By Sally Damm, LNHA

A person goes to the hospital to get well and have babies but people that are admitted to the nursing home go to die. Do you believe this? How many times have you heard “promise me you’ll never put me in a nursing home”. As a multiple-award winning nursing home and long term care administrator with 30+ years of administrative experience I can say with confidence that staffing per resident needs is one of the keys to positive outcomes. As a nursing home administration expert witness, I can also say with confidence that staffing is an issue that can arise in nursing home litigation.

The survey (inspection) process for Skilled Nursing Facilities (SNFs) and Intermediate Care Facilities (ICFs) in the United States (US) is controlled by the Centers for Medicare & Medicaid Services (CMS). CMS is part of the Department of Health and Human Services (HHS).  CMS delegates to individual State Survey Agencies the performance of inspections of nursing homes under the agreements in Section1864 of the Social Security Act (the Act).  The survey is referred to collectively as the certification process.

The facilities must have sufficient direct care and licensed nursing staff on the floor to meet the residents’ emotional, mental, physical, spiritual, medical, nutritional, psychosocial well-being and the daily living activity needs. The hours per patient day (HPPD) also needs to be appropriate and the staff assigned to care for the residents must perform as expected.

The first national survey of nursing homes was conducted in 1954. The inspection (survey) of today is conducted by the surveyors (inspectors) using a variety of methods rolled out in 1987 referred to as OBRA87. The implementation of this process has continued for the past 29 years. However, the concerns of 1954 still exist today. The frequency of deficiencies show that quality problems continue to exist in many nursing facilities.

The FORM CMS–20062 (4/2013) is one of the protocols used by the inspectors. The inspectors use, but are not limited to:

  • Interviewing a cross section of staff, individual residents, and legal representatives;
  • Reading and reviewing written progress notes in the resident file and available documentation
  • Comparing the number of staff scheduled to work to the number of licensed nurse(s) (RN, LPN for example), and Certified Nurse Assistants (C.N.A. for example) to the number of people that are physically present and working directly with the resident (s) compared to the schedule.
  • Determining whether the schedule reflects the following required coverage:
    -24-hour licensed nurse,
    -8-hour registered nurse, 7 days a week, and
    -Full-time director of nursing.
  • Determining whether the RNs, LPNs, and C.N.A.s are available, accessible and assigned to:
    • Supervise and monitor the delivery of care by nursing assistants per residents’ care plans;
    • Conduct an assessment, access and respond appropriately to resident condition changes;
    • Monitor nutritional services, fluid intake and dining activities to detect concerns or changes in residents’ needs;
    • Observe the response of staff to nursing assistants’ requests for assistance;
    • Immediately correct inappropriate or unsafe techniques conducted by licensed nurses, nursing assistants’, or other staff within the facility;
    • Identify if the orientation process of new and temp agency staff is appropriate and if on-going training and/or educational opportunities have been conducted for compliance and staff’s knowledge of best practices;
    • Assure that employees from non-nursing departments that meet the residents are knowledgeable about the needs of the residents and can deliver and or seek assistance to ensure the care as written on the individualized care plan is carried out;
    • Provide for the turning, positioning, and skin care for those residents identified to be at risk for pressure ulcers;
    • Provide incontinence care as needed; and
    • Assure that staff are appropriately organized throughout the building to meet the needs of the residents according to the classified acuity of care as identified using the Minimum Data Set (MDS) tool;

Presently individual states can determine a mandated staffing ratio or the state may implement the less clear cut standard of “sufficient staff to meet the resident’s total needs at all times”. Hours per patient day (HPPD) is a common expression to justify the amount of man-hours required to care for people within the healthcare field.  This measure tracks the total number of direct department hours, compared to the number of patients in the facility.

Using the following table as published in Health Serv Insights .2016;9:13-19 may help the reader understand sufficient staffing by the numbers in the nursing department.

PMC full text: Health Serv Insights. 2016; 9: 13–19.

Published online 2016 Apr 12. doi:  10.4137/HSI.S38994

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Table 1

Nursing hours per resident day reported in all U.S. nursing homes in 2014 compared to recommended minimum staffing levels and expected staffing levels.

90% N = 1,539 1.36 1.26 3.27 5.39
75% N = 3,848 0.98 1.02 2.80 4.55
Mean 1.00 0.90 2.64 4.54
Median N = 7,696 0.72 0.81 2.40 3.97
25% N = 3,848 0.53 0.60 2.08 3.53
10% N = 1,539 0.39 0.39 1.83 3.18
CMS study recommended minimum standard (2) 0.75 0.55 2.80 4.10
Average CMS expected staffing based on resident acuity (3) 1.08 0.66 2.43 4.17

Notes: (1) CMS Casper Nursing Home Staffing Data (2014). (2) USCMS. (2001). (3) Abt Associates (2015).

Abbreviations: RN, registered nurses; LVN/LPN, licensed vocational or licensed practical nurse; CNA, certified nursing assistants.

Staffing of direct care staff, (those who touch the resident in their assigned position) can have a critical influence on patient quality of life and safety. Nursing home staffing levels must meet certain governmental standards. A nursing home administration expert witness may be helpful in analyzing whether or not staffing was sufficient in a particular situation.

Sally Damm is a multiple-award winning nursing home and long term care administrator. She has 30+ years administrative experience including being the head administrator of two different facilities. Ms. Damm is Licensed Nursing Home Administrator, Qualified Assisted Living Administrator, Licensed Social Worker Associate, Preceptor and long-term-care support and services expert witness.