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How to Help Nursing Home Residents Through the Staffing Crisis

Both workers and standards are lacking right now. Here’s how you can help your loved one

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Nursing homes are suffering a staffing crisis. Although worker shortages were an issue before COVID-19, the industry has lost some 235,000 jobs since the beginning of the pandemic, representing a 15 percent reduction of the workforce. The crisis — driven by dangerous working conditions, poor pay and benefits, burnout and more — has led to some of the worst staffing shortages the industry has seen. An AARP analysis found that at least a fifth of U.S. nursing homes have reported a lack of staff every month since summer 2020, when the federal government began collecting such data. In recent months, the shortages have grown worse.

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Studies show that low staffing levels in nursing homes translate into poorer quality care for residents. The problems residents can experience because of inadequate staffing include decreased physical functioning, urinary tract infections, higher hospitalization rates, weight loss and dehydration, increased COVID-19 cases and higher mortality rates.

Yet U.S. nursing homes are not subject to federal minimum staffing requirements. Federal law only requires nursing homes to provide “sufficient” nursing staff to meet residents’ needs. Other than mandating that a registered nurse be on duty for eight hours a day, and that facilities have around-the-clock licensed nurse services, what counts as “sufficient” is subjective.

President Joe Biden has announced a plan for a federal minimum staffing requirement that could mandate certain amounts and types of care per resident for the nation’s 15,000 federally funded nursing homes, which AARP supports. But such a rule is not expected until next year.

In the meantime, there’s a patchwork of state staffing requirements for nursing homes, including at least 18 states that have none. While some states are working to introduce or strengthen requirements — with AARP’s support — others, like Florida, are doing the opposite.

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Both the lack of staff and standards are placing nursing home residents in danger, experts say. “We’re in the biggest workforce crisis in long-term care service that I’ve ever seen,” says Robert Applebaum, a researcher at the Scripps Gerontology Center at Miami University in Ohio, who has studied long-term care for 40 years. “Families do need to be more diligent than ever before.”

If you currently have a parent, spouse, sibling or other loved one in a nursing home, ask yourself these questions:

1. Have I checked the data?

Every nursing home that participates in the federal Medicare program, which is the vast majority of U.S. nursing homes, is required to submit staffing data to the federal government. The data is posted on the Care Compare website, where you can see a facility’s averages for several staffing categories, including overall staffing, weekend staffing and staff turnover, and check how it compares with other facilities in the state and nation. Each nursing home is rated in a variety of categories, on a five-star scale. “I personally would avoid any nursing home with less than four stars for their overall and staffing ratings,” says Richard Mollot, executive director of the Long Term Care Community Coalition (LTCCC), a national nonprofit advocacy organization.

A 2001 report commissioned by the federal government found that at least 4.1 hours of direct nursing care per resident per day was needed to prevent harm or jeopardy to residents. It recommended that at least 45 minutes of that care be provided by a registered nurse (RN). Nursing homes are not required by federal law to meet these levels, but many nursing home experts say they’re good benchmarks for consumers.

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2. Am I visiting frequently?

This is “absolutely critical," according to Applebaum. First, because you’ll be able to see where the facility is falling short. Secondly, visitors help hold facilities accountable. “The more people that are walking through that door, the better a facility is going to perform,” he says. “Knowing they’ve got people in there who are paying attention to what’s going on is really important.”

Applebaum encourages families and friends to create a visiting schedule that sends different people into the facility at different times. He also recommends touring a facility before placing a loved one in it: “You can’t believe how many times that doesn’t happen.”

When visiting, look for signs of staffing shortages, which can show up in a resident’s appearance or demeanor, says Jocelyn Bogdan, senior policy specialist at National Consumer Voice for Quality Long-Term Care, a national nonprofit advocacy organization. Common signs include weight loss; unwashed hair, unclipped nails or unbrushed teeth; missing dentures, hearing aids or glasses; pressure sores, bruises and cuts; and declines in energy level and alertness.

Signs of staffing shortages can also show up in the building, including unanswered call lights; unstocked hand sanitizer and soap dispensers; dirty towels and bedding; untidy rooms, bathrooms or common areas; a lack of personal protective equipment on staff; and workers who appear unwell.

