‘It’s Almost Like a Ghost Town.’ Most Nursing Homes
Overstated Staffing for Years
Stan Hugo with his wife, Donna, who is a resident at the
Beechtree Center for Rehabilitation and Nursing in Ithaca, N.Y. Mr. Hugo tracks
staffing levels at the skilled nursing facility.CreditHeather Ainsworth for The
New York Times
By Jordan Rau
July 7, 2018
ITHACA, N.Y. — 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.
How Staffing Fluctuates at Nursing Homes Around the United
States
The number of workers at more than 14,000 nursing homes
across the nation varies drastically.
July 7, 2018
“Volatility means there are gaps in care,” said David
Stevenson, an associate professor of health policy at Vanderbilt University
School of Medicine in Nashville, Tenn. “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.
Jay Vandemark, who entered Beechtree after he suffered a
stroke that immobilized his left side, complained that the center didn’t have
enough workers on some shifts. “It’s almost like a ghost town,” he
said.CreditHeather Ainsworth for The New York Times
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 for-profit 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.
Mr. 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.
New rating method is still flawed
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 measure different time periods
and have different criteria for how to record hours that nurses worked. The
nursing home industry also objected, with Mr. 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.
With nurse assistants earning an average of just $13.23 an
hour in 2017, nursing homes compete for workers not just with better paying
employers like hospitals, but also with retailers. Understaffing leads
predictably to higher turnover.
Payroll records at Beechtree show that on its highest
staffed days, it had one aide for every eight residents, but there was only one
aide for 18 residents at the lowest staffing level.CreditHeather Ainsworth for
The New York Times
“They get burned out and they quit,” said Adam Chandler,
whose mother lived at Beachtree until her death earlier this year. “It’s been
constant turmoil, and it never ends.”
Medicare’s payroll records for the nursing homes showed that
there were, on average, 11 percent fewer nurses providing direct care on
weekends and 8 percent fewer aides. Staffing levels fluctuated substantially
during the week as well, when an aide at a typical home might have to care for
as few as nine residents or as many as 14.
A family council forms
Beechtree actually gets its best Medicare rating in the
category of staffing, with four stars. (Its inspection citations and the
frequency of declines in residents’ health dragged its overall star rating down
to two of five.)
To Stan Hugo, a retired math teacher whose wife, Donna, 80,
lives at Beechtree, staffing levels have long seemed inadequate. In 2017, he
and a handful of other residents and family members became so dissatisfied that
they formed a council to scrutinize the home’s operation. Medicare requires nursing
home administrators to listen to such councils’ grievances and recommendations.
Sandy Ferreira, who makes health care decisions for Effie
Hamilton, a blind resident, said Ms. Hamilton broke her arm falling out of bed
and has been hospitalized for dehydration and septic shock.
“Almost every problem we’ve had on the floor is one that
could have been alleviated with enough and well-trained staff,” Mrs. Ferreira
said.
Beechtree declined to discuss individual residents, but said
it had investigated these complaints and did not find inadequate staffing on
those days. Mr. Camerota also said that Medicare does not count assistants it
hires to handle the simplest duties like making beds.
In recent months, Mr. Camerota said, Beechtree “has made
major strides in listening to and addressing concerns related to staffing at
the facility.”
Mr. Hugo agreed that Beechtree has increased daytime
staffing during the week under the prodding of his council. On nights and
weekends, he said, it still remained too low.
His wife has Alzheimer’s, uses a wheelchair and no longer
talks. She enjoys music, and Mr. Hugo placed earphones on her head so she could
listen to her favorite singers as he spoon-fed her lunch in the dining room on
a recent Sunday.
As he does each day he visits, he counted each nursing
assistant he saw tending residents, took a photograph of the official staffing
log in the lobby and compared it to what he had observed. While he fed his
wife, he noted two aides for the 40 residents on the floor — half what Medicare
says is average at Beechtree.
“Weekends are terrible,” he said. While he’s regularly there
overseeing his wife’s care, he wondered: “What about all these other residents?
They don’t have people who come in.”
This article was produced in collaboration with Kaiser
Health News, an editorially independent program of the Kaiser Family
Foundation. The author is a reporter for Kaiser Health News.
