staffed to provide quality care to residents, said Matthew Barrett, president and CEO of the Connecticut Association for Health Care Facilities, which represents 150 of the 224 nursing homes in the state.
Many facilities in Connecticut are exceeding the minimums, which Barrett called “dated,” and the association has supported legislation to raise the minimum staffing levels.
A recent analysis by Kaiser Health News reported that out of 188 Connecticut nursing homes, 12 had staffing levels below or much below average, 46 were ranked average and 130 had levels above or much above average. For registered nurse staffing levels, nine facilities were below or much below average, 31 were average and 148 were above or much above average. In its analysis, KHN examined daily nursing home payroll records released by the Centers for Medicare & Medicaid Services that reported staffing levels from January to March.
Nursing Home Compare, an online tool run by CMS that assesses nursing homes based on several quality standards, shows 39 Connecticut facilities have staffing levels much above average, 88 rated above average, 41 at average, eight below average and 46 much below average as of this month. Staffing levels for two facilities weren’t available.
“I don’t think you can say this is purely all about the staffing,” said Ann Spenard, principal and vice president at Qualidigm, a Wethersfield-based consulting organization that works with nursing homes. “A lot of it is about the culture.”
For example, she said, staff members at some facilities are not encouraged to ask for help or speak up when they can’t meet all of their job demands. Some employees feel certain tasks aren’t their job and teamwork isn’t valued, Spenard said. Barrett echoed that sentiment. “The staffing numbers themselves don’t necessarily tell the quality-equation story. The issues of quality are not always easily explained with the staffing ratio analysis,” he said.
Turnovers affect care
Staff turnover is a challenge for many facilities, Spenard said. Nursing home jobs are rewarding, she noted, but caring for such a needy population can be demanding — physically and emotionally.
“Our turnover rate in this industry is almost 44 percent, and RNs have a median turnover rate of 50 percent,” she said. Many RNs would rather work in hospitals, where they can earn more money, and tend to move on from nursing homes once they have enough work experience, she said.