Report on Nursing Home Staffing Levels

Research conducted based on staffing reports that Illinois nursing homes have submitted to the Center for Medicaid and Medicare Services (www.cms.gov)

I. KEY FINDINGS – Nursing Homes Remain Understaffed:

More than 18 months after Illinois ushered in a landmark law intended to protect the health and safety of Illinois’ nursing home residents, many still live in facilities that continue to circumvent legal-required staffing levels, according to data the homes have reported to federal regulators.  The data, which nursing homes must disclose to the federal Centers for Medicare and Medicaid Services (CMS), reflects a widespread population at risk.  The analysis shows that:

• More than one in three Chicago nursing home residents (35 percent) live in a facility where staffing levels do not adhere to much-heralded state standards.  Statewide, 16 percent of all Illinois nursing home residents are consigned to the same precarious conditions, based on conservative estimates from these official records.

• Cumulatively, an estimated 11,000 Illinoisans reside in a nursing home where staffing is below the capacity required by the law.

• These numbers are likely to escalate dramatically once stricter staffing requirements prescribed by the 2010 law become effective in 2013.

• The ramifications of these numbers can be nothing short of life-threatening.  Research shows a range of traumatic outcomes – including deaths, assaults, and infectious health risks – at nursing homes that fail to comply with minimum staffing requirements.

II. UNDERSTAFFING TODAY – Understanding the Numbers:

Data used here comes directly from the staffing information that nursing homes reported to CMS and is contained in the regularly updated “Nursing Home Compare – About Nursing Home Staff” database posted by the agency.

The charts below tally the number and corresponding percentages of nursing homes that fail to meet legally mandated staffing requirements of 2.1 hours of direct care per resident, per day for individuals needing “intermediate care” (see column 1).   If we assume that every resident in every nursing home needs only an intermediate level of care – an assumption that would understate the actual magnitude of care needs in many facilities  – the data supplied to CMS indicates that 19 percent of Chicago area nursing homes residents (column 9), and 9 percent of the statewide nursing home population (column 9) dwell in institutions where the staffing assistance is deficient under Illinois standards.

Moreover, the population of most nursing homes is hardly as homogenous as the calculations above would presume.   In most nursing homes, the resident population compromises a mix of individuals needing intermediate care, as well as a bloc of those requiring more skilled care, for which the legally required staffing minimum is 3.0 hours of direct care per individual, per day. So a more accurate estimate of the number of nursing home residents subjected to below-minimum staffing levels must take into account the diversity of the population.  We’ve factored that variable in our estimates in a manner intended to be as conservative as possible.  Here’s how estimates were reached:

The estimated care needs of the population within each reporting nursing home was measured using Medicaid cost report and nursing component rate data. Estimates are based on the number of residents in each nursing home who are covered by Medicare or Medicaid.   Knowing this figure allows us to ascertain the level of care each Medicare/Medicaid-funded resident needs.  For instance, Medicare subsidizes skilled care need only, for which the staffing requirement is 3.0 hours per resident per day.  Any facility that does not meet that threshold for staffing capacity is leaving its Medicare-paying residents understaffed.  Similarly, we can assess the care needs of the Medicaid-paying population according to the rate Medicaid is covering.   Using these two designations, we estimated the staffing capacity necessary to accommodate the needs of the particular resident community in each nursing home.  Based on that standard, the number and percentages of nursing home residents living in facilities that violate legally required staffing minimums increases substantially (see Column 10).  More than one in three – 35 percent of all Chicago nursing home residents – are in this predicament.  Statewide, the percentage is 16 percent.

Current Conditions

III. FORECAST – The Problem is Destined to Deteriorate Quickly:

As you know, under the watershed 2010 nursing home legislation, the legally required staffing minimums for nursing homes will rise next January to 2.3 hrs/intermediate and 3.4 hrs/skilled.  Using that as the standard, Illinois is flirting with a alarming surge in understaffed facilities that within less than a year, unless the sites undergo a dramatic infusion capacity.  Even assuming, as we did above, that every resident in every nursing home needs only intermediate care (Column 9), 23 percent of them in Chicago will live in an understaffed facility next January unless substantial capacity is added.   Based on conservative estimates  of the care needs of the actual populations within each home (Column 10), half of all Chicago nursing home residents will inhabit an understaffed facility by the end of the year, and a quarter of all statewide residents will be in the same quandary.

Conditions Looming in Less Than a Year

IV. The Human Repercussions:

The following reports, drawn from Illinois Department of Public Health inspection records, chronicle resident injuries, fatalities or other traumatic outcomes that occurred at a sample of nursing homes that are currently understaffed.  These are just a few of the several number of similarly troubling incidents.

1. Abbington Rehab (resident death)

- On July 13, 2011 at Abbington Rehab & Nursing Center in Roselle, a resident known to wander left the facility unnoticed. He was struck and killed by a train. The IDPH investigation of the incident cited the facility for failing to ensure a resident identified as high risk for wandering was provided with adequate supervision. Nursing notes starting two months earlier document the resident’s previous unauthorized departures from the facility, including several to visit a convenience store across the train tracks where he liked to buy cigarettes.

http://www.idph.state.il.us/ltc/docs/SurveyResult/6000020FA08092011.pdf

2. Plaza Nursing (sexual assault of resident by former resident, facility reported below staffing minimum)

- A resident was discharged after making repeated advances, including inappropriate touching and fondling, against another resident, who is suffering from brain damage and is unable to communicate. Staff had been informed of the reason for the resident’s discharge.

- On 8/23/11, the former resident re-entered the building (it was stated that “all of the residents know the [security] code.”) and was found sexually assaulting (engaging in oral sex with) the same resident he had targeted before. The victim was unable to call for help due to her brain damage.

http://www.idph.state.il.us/ltc/docs/SurveyResult/6001077FA08302011.pdf

3. Fairview of Joliet (resident death, failure to provide care)

- On 5/24/11, a CNA assigned to clean and change linens observed that a resident had become unresponsive and was in significant distress. This worker reported the condition to the supervising RN immediately before returning to her duties, but no action was taken by the RN.

- Approximately 90 minutes later, the CNA returned to find that no action had been taken and the resident was continuing to decline, at which point the CNA demanded immediate emergency action. Two RNs arrived, determined that the resident was not breathing and had died. The RNs declined to conduct CPR because “what was the point… he is already gone and would not be revived.” The RNs instructed the CNA “this (incident) will not leave this room that they did not do CPR. They are not going to know CPR was not done, there will be no autopsy.”

- The CNA reported the incident to the Director of Nursing and the HR Director, both of whom took no action. IDPH investigators later concluded that timely and appropriate intervention could have prevented the death of the resident.

- Also in May 2011, the facility was cited for inadequate staffing. Call lights were left unanswered, including after falls or when incontinent care was needed. No staff was available to break up a physical fight between residents. Residents were forced to retrieve medication from nurse station as no staff was available to distribute medication.

- Therapists assigned to a resident admitted for restorative therapy were constantly called away to perform other duties due to a lack of staff. Thus the resident, who requires a daily walk of 25 feet to recover, had been walked once in four months. The resident described being left with a bedpan because the toilet handrails were unable to support her weight and no staff was available to assist her during the night.

http://www.idph.state.il.us/ltc/docs/SurveyResult/6004766FA07182011.pdf

http://www.idph.state.il.us/ltc/docs/SurveyResult/6004766FA05052011.pdf