Low Staffing, High Turnover Blamed for Poor Nursing Home Care

June 8, 2004
A recent survey finds that more than one-third of California's freestanding nursing homes do not meet the state's minimum nurse staffing standards (3.2 hours or more per resident. The finding is one of several in a "snapshot" report prepared by the California HealthCare Foundation (CHCF).

The low staffing levels contributed to more than two-thirds of the staff in California's nursing homes leaving their jobs in 2002. Low staffing and high turnover rates were important contributing factors to poor quality care and a 38 percent increase in complaints between 2000 and 2002.

The CHCF report found that the most common clinical measures of poor quality -- weight loss, time spent in bed, and use of physical restraints -- continued to be serious problems in 2002.

"Low staffing led to 78 percent of nursing homes not complying with federal care and safety regulations during mandatory inspections," said the report's author, Charlene Harrington, Ph.D., School of Nursing, University of California, San Francisco. "An additional 11 percent of the nursing facilities were cited for very serious quality of care problems."

State monitoring by the Department of Health Services resulted in 43 percent of nursing homes receiving deficiencies (warnings for minor problems) and 26 percent receiving citations, which include fines and are indications of more serious violations.

Other findings in the report include:

• The number of facilities with inadequate staffing (according to state requirements) decreased from 46 to 37 percent between 2001 and 2002;
• 93 percent of nursing homes did not meet staffing ratio guidelines of 4.1 hours per resident, per day, recommended in a report to the Centers for Medicare and Medicaid Services; Annual nursing staff turnover rates ranged from 5 to 304 percent. The majority are nursing assistants who earn an average of $10.35 per hour;
• In 2002, 10 percent of nursing home residents experienced substantial weight loss; 9 percent were in bed all or most of the time, and 17 percent were placed in physical restraints;
• Nearly half of the state's nursing homes reported either no profit or a net loss in 2002, and 160 were in bankruptcy between 1999 and 2002;
•Among freestanding nursing homes that receive Medi-Cal reimbursement, the proportion of those that broke even or lost money grew by an average of 26 percent.

Non-profit nursing homes, representing just 18 percent of the state's total, faired better than for-profit facilities, which had:

• An average of 3.3 nursing hours per resident per day compared with 4.1 for nonprofits;
• Staff turnover rates of 70 percent, compared to 49 percent for nonprofits;
• 37 percent more violations than nonprofits.

The report found that in spite of an aging population (the number of residents aged 85 and over is expected to double by 2030) there is ample capacity in the state's 1,400 nursing homes. Occupancy has declined from 85.9 percent in 1991 to 80.9 percent in 2001.

"Nursing homes must do a better job of caring for the 110,000 Californians currently in their facilities, not to mention preparing for a rising tide of elderly citizens who deserve more," said Mark Smith, M.D., CHCF president and CEO.

"Nursing homes face difficult challenges -- low-paid staff, high turnover rates, low margins, and declining reimbursement from government agencies-but seniors deserve quality care and their families must have confidence that loved ones are in a safe environment."

Detailed information on every nursing home in the state-including quality ratings, staffing levels, and results of complaint and inspection visits-can be found at www.calnhs.org. The data is current as of May 2004.

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