How to Report an Understaffed Nursing Home

As a family caregiver, deciding to place a loved one in a nursing home can be a tough decision. You may want to keep them close, but sometimes their care needs are much more than you can offer. While the promise of professional care and comfort is reassuring, an underlying concern plagues many facilities: understaffing. The consequences of understaffing can range from minor inconveniences to severe neglect, potentially compromising the well-being of residents and the institution's reputation.

Why are nursing homes understaffed?

Nursing homes face understaffing issues due to a combination of systemic, economic, and operational challenges:

• Funding and financial constraints: Many nursing homes operate with tight budgets, particularly those relying heavily on Medicaid reimbursements, which may not fully cover the cost of care. This financial strain can limit the facility's ability to hire and retain sufficient staff.
• Workforce shortages: The healthcare sector, especially long-term care, experiences chronic shortages of qualified staff, including nurses and nursing assistants. Factors contributing to this shortage include an aging population requiring more care, insufficient numbers of new graduates from nursing programs, and high turnover rates due to stressful working conditions.
• Low wages and benefits: Positions in nursing homes often offer lower wages and fewer benefits compared to similar roles in hospitals or private healthcare settings. This can make attracting and retaining skilled staff difficult, leading to vacancies and increased workloads for existing employees.
• High turnover rates: The demanding nature of the work, coupled with low job satisfaction and burnout, leads to high turnover rates among nursing home staff. This creates a cycle of constant recruitment and training, detracting from the continuity and quality of resident care.
• Regulatory and administrative burdens: Nursing homes face numerous regulatory requirements that can divert resources from direct care. Administrative tasks and compliance efforts can overwhelm existing staff, exacerbating understaffing issues.
• Pandemic impact: The COVID-19 pandemic has intensified staffing challenges in nursing homes, with increased demand for healthcare workers across all settings and heightened risks for staff and residents in these facilities. Concerns about exposure and illness have led to staff shortages due to sickness, quarantine, or fear of working in high-risk environments.
• Inadequate staffing models: Some nursing homes may need to adjust staffing levels appropriately based on the acuity of resident needs, which can overwhelm staff and prevent them from providing adequate care to all residents.
• Recruitment and retention challenges: Attracting and keeping new staff is an ongoing challenge. The competitive healthcare job market and the physically and emotionally demanding nature of nursing home care can deter potential employees.

These factors collectively contribute to the understaffing crisis in nursing homes, impacting the quality of care provided to residents and highlighting the need for comprehensive strategies to address workforce challenges in the long-term care sector.

CMS's New Staffing Rules

The Centers for Medicare & Medicaid Services (CMS) has established new minimum staffing standards for long-term care facilities in response to the ongoing understaffing crisis. These new rules mandate specific staffing levels to ensure residents receive adequate care. According to CMS, the new staffing standards require:

• A registered nurse (RN) must be on duty 24 hours a day, seven days a week.
• A minimum of 0.55 hours of RN time per resident per day.
• A minimum of 2.45 hours of nursing assistant time per resident per day.

These standards aim to improve the quality of care in nursing homes by ensuring enough qualified staff members meet residents' needs. Facilities failing to meet these requirements may face penalties, including fines and other enforcement actions.

Impacts of understaffing on nursing home residents

Understaffing in nursing homes can have profound and multifaceted impacts on residents, affecting their physical health, emotional well-being, and overall quality of life:

• Decreased quality of care: With fewer staff members to attend to residents, the quality of care can significantly diminish. Essential tasks may be rushed or overlooked, leading to inadequate attention to residents' needs.
• Increased risk of neglect and abuse: Understaffing can lead to neglect, where basic needs such as hygiene, nutrition, and hydration are not adequately met. In extreme cases, it can also increase the risk of abuse, as overburdened staff may become impatient or neglectful.
• Health complications: The lack of adequate care and supervision can lead to various health complications for residents, including bedsores (pressure ulcers), infections, malnutrition, dehydration, and unmanaged chronic conditions. These issues can arise from insufficient assistance with mobility, inadequate wound care, or failure to administer medication properly.
• Psychological effects: Residents may experience increased feelings of loneliness, isolation, and depression due to the lack of social interaction and engagement when staff do not have enough time to provide companionship, stimulation, or respond to emotional needs.
• Increased hospitalizations: Poor care quality and the resultant health complications can lead to more frequent hospital admissions for conditions that could have been prevented with proper care and supervision.
• Decreased safety: Understaffing can compromise resident safety, leading to a higher incidence of falls, medication administration errors, and other accidents. Without sufficient supervision, residents with mobility or cognitive impairments are particularly at risk.
• Lowered resident satisfaction: The cumulative effect of these issues can lead to decreased satisfaction with the living environment among residents, impacting their sense of dignity and quality of life.
• Family stress and anxiety: Families of nursing home residents may experience increased stress and anxiety about the level of care their loved ones are receiving, especially if they observe signs of neglect or deterioration in the resident's condition.

