In some Virginia nursing homes, residents see a nurse for about nine minutes every day.
If they don’t see a staff member often enough, they could develop pressure sores because they weren’t turned over in bed. Or they might not get the right medication or help with food and hydration.
“So many of our individuals in nursing facilities are compromised to the point that they cannot eat on their own and they can’t have someone sit with them,” because of the staffing shortage, said Joani Latimer, Virginia’s long-term care ombudsman in the Department for Aging and Rehabilitative Services. “That’s not a one-minute task.”
Latimer’s job is to advocate for those living in Virginia’s long-term care facilities, and she said about 50 percent of the complaints her office receives have to do with inadequate staffing.
Virginia has the 11th highest number of nursing homes with a below-average staffing rating in the country, according to new federal data analyzed by Kaiser Health News.
And in July the Centers for Medicare and Medicaid Services downgraded 19 of Virginia’s nursing homes to 1 out of 5 stars on its staffing rating system, either because the new data revealed they had too few registered nurses or they did not provide the required information.
The federal government previously relied on the nursing homes’ own claims of how many hours a day their staff members worked to develop the star rating system, allowing the homes to misrepresent the numbers. Now, it uses payroll records to paint a more accurate picture.
For some long-term care advocates, the new data is not surprising. Latimer has seen problems with staffing for years at nursing homes across the state. And Lauren Ellerman, a lawyer with Frith Ellerman & Davis Law Firm in Roanoke who focuses on nursing home abuse and neglect, said she often talks to families who report poor staffing.
“It should surprise nobody who deals with nursing homes that nursing homes are understaffed,” she said.
Federal law requires nursing homes have a registered nurse on staff at least eight hours a day, including on weekends. But there aren’t any requirements for a specific staff-to-resident ratio.
Nor does Virginia have such a requirement. Its rules state only that the facility should have nurses and nurse aides “in sufficient number to meet the assessed nursing care needs of all residents.”
Typically, a registered nurse in Virginia will spend 37 minutes with a resident, according to the Centers for Medicare and Medicaid Services. That’s three minutes less than the national average of 40 minutes. Meanwhile, nurse aides spend about two hours and nine minutes with residents in Virginia, compared to the national average of two hours and 18 minutes.
A spokeswoman for the Virginia Health Care Association, which represents the state’s nursing homes and assisted living facilities, said in an emailed statement that “adequate staffing is only one of several important elements of providing quality care.”
“Our members have always supported adequate staffing as a key element of quality care. However, judging the quality of a nursing home based solely on staffing is misguided. There are centers with high staffing levels and poor outcomes and numerous deficiencies and there are centers with low staffing with good inspection reports and good quality outcomes.”
Jenny Inker, a professor in Virginia Commonwealth University’s Department of Gerontology, said drawing strong conclusions from the amount of time a nurse spends with a resident might be misguided because nurses can delegate tasks to other staff members who are still able to meet the resident’s physical, psychological and social needs.
“All providers should know how much care is required by each resident and what that totals up to,” she said. “If you have sufficient staff to meet that, the bottom line is you’re meeting people’s needs.”
But Latimer, the state ombudsman, said she is most concerned by the lack of time residents have with registered nurses, which are the highest trained professionals required at a nursing home.
“That professional judgment is really critical, and if you have a combination of not having adequate presence on that level and then having aides that are too rushed to even observe changes, that’s a huge deal,” she said.
Melissa Andrews, president and CEO of LeadingAge Virginia, an association of nonprofit nursing homes and senior services organizations, said nonprofit nursing homes typically have better staffing rates than their for-profit counterparts. But all nursing homes have trouble recruiting staff.
“There’s a general labor market crisis in the health care sector,” she said. “With this growing demographic of older adults, there simply aren’t enough people to do the work we need to do.”
Not only are the facilities competing for registered nurses against others in the health market, they’re also fighting with fast food restaurants and big box stores for their nursing aides, Andrews said.
Latimer said retention is every bit as difficult for nursing homes as recruitment. Burnout is all too common in these roles. That might be in part because there aren’t enough staff to care for the patients, putting more of a burden on those who are there. And workers don’t often feel respected or compensated appropriately, Latimer said.
“I can personally recall conversations with nursing staff … that describe the difficulty and tragedy of wanting to do this work and not being equipped to do it,” she said. “And just leaving at the end of that day with their residents’ needs unmet, and it’s just a difficult thing.”
Ellerman, the Roanoke lawyer, thinks adding a staffing ratio to Virginia’s rules would go a long way toward fixing the problem. She said right now, nursing homes aren’t required to consider staffing ratios in deciding how many residents they can accommodate. Rather they determine how many new residents they can accept based the number of beds available.
“It’d be like a restaurant saying you can go sit in that section over there, but we don’t have a waitress who will serve you,” she said. “That’s the model that for-profit nursing homes are operating on.”
A staffing ratio would require facilities to have a certain number of staff based on their number of beds.
Latimer said she sees the benefit of a ratio, particularly because both federal and state rules are so vague they make it difficult for regulators to ensure a facility has adequate staff.
But she thinks improving the culture for the staff might be the better, if more difficult, route to take, particularly for increasing retention.
“You really need to create an environment that’s a good place for people to work and that’s a combination of feeling respected for the really valuable work they do, and being reasonably compensated for that — just being supported in how important their role is to the quality of life and quality of care of the resident,” she said. “And I do think that tends to get lost.”
Visualization courtesy of Kaiser Health News.