The Importance of Staffing

What is staffing?

Staffing is the ratio of care providers to residents. If I told you there was one teacher in a classroom and asked if the children were getting a good education, you would ask, among other things, how many students are there, right?

The staffing ratio is measured per patient day, midnight to midnight. Why? Because more staff is needed during the day shift, when there are multiple meals, various therapies, assisted trips to the bathroom, baths, numerous medication passes, diaper changes, etc. During the night shift, most residents are sleeping.

Let me give you an example. If there are 10 residents in a facility and during a 24-hour period there are 5 staff members who work hour shifts and provide direct care to those residents, then there is a total of 40 hours of care provided. The ratio is expressed as hours per patient day (PPD), so in my example you would divide 40 (the hours of care provided) by 10 (the number of residents) and arrive at PPD staffing ratio of 4.0. This means, in theory, in a 24-hour period each resident should get 4.0 hours of staff time and attention.

Why is staffing important? Numerous studies have proven that staffing is the single most important predictor of patient outcome in a nursing home. Even more important than diagnosis. Consider that for a moment! This means a sick person in a properly staffed nursing home has a better chance for a positive outcome than a well person in an understaffed nursing home. Having done nursing home litigation for the last thirteen years, I can tell you this is absolutely true.

95% of the Elder Abuse cases I file involve understaffing. Staffing is the single largest item on the operating budget of every nursing home. The corporation that runs the nursing home wants to maximize profits, so they start by cutting one nurse, then a Certified Nursing Assistant (CNA), then more staff, and before long the question is simply this: what is the fewest number of people we can possibly employ in this place? This is why most nursing homes have employee turnover of 80% to 90% per year. It is demoralizing to work in a place where, no matter how hard you try, you can’t get all the work done. And they aren’t making crates, they’re (supposed to be) taking care of people.

The standard of care in California is a minimum PPD of 4.1. Unfortunately, because of the incredibly powerful nursing home lobby in Sacramento, the “legal minimum” right now in California is 3.2. This means the State of California will only enforce 3.2; it’s up to us to enforce 4.1. When the 3.2 bill was passed several years ago, it was supposed to go up by .1 per year, but we are still waiting.

What is Elder Abuse?

Elder Abuse can come in many forms. I specialize in litigation against long term care facilities such as Skilled Nursing Facilities, Residential Care Facilities for the Elderly (RCFE), Assisted Living Facilities and Intermediate Care Facilities.

California law defines elder abuse as "physical abuse, neglect, financial abuse, abandonment, isolation, abduction or other treatment with resulting in physical harm or pain or mental suffering, or the deprivation by a care custodian of goods or services that are necessary to avoid physical harm or mental suffering." (Welfare & Institutions Code, Section 15610.07 and in Penal Code 368) "Elders" are defined as persons 65 years of age or older.

Neglect is further defined as: "The failure to exercise that degree of care that a reasonable person in a care providing capacity would exercise such as failure to assist in personal hygiene, provision of food, clothing or shelter, provision of medical care, or to protect from health and safety hazards or to prevent malnutrition or dehydration."

There are certain fact patterns that commonly arise in Elder Abuse litigation, such as the development of bedsores in a Skilled Nursing Facility and the failure to transfer to a higher level of care in an RCFE.

My office provides free consultations, and this includes consultations with other lawyers who have questions about this highly specialized type of litigation.

Medicare's Rating System For Nursing Homes

Over a year ago, the Centers for Medicare and Medicaid Services (CMS) implemented their new "five star rating system" as a way to assist consumers in compare nursing homes and identify the strong and weak points of each facility. (www.medicare.gov/NHCompare)

The Nursing Home Compare Website features a rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are supposed to have above average quality and nursing homes with 1 star are supposed to have quality “below average”. There is one overall rating for each nursing home, and a separate rating for each of the following:

. Health Inspections – This rating uses information from the last 3 years of onsite inspections, including both standard surveys and any complaint surveys. Onsite visits help to determine the extent each facility meets Medicare's minimum quality requirements. More recent survey findings are weighted more heavily than those in prior years.

. Staffing – The staffing rating has information about the number of hours of care on average provided to each resident each day by nursing staff. This rating does take into consideration the level of need of residents ("Acuity"). For example, a mix of patients requiring a higher level of care means that nursing home should have more staff per patient, compared to another facility where the level of patient care based on need is not as high.

. Quality Measures – The quality measure rating has information on 10 different physical and clinical measures for nursing home residents - for example, the prevalence of pressure sores or changes to resident's mobility (ability to move about), or percent of residents with moderate to severe pain. This information is collected by the nursing home for all residents. The quality measures offer the consumer information about how well, in general, a nursing home is caring for its residents' physical and clinical needs.

Although the rating system is one way for consumers to get an idea of how nursing homes measure up, no rating system can address all of a family’s considerations that go into a decision about which nursing home may be best for their loved one. There is no substitute for making your own visit to a nursing home, talking with administration and staff, and making sure your loved one will be comfortable there. Remember also, the nursing home rating system cannot take into account factors like whether the nursing home is close to family so visits to their loved one can be more frequent, compared to a facility further away.

The rating system should be used as a tool, and keep in mind it is a "lagging indicator". You are viewing a measure of the nursing home over the last couple years, and when employee turnover ranges at close to 100% at the majority of nursing homes, quality can change quickly.