Articles Posted in Understaffing

A new edition of the Long Term Care Community Coalition Elder Justice Newsletter asks a simple question: does providing a nursing home resident breakfast in their soiled bed constitute harm? How about failing to provide a stop date for a resident’s psychotropic medication?

“No Harm” deficiencies refer to citations of rule violations at nursing homes in which health inspectors determined that the violations caused “no harm” to residents. As the LTCCC notes, data provided by the Centers for Medicare & Medicaid Service, which mandate minimum standards of care for nursing homes participating in their programs, show that more than 95% of nursing home health citations describe “no harm” deficiencies. The LTCCC argues, however, that these no harm citations reflect systemic failures to recognize the suffering of nursing home residents, which in turn results in systemic failures to hold nursing homes accountable through financial penalties. “In the absence of a financial penalty,” the newsletter states, “nursing homes may have little incentive to correct the underlying causes of resident abuse, neglect, and other forms of harm.”

The newsletter proceeds to provide instances of health violations in which regulators determined that no harm was done to the resident in question. For example:

New York Senator Kirsten Gillibrand proposed a new federal law aimed at improving staff levels at nursing homes across the country. According to Sen. Gillibrand, the impetus for the new legislation on nursing homes comes from a bipartisan report released this summer, which detailed widespread problems at nursing homes across the state and country. Speaking to reporters, the New York Senator said, “Unfortunately, a report came out on nursing homes and long-term care facilities that have had problems, and 17 are located in New York State.” 

Sen. Gillibrand is referring to the 488 nursing home facilities across the country which the report found a “persistent record of poor care.” Currently, the federal government only applies extra scrutiny on 88 so-called “special focus facilities” across the country. This leaves 400 nursing homes with records of abuse and neglect without sufficient oversight.

According to Sen. Gillibrand, insufficient and incompetent staffing is one of the root causes of the poor performance and conditions at these nursing homes. The bill she proposed in the Senate last month aims to fix that problem. The bill, which has bipartisan backing and is sponsored by Colorado Republican Cory Gardner, would expand access to Medicare and Medicaid data to “nursing homes, home health agencies, and hospice programs,” reports The Buffalo News. The bill, called Promote Responsible Oversight and Targeted Employee Background Check Transparency for Seniors (PROTECTS) Act, would improve the standard of living at nursing homes by “bringing more transparency to workforce quality,” says Sen. Gillibrand. 

A new study in the Journal of the American Geriatrics Society concludes that nursing homes with low staffing levels, low quality scores, and high concentrations of disadvantaged residents also experience “higher rates of confirmed COVID-19 cases and deaths.”

The study’s lead author, Yue Li, a professor at the University of Rochester Medical Center Department of Public Health Sciences, said in a statement: “In nursing homes, quality and staffing are important factors, and there already exists system-wide disparities in which facilities with lower resources and higher concentrations of socio-economically disadvantaged residents have poorer health outcomes… These same institutional disparities are now playing out during the coronavirus pandemic.”

The study notes that long-term care facility residents are demonstrably vulnerable to respiratory diseases like influenza and coronaviruses, and that research suggests COVID-19 “disproportionately impacts older adults and individuals with chronic health conditions.” This makes nursing homes, which have high concentrations of elderly adults with chronic health conditions, especially vulnerable to COVID-19. Since the pandemic reached the United States, roughly 50,000 deaths related to the novel coronavirus “have been linked to nursing homes,” according to the study.

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A new report by the Washington Post suggests that “thousands of nursing homes” across the United States were ill prepared for the novel coronavirus pandemic. Federal guidance as well as advice from researchers and medical experts encouraged a policy of treating patients in place, the article notes, believing that hospitals “are not friendly environments for the frail and elderly.” But, the Post suggests, nursing homes “neglected” the fact that treating patients in place “requires having effective means of treatment, staff who know how to deploy that treatment and procedures to stop the spread of infection.” The result was that even though nursing homes “did not swamp hospitals” with coronavirus patients, they also did not prevent “the deaths of more than 30,000 of their residents, or, in many cases, even provide decent palliative care.”

The Post discusses one nursing home in upstate New York, Absolut Care Care of Aurora Park in East Aurora. Public records indicated that 153 residents at the nursing home were infected, with 61 deaths by May 31, 2020. This figure “includes deaths on site and among those taken to hospitals,” the Post says, and is disputed by the facility’s owners, though they “did not provide their own tally.” A nurse who quit working at the facility in early May told the Post that “Once it was there it just spread like wildfire… It was very hectic, chaotic.”

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Federal data suggests that most nursing facilities “failed to maintain sufficient staffing to meet every resident’s needs” in the months leading up to the coronavirus pandemic, according to a new release by the Long Term Community Care Coalition.

The LTCCC has packaged that federal data regarding staffing figures for every nursing home in the United States in a “user-friendly” form, allowing members of the public, journalists, and policymakers to “identify and assess” nursing homes that are and are not meeting their residents’ essential staffing needs. The files for Q4 2019 are available on its website. Users can use the data to learn about staffing levels for nursing staff as well as activities staff and administrators; they can also use it to evaluate how much a given nursing home facility relies on contract workers to care for its residents.