Watch closely for the introduction of new medications for your loved one. “When there is not enough staff in facilities,” says Bogdan, “you’re more likely to start seeing antipsychotic drugs being prescribed,” particularly among residents with dementia. National Consumer Voice has a range of resources to help families recognize and combat the misuse of these drugs as chemical restraints.

If you can’t be there in person frequently, consider a tech device, such as a smartphone or tablet, that can help you connect with your loved one more readily.

3. Am I seeking answers?

Pose questions to as many different workers or departments of a facility as possible, says Amy Goyer, AARP’s national family and caregiving expert. That will help you gain varied intel on the staffing situation. A facility administrator, for example, should be able to tell you about their facility’s recruiting efforts — what roles they’re hiring for, how many applications they’ve received, etc. A social worker probably won’t know those answers but could have insights into how shortages are affecting your loved one’s social experience — whether certain activities have been reduced or canceled, or whether their favorite nurse has moved wards or resigned, for example.    

Goyer also recommends being specific and persistent. “Ask what the current staff-to-patient ratio is today, rather than on average, and ask frequently,” she says. Also consider open-ended questions that require more than a yes or no answers. For example, ask:

• “How often does my mother get repositioned or turned?” instead of “Is my mother getting repositioned or turned?”

• “When was my father last bathed?” instead of “Has my father been bathed?”

• “What activities are taking place today?” instead of “Are activities taking place today?”

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Seek answers from direct care staff, including certified nursing assistants (CNAs), licensed practical nurses (LPNs) and RNs, recommends Marjorie Moore, the executive director of Voyce, a national nonprofit advocacy organization for people living in long-term care. These workers may be more open and honest than administrators about staffing shortfalls. “They’re really bearing the brunt of this crisis, so you might find they’re willing to share their challenges with you.” Most care deeply about their residents and have their best interests at heart, so want to work with you to keep them safe, she says.

“Be assertive but not aggressive,” Moore adds. “You need to advocate for your loved one and make sure you can get to the bottom of things, but many of these workers are doing tough jobs for usually very poor pay, so be kind where possible.”

Don’t forget to engage residents, says Bogdan of National Consumer Voice. Helpful questions include: Do you get the help you need from staff when you need it? What activities have you been doing? How do you like living here? Are you hungry or thirsty? “If it’s hard to communicate with your loved one — say, if they have dementia — there might be another resident in the facility who can clue you in,” she says. Many nursing homes have resident or family councils where you can share or listen to staffing concerns.

4. Am I assisting where possible?

Family members can often perform the same tasks that a worker usually would, such as helping residents dress, taking them for a walk, entertaining them, ensuring they get adequate fluids, or assisting them in going to the bathroom. “Fill the gaps,” says AARP’s Goyer.

Charlene Harrington, professor emerita and a nursing home researcher at the University of California, San Francisco, recommends visiting your loved one at mealtimes if they need help with feeding. She says staff often struggle most with shortages at these times, when many residents need assistance all at once. She also recommends incorporating exercise for your loved one into your visits.

According to Lindsay Raupe, the director of social services at a faith-based continuing care center in northern Oklahoma, it’s “the little things” that help. “One lady brought up a cake for the whole staff to help celebrate her mom’s birthday — that was sweet,” she says. “My favorite drink is Coca-Cola. One lady brought me a Coke one day because she said I looked tired. It touched my heart to know she noticed and cared.”   

5. Do I need to seek outside help?

Ways to Advocate for Your Loved One in a Nursing Home

If you’re concerned or unsure about the care your loved one is receiving, contact your state’s long-term care ombudsman. Ombudsman programs were established by the federal Older Americans Act in all 50 states, plus the District of Columbia, Puerto Rico and Guam, to address problems related to the health, safety, welfare and rights of residents of nursing homes and long-term care communities. Staff and volunteers at ombudsmen offices advocate for residents of long-term care facilities and investigate and resolve complaints. Residents, family members, representatives or staff members can all file complaints. The service is free of charge and, if requested, confidential.

If an issue isn’t resolved, you can file a complaint with your state survey agency, which inspects nursing homes to determine if they’re complying with federal and state requirements. Your local ombudsman program can support you in filing a complaint.

Experts also recommend keeping correspondence (emails, texts and notes) with your loved one’s nursing home regarding complaints or concerns. These records could provide valuable documentation in conversations with nursing home administrators, or when working with state regulators, ombudsmen or advocates.

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