‘Staggering’ 75% of nursing homes almost never meet expected RN staffing levels, study finds

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Three-fourths of the nation’s nursing homes never meet federal staffing expectations for registered nurse staffing, and RNs are often missing from such facilities on the weekends, according to a new review of a year’s worth of payroll data.

The research also found that 70% of facilities self-reported higher total direct staffing under the CASPER system than in the now-standard Payroll-Based Journal. The discrepancy was most pronounced at for-profit facilities, followed by non-profits and then government-run buildings.

Researchers from Harvard and Vanderbilt medical schools examined records from 15,399 nursing homes covering April 2017 through March 2018. Their results were published online by Health AffairsMonday afternoon.

Study co-author David Grabowski, a professor in the Department of Health Care Policy at Harvard, said he found the RN data “‘staggering,” and that the study results could have broader implications than just immediate revelations about staffing.

“Most of the quality measures reported on Nursing Home Compare are self-reported,” Grabowski noted to McKnight’s. “Unfortunately, CMS rarely audits measures such as the rates of pressure ulcers or pain. As a result, these measures are subject to the same reporting bias we saw with staffing under the CASPER system. We would encourage CMS to increase the auditing of these measures in order to improve the quality of the used in reporting, monitoring and enforcement.”

Grabowski said 75% of SNFs were almost never in compliance with the Centers for Medicare & Medicaid Services’ expectations for staffing given their residents’ particular acuity levels, based on the Staff Time and Resource Intensity Verification Project.

While PBJ data proved 96% of nursing homes had an RN onsite for at least eight hours a day 80% of the year, the weekends told a different story. For RN staffing, 91% of facilities met the expected level less than 60% of the time. Overall staffing also was lower on the weekends, with reductions in LPN and nurse aide hours too.

Larger facilities, on average, had bigger weekend decreases, while facilities with higher five-star overall ratings or lower shares of Medicaid residents had smaller fluctuations.

“Adverse events such as falls and medication errors might be more likely to occur during those understaffed days,” the researchers wrote. “For this reason, CMS should leverage the daily payroll data to incorporate staffing variation over time, in addition to average staffing levels, in its calculation of star ratings.”

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