Most nurs­ing homes rou­tinely mask low staff lev­els, new records show

The Charlotte Observer (Sunday) - - News - BY JOR­DAN RAU New York Times

Most nurs­ing homes had fewer nurses and care­tak­ing staff than they had re­ported to the gov­ern­ment for years, ac­cord­ing to new fed­eral data, bol­ster­ing the long-held sus­pi­cions of many fam­i­lies that staffing lev­els were of­ten in­ad­e­quate.

The records for the first time re­veal fre­quent and sig­nif­i­cant fluc­tu­a­tions in day-to-day staffing, with par­tic­u­larly large short­falls on week­ends. On the worst staffed days at an av­er­age fa­cil­ity, the new data show, on-duty per­son­nel cared for nearly twice as many res­i­dents as they did when the staffing ros­ter was fullest.

The data, an­a­lyzed by Kaiser Health News, come from daily pay­roll records Medi­care only re­cently be­gan gath­er­ing and pub­lish­ing from more than 14,000 nurs­ing homes, as re­quired by the Af­ford­able Care Act of 2010. Medi­care pre­vi­ously had been rat­ing each fa­cil­ity’s staffing lev­els based on the homes’ own un­ver­i­fied re­ports, mak­ing it pos­si­ble to game the sys­tem.

The pay­roll records pro­vide the strong­est ev­i­dence that over the last decade, the gov­ern­ment’s five-star rat­ing sys­tem for nurs­ing homes of­ten ex­ag­ger­ated staffing lev­els and rarely iden­ti­fied the pe­ri­ods of thin staffing that were com­mon. Medi­care is now re­ly­ing on the new data to eval­u­ate staffing, but the re­vamped star rat­ings still mask the er­ratic lev­els of peo­ple work­ing from day to day.

At the Beechtree Cen­ter for Re­ha­bil­i­ta­tion & Nurs­ing here, Jay Van­de­mark, 47, who had a stroke last year, said he of­ten roams the halls look­ing for an aide not al­ready swamped with work when he needs help putting on his shirt.

Es­pe­cially on week­ends, he said, “It’s al­most like a ghost town.”

Nearly 1.4 mil­lion peo­ple are cared for in skilled nurs­ing fa­cil­i­ties in the United States. When nurs­ing homes are short of staff, nurses and aides scram­ble to de­liver meals, ferry bed­bound res­i­dents to the bath­room and an­swer calls for pain med­i­ca­tion. Es­sen­tial med­i­cal tasks such as repo­si­tion­ing a pa­tient to avert bed­sores can be over­looked when work­ers are over­bur­dened, some­times lead­ing to avoid­able hos­pi­tal­iza­tions.

“Volatil­ity means there are gaps in care,” said David Steven­son, an as­so­ci­ate pro­fes­sor of health pol­icy at Van­der­bilt Uni­ver­sity School of Medicine in Nashville, Ten­nessee. “It’s not like the day-to-day life of nurs­ing home res­i­dents and their needs vary sub­stan­tially on a week­end and a week­day. They need to get dressed, to bathe and to eat every sin­gle day.”

David Gif­ford, a se­nior vice pres­i­dent at the Amer­i­can Health Care As­so­ci­a­tion, a nurs­ing home trade group, dis­agreed, say­ing there are le­git­i­mate rea­sons staffing varies. On week­ends, for in­stance, there are fewer ac­tiv­i­ties for res­i­dents and more fam­ily mem­bers around, he said.

“While staffing is im­por­tant, what re­ally mat­ters is what the over­all out­comes are,” he said.


While Medi­care does not set a min­i­mum res­i­dent-to-staff ra­tio, it does re­quire the pres­ence of a reg­is­tered nurse for eight hours a day and a li­censed nurse at all times.

The pay­roll records show that even fa­cil­i­ties that Medi­care rated pos­i­tively for staffing lev­els on its Nurs­ing Home Com­pare web­site, in­clud­ing Beechtree, were short nurses and aides on some days. On its best staffed days, Beechtree had one aide for every eight res­i­dents, while on its low­est staffed days, there was only one aide for 18 res­i­dents. Nurs­ing lev­els also var­ied.

