What Constitutes Enough Staff for Adequate Care of Residents?

Federal law requires all nursing homes to provide enough staff to adequately care for residents. However, there are no federal standards to guide that requirement, and not having enough staff is a decades’long issue for nursing homes. Basically,except for the minimal standards for staffing required by the federal and state governments, nursing homes carry the responsibility for raising the bar and setting high standards in the quality of care provided by staff.

Unfortunately,more and more nursing homes are understaffed due to the costs involved with having higher levels of RNs, LPNs and LVNs, and CNAs. Cuts in government funding that pays for residents’ care has had a significant impact on the budgets of facilities with high populations of Medicaid residents. Additionally, in an already difficult and high stress environment, many nurses and nurse’s aides are choosing to work in hospitals and other areas of nursing practice. This shortage in trained medical personnel is felt universally; but, it is felt to an even greater extent in facilities that are located in small towns and rural areas where the number of licensed nurses and certified aides is limited.

Although all staff in a facility are valued members of the team, the staff in a nursing home with the greatest impact on residents are the staff who provide direct care for them on a daily basis. They are comprised of

Registered Nurses(RNs),
Licensed Practical Nurses (LPNs) and Licensed Vocational Nurses (LVNs), and
Certified Nursing Assistants (CNAs)

Today, being short-staffed means that the existing staff are forced to pick up the slack, and they are pushed to work faster and for longer periods of time. While overtime pay may be a positive thing financially, being overworked as a regular part of the job produces exhaustion,mistakes, and a reduction in the level of care a patient receives. In the compliance-sensitive atmosphere of the Centers for Medicare & Medicaid Services (CMS), short-staffing has been tagged as a major contributor to reportable incidents of neglect and abuse. According to one special report from the United States Senate, being understaffed has been connected with residents experiencing increases in pressure ulcers, dehydration, and malnutrition-all three of which can be linked to abuse, neglect and increased hospitalization. And, not insignificantly these kinds of things result in citations and potential fines.

Front-line direct caregivers, when given too many residents on their assignments and asked to work too many hours, experience burnout, exhaustion, and are more prone to errors. A recent news item provided a sad example of this when it reported about an elderly nursing home resident who loved and routinely enjoyed a warm Jacuzzi tub bath just prior to going to bed. The news story tells how the aide, who was responsible for caring for this resident, put her in the tub; but then, the aide was called to help with another resident who had fallen; and then, was asked to assist with yet another resident, and on and on. Early the next morning, the aide suddenly remembered the woman in the tub and hurriedly went to check on her. She found the woman, still in the tub-now filled with cold water, and the woman was deceased.

What is the answer? The federal government requires that a facility provide a sufficient number of staff to accomplish the care plans for the residents in its care-a statement that for some is open for interpretation. With this in mind,perhaps it would be a good idea when considering something like improving the problem of adequate staffing, for nursing homes to first make sure that a nursing home is meeting specified federal and state staffing requirements. The Nursing Home Reform Law (1987) requires the following regarding numbers of staff:

1 RN in a consecutive 8-hour period (usually during the day), 7 days a week
1 Licensed nurse (RN, LPN, LVN), 24-hours a day, 7 days a week
1 Director of Nurses (DON) who is an RN (cannot be the RN in facilities with 60 or more beds)
Sufficient nursing staff to meet residents’ needs
CNAs must receive at least 75-hours of training and demonstrate competency to provide care to residents.

Also, it should be noted that states vary in terms of their requirements for nursing home staffing, and facilities need to be aware of their state’s requirements while bearing in mind the federal government’s standards.

Another approach to the problem of staffing given the constraints of a facility’s budget and funds, is to explore things that can make the nursing home a better place to work, and provide greater satisfaction for its residents. Stability in staffing is one of the keys to maintaining adequate staffing and satisfied residents. When nursing homes achieve stable staffing, certified nursing assistants (CNAs), nurses, and administrators work in the nursing home long enough to learn each resident’s needs and preferences. A stable staff allows the nursing home to benefit from experience and knowledge that staff gain overtime, increasing the overall competence and confidence of staff, while building strong bonds between residents and caregivers. Here are some ideas that can help build staff stability-

Allow front-line staff to have in-put about their work environment. Sometimes the best solutions and ideas come from the “bottom-up” rather than from the “top-down.”
One large nursing home conglomerate approached the staffing issue by having their corporate management personnel become CNAs and work for a period of time in that capacity. It totally transformed management’s thinking about what was involved in providing care from a staffing perspective.
Provide consistent staff assignments – Residents are more comfortable with caregivers they know. So, when the same staff member consistently serves a resident, they learn the resident’s needs and preferences, and this creates a mutual bond between the resident and the caregiver.
Reward staff for excellence in providing care. Provide opportunities for career development through training and education.

Here is a site that might be found useful: https://www.nhqualitycampaign.org. It is the National Nursing Home Quality Campaign site. Here is the stated purpose and overview from the website:

The National Nursing Home Quality Improvement (NNHQI) Campaign exists to provide long term care providers, consumers and their advocates, and quality improvement professionals with free, easy access to evidence-based and model-practice resources to support continuous quality improvement. The Campaign promotes focus on individuals’preferences, staff empowerment, and involving all staff, consumers, and leadership in creating a culture of continuous quality improvement.

This site provides a new Enhanced Staffing Stability Tool that allows each facility to track its own turnover and retention rates,enables the printing of graphs, and helps calculate the cost of recruitment and replacement efforts. It includes an in-tool dashboard for managing the components of onboarding and terminations, and it is free of charge. In addition, there are more than a dozen other useful tools to enhance quality of care for residents and quality of work life for staff.