Addressing understaffing in nursing homes is critical to ensuring that residents receive the care, respect, and dignity they deserve. It requires concerted efforts from policymakers, industry leaders, and communities to invest in workforce development, improve working conditions, and enforce standards that protect the well-being of some of society's most vulnerable members.

Navigating the legal and ethical landscape

To safeguard the well-being of nursing home residents, family caregivers, and advocates must thoroughly understand the legal standards and ethical principles governing nursing home operations. This knowledge is a powerful tool in ensuring facilities fulfill their obligations to provide high-quality care.

Understanding legal requirements

Nursing homes are regulated by federal and state laws that outline the standards for resident care, including staffing levels. For instance, the Federal Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, sets national minimum standards for nursing homes receiving Medicare and Medicaid funding. These standards include requirements for staffing that are sufficient to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

At the state level, laws may impose more stringent staffing requirements. These regulations often specify the minimum number of nursing staff per resident, considering the varying levels of care residents may require. By familiarizing yourself with these laws, you can assess whether a nursing home is potentially understaffed according to legal benchmarks.

Ethical considerations

Beyond legal compliance, addressing understaffing issues also touches on the ethical obligation to provide dignified and compassionate care to older adults. The principle of beneficence—acting in the best interest of the residents—demands that nursing homes maintain staffing levels that enable attentive, personalized care. Additionally, the principle of justice underscores the right of all nursing home residents to receive equitable care, regardless of their socioeconomic status or the level of care they require.

Taking action: A guide to reporting understaffing

Armed with knowledge of relevant laws and ethical standards, family caregivers can become effective advocates for their loved ones. Here are some steps to consider if you suspect a nursing home is understaffed:

• Document observations: Keep detailed records of instances where inadequate staffing affects the quality of care, including dates, times, and descriptions of specific incidents.
• Engage with facility management: Initially, bring your concerns to the nursing home's administration. A constructive dialogue can sometimes resolve issues without the need for further action.
• Know your reporting channels: If concerns are not adequately addressed, be prepared to escalate the matter. Every state has an agency responsible for licensing and regulating nursing homes, often accessible through the Department of Health or a similar entity. Additionally, the Long-Term Care Ombudsman Program provides an advocacy service for residents of nursing homes and their families.
• Legal action: In cases where understaffing results in harm or significant risk to residents, consulting with a legal professional specializing in elder law may be advisable to explore options for legal recourse. You can file a complaint anonymously if you're worried about retaliation. Confirming your loved one receives the best care possible by providing detailed and accurate information.

What happens after the report?

After a report of understaffing in a nursing home is made, it triggers a review by the appropriate regulatory agency, such as the Department of Health. This agency evaluates the complaint to determine if an investigation is needed. If so, inspectors visit the facility to examine staffing records, interview staff and residents, and observe care practices to verify compliance with legal staffing requirements.

If the investigation confirms understaffing, the nursing home may face penalties ranging from fines to more severe actions like license revocation, depending on the severity of the issue. The facility is then required to rectify the problem, potentially by hiring more staff or altering policies to ensure adequate resident care. Throughout this process, the complainant may receive updates about the investigation's status and outcomes, promoting accountability and improved care standards within the nursing home.

The impact of advocacy

Reporting understaffing is not merely a legal obligation—it's a moral imperative. By advocating for adequate staffing, you are contributing to a more significant effort to uphold the dignity and rights of nursing home residents. Your actions can ripple effect, encouraging improvements for your loved ones and current and future residents who deserve a standard of care that respects their humanity and individual needs.

Protecting yourself and your loved one

Whistleblowers have rights. Federal and state laws protect you from retaliation by the nursing home. Legal resources can assist you if you experience any adverse consequences due to your complaint. Any nursing home that retaliates against you or your care recipient is breaking the law.

Finding support and resources

Don't go it alone. Find helpful communities and online caregiver support to help you through this process. Organizations offer guidance and support for families navigating nursing home concerns. Joining support groups with other families facing similar situations provides invaluable emotional and practical resources.

A call to action

Understaffing in nursing homes is a silent threat to the well-being of our most vulnerable. By understanding the issue, recognizing its signs, and taking action through reporting, caregivers become guardians of safety and dignity. Remember, a single voice has the power to spark change. Make it heard. Speak up, report understaffing, and safeguard the precious right to quality care.

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• What Are Nursing Home Diversion Programs?
• When To Move From Assisted Living To Nursing Home