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Cobble Hill Health Center in Brooklyn, New York suffered one of the highest COVID-19 death tolls in New York, according to recent news reports. An April 20, 2020 article by the Associated Press states that the facility listed 55 deaths by that date, “among the most of any such facility in the country.” The AP report states further that of 8,003 nursing home deaths it counted across the United States, one-third took place in New York.

In an interview with the AP, Cobble Hill Health Center’s Chief Executive Officer, Danny Tuchman, said that “he believes many other homes have more deaths than Cobble Hill but his has been singled out for its honesty.” He noted that a state survey of nursing home deaths did not require nursing homes to comply, and that he included “possible” COVID-19 fatalities in his response, emphasizing that Cobble Hill Health Center did not have testing kits and as such could not test any of its residents for the coronavirus. Tuchman told the AP that he did not know how the coronavirus entered the facility, acknowledging that it may have been carried by a paramedic or other staffer who was not symptomatic.

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Corporate nursing homes may provide lower quality care to its residents and low salaries for its meager staff but they appear to be doing well when it comes to turning a profit. According to ABC News, some for-profit nursing homes are in violation of the Fair Labors Standards Act for the horrific and exploitative way they treat their staff. An undercover investigation found “rampant wage theft” with nursing home staff working for $2 to $3.50 an hour – less than half the federal minimum wage, which is set at an anemic $7.25 per hour. These nursing home chains tend to hire immigrants, knowing they will be afraid of dealing with law enforcement.

The undercover investigation found that these workers usually awake before dawn to “cook meals, shower residents and scrub toilets.” These for-profit nursing homes who are engaging in behavior that could constitute human trafficking typically only hire staffers who will live at the facility. This means the early mornings lead to nights “deprived of sufficient sleep” as they respond to nursing home residents, change diapers, dispense medication, and deal with unruly patients. The nursing home then charges the staff a fee of $25 each day for “lodging” which leaves workers feeling “desperate and trapped.” The national news publication says nursing home workers are rarely allowed a day off and must pay for their substitute when offered this basic human right.

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Hopkins Center for Rehabilitation and Healthcare received 23 citations for violations of public health code between 2016 and 2019, according to New York State Department of Health records accessed on January 21, 2020. The facility has also been the subject of a 2015 fine of $10,000 in connection to findings it violated health code provisions regarding residents’ right to formulate advance directives; and a 2012 fine of $4,000 in connection to findings it violated health code provisions regarding accidents and administration. The Brooklyn nursing home’s citations resulted from a total of three surveys by state inspectors. The deficiencies they describe include the following:

1. The nursing home did not implement adequate measures to prevent and control infection. Section 483.80 of the Federal Code states that nursing homes must “establish and maintain an infection prevention and control program” that provides residents a “safe, sanitary and comfortable environment.” An August 2019 citation found that the nursing home did not ensure the maintenance of infection control practices, specifically finding that residents’ oxygen tubing made contact with the floor “on multiple occasions”; that a Certified Nursing Assistant entered the room of a resident on contact precautions “without wearing a gown and gloves”; and a Registered Nurse touched a resident’s head and bedding while wearing gloves, then connected a feeding tube without conducting hand hygiene or putting on clean gloves. The citation described these deficiencies as having the “potential to cause more than minimal harm.”

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A recent report published by Harvard University shows much lower staff levels at nursing homes across the country than previously reported. The author of the study, Fangli Geng, says that a recent change in how nursing homes report their staffing levels shows that up to 70 percent of nursing homes had previously overreported the number of staff between April 2017 and March 2018. The faulty reporting was almost exclusively confined to weekends, especially when counting registered nurses or RNs.

The author of the study point to the more accurate form of reporting currently used by the government. Previously, the number of nurses on staff at a nursing home would be calculated by using the payroll data in the month immediately preceding a health inspection visit. Because nursing home inspections usually occurred around the same time each year, nursing homes apparently increased their staff levels around this time. As part of the Affordable Care Act, nursing homes were required to transmit all payroll data to the federal government – providing a more accurate and complete understanding of nursing staff levels. 

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Queens Boulevard Extended Care received 16 citations for violations of public health laws between 2015 and 2019, according to New York State Department of Health records accessed on December 19, 2019. The Woodside nursing home’s citations resulted from a total of three inspections by state authorities. The deficiencies they describe include the following:

1. The nursing home did not provide adequate treatment and services to promote the prevention and healing of pressure ulcers and bedsores. Section 483.25(c) of the Federal Code stipulates that nursing home facilities must provide treatment and services to promote the healing of pressure injuries / ulcers, and to ensure that residents admitted without pressure ulcers do not develop them unless medically unavoidable. An August 2019 citation found that Queens Boulevard Extended Care did not provide a resident with a level of treatment and services consistent with professional standards to promote the healing of their ulcers. An inspector specifically found that the facility did not implement the use of pressure relieving devices for a resident who had bilateral heel wounds. The inspector observed a Registered Nurse performing wound care treatment to both of the resident’s feet, but without putting pressure relieving devices in place after completing the wound care. A review of care records did not find any “documented evidence for the application of the use of heel protectors while in bed,” although facility policy provided for the use of pressure relief assistive devices in instances when pressure relief was warranted.

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