The Cen­ters for Medi­care & Med­i­caid Ser­vices, the fed­eral agency that over­sees nurs­ing home inspections, said in a state­ment that it “is con­cerned and tak­ing steps to ad­dress fluc­tu­a­tions in staffing lev­els” that have emerged from the new data. This month, it said it would lower rat­ings for nurs­ing homes that had gone seven or more days with­out a reg­is­tered nurse.

Beechtree’s pay­roll records showed sim­i­lar staffing lev­els to those it had re­ported be­fore. David Camerota, chief op­er­at­ing of­fi­cer of Up­state Ser­vices Group, the for­profit chain that owns Beechtree, said in a state­ment that the fa­cil­ity has enough nurses and aides to prop­erly care for its 120 res­i­dents. But, he said, like other nurs­ing homes, Beechtree is in “a con­stant bat­tle” to re­cruit and re­tain em­ploy­ees even as it has in­creased pay to be more com­pet­i­tive.

Camerota wrote that week­end staffing is a spe­cial chal­lenge as em­ploy­ees are guar­an­teed every other week­end off. “This im­pacts our abil­ity to have as many staff as we would re­ally like to have,” he wrote.


In April, the gov­ern­ment started us­ing daily pay­roll re­ports to cal­cu­late av­er­age staffing rat­ings, re­plac­ing the old method, which re­lied on homes to re­port staffing for the two weeks be­fore an in­spec­tion. The homes some­times an­tic­i­pated when an in­spec­tion would hap­pen and could staff up be­fore it.

The new records show that on at least one day dur­ing the last three months of 2017 – the most re­cent pe­riod for which data were avail­able – a quar­ter of fa­cil­i­ties re­ported no reg­is­tered nurses at work.

The Cen­ters for Medi­care & Med­i­caid Ser­vices dis­cour­aged com­par­i­son of staffing un­der the two meth­ods and said no one should ex­pect them to “ex­actly match.” The agency said the meth­ods mea- sure dif­fer­ent time pe­ri­ods and have dif­fer­ent cri­te­ria for how to record hours that nurses worked. The nurs­ing home in­dus­try also ob­jected, with Gif­ford say­ing it was like com­par­ing Fahren­heit and Cel­sius tem­per­a­tures.

But sev­eral prom­i­nent re­searchers said the con­trast was not only fair but also war­ranted, since Medi­care is us­ing the new data for the same pur­pose as the old: to rate nurs­ing homes on its web­site. “It’s a worth­while com­par­i­son,” said David Grabowski, a pro­fes­sor of health care pol­icy at Har­vard Med­i­cal School.

Of the more than 14,000 nurs­ing homes sub­mit­ting pay­roll records, seven in 10 had lower staffing us­ing the new method, with a 12 per­cent av­er­age de­crease, the data show. And as nu­mer­ous stud­ies have found, homes with lower staffing tended to have more health code vi­o­la­tions – an­other cru­cial mea­sure of qual­ity.


Even with more re­li­able data, Medi­care’s five-star rat­ing sys­tem still has short­com­ings. Medi­care still as­signs stars by com­par­ing a home to other fa­cil­i­ties, es­sen­tially grad­ing on a curve. As a re­sult, many homes have kept their rat­ing even though their pay­roll records showed lower staffing than be­fore. Also, Medi­care did not rate more than 1,000 fa­cil­i­ties, ei­ther be­cause of data anom­alies or be­cause they were too new to have a staffing his­tory.

There is no con­sen­sus on op­ti­mal staffing lev­els. Medi­care has re­buffed re­quests to set spe­cific min­i­mums, declar­ing in 2016 that it pre­ferred that fa­cil­i­ties “make thought­ful, in­formed staffing plans” based on the needs of res­i­dents.

Still, since 2014, health in­spec­tors have cited one of every eight nurs­ing homes for hav­ing too few nurses, fed­eral records show.


Stan Hugo vis­its with his wife, Donna Hugo, who has Alzheimer’s, at the Beechtree Cen­ter for Re­ha­bil­i­ta­tion & Nurs­ing in Ithaca, N.Y., April 22. In 2017, Hugo and a hand­ful of other res­i­dents and fam­ily mem­bers be­came so dis­sat­is­fied that they formed a coun­cil to scru­ti­nize the home’s op­er­a­tion.

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