A new federal method of counting nursing home employees shows many homes lack full staffing.
By Thomas Goldsmith, North Carolina Health News
Last Nov. 6, Hillside Nursing Center in Wake Forest admitted a woman with a diagnosis of COPD and hypoxemia, or a low level of blood oxygen.
Nursing notes from Nov. 7 describe the woman, identified in a state report filed with federal regulators only as Resident #4, as “alert and verbal with some confusion.”
Ten days later, she was dead.
In the interim, according to a series of documents completed by state reviewers, staff apparently varied the amount of oxygen Resident #4 was receiving several times, without consulting her doctor and counter to orders on her chart. Her blood oxygen saturation level fell as low as 60 percent (normal is 95-100 percent) as staff members including a physical therapist observed the problem without calling in medical supervision.
“They (the facility) should have told me. I never got a phone call,” her physician said, according to a report compiled by state investigators for the federal Centers for Medicare and Medicaid Services.
“They didn’t give me a chance to try to do something for her,” the doctor told inspectors, according to the investigators’ document. “She obviously was having a problem.”
In its response to a Department of Health and Human Services statement of deficiencies, Hillside promised to do a better job of monitoring blood oxygen and making sure that staff records were properly maintained. The facility did not admit wrongdoing.
Having enough people to handle the unrelenting work and communication at skilled nursing centers remains vital to proper care for the older people and those with disabilities housed there.
That’s part of the reason why the federal Centers for Medicare and Medicaid Services recently spent several years crafting a new approach to checking on staffing at nursing homes. Instead of relying on the residential centers to self-report staffing numbers, CMS checked through years of paycheck records, revealing, in the cases of hundreds of nursing homes nationally, much lower levels of staffing than those seen under the former method.
Larry Celeste, Hillside Nursing Home administrator, said the center would not comment on topics of residents’ care for reasons of privacy.
“However, we will note that the DHS (sic) Survey Finding you reference, which are public records, do not find that the resident died as a result of any action or inaction by Hillside staff,” Celeste emailed in response to phone calls.. “Additionally, there was no statement or findings in the survey regarding low staffing at Hillside.”
Protecting the public by regulating the practice of nursing NC Board of NursingHillside Nursing Center, with an overall rating of four stars out of five, received a two-star, below-average designation for its staffing from CMS’s nursinghomecompare system. Based on the needs of its residents, Hillside would be expected to provide 3.24 hours of total staffing per day, according to CMS data, that includes help from registered nurses, licensed practical nurses and nursing aides. But use of payroll records shows the center was giving each resident an average of 2.18 hours of nursing and nurse aide care daily, or nearly one-third less than expected.
“Data not available”
“You can’t really deliver quality care if you don’t have enough people working,” said Thomas Konrad, who researches health-care staffing at the UNC Sheps Center for Health Services Research.
How did we get this information?
People who are concerned about nursing-home quality can find star ratings and other detailed information at nursinghomecompare.gov. Information can be sorted by facility name, county, town name, or Zip code.
When people complain about a nursing home, or when a home receives a periodic inspection that uncovers problems, employees of county social services departments and the North Carolina Department of Health and Human Services carry out an on-site investigation. That “Statement of deficiencies and plan of correction” (otherwise known as a Form: CMS 2567) provides anonymized information about the problem and the steps the facility commits to to correct those problems. Those forms are publicly available after they’re completed.
“The first thing that you see is people having to wait for someone to answer a call bell,” he said.
“You see it in inadequate responses clinically. That’s why staffing has been a primary indication of quality.”
Hillside was bulging with residents — 143 for 130 licensed beds — at the time staff were trying to keep up with oxygen levels for Resident #4, according to a state inspection. And incomplete record-keeping means that staffing levels for several days during her residency were not accurate or couldn’t be determined, according to the statement of deficiencies.
“It was observed that Daily Census & Staffing numbers were not accurate for the month of November 2017,” state inspectors wrote in their report, which went to both state and federal regulators.
In the most recent CMS surveys, 77 facilities, or 18 percent of North Carolina’s 422 homes for its most vulnerable citizens, earned the lowest slot in the federal five-star rating on staffing. Thirty-eight were downgraded to that level under the new method of reporting, many of those downgraded didn’t report data at all.
Nursing homes receive an overall rating from CMS, based on their ratings in specific categories such as staffing. About 42 percent of North Carolina centers received one or two stars, far below average, or much below average.
“Ambulating in the hallway”
In 2017, the family of Betty Purser Brooks, of Concord, sued the owners of Brian Health and Rehabilitation Center/Cabarrus following Brooks’ death in 2015 at age 85 after falling in a hallway at the center. The lawsuit charged that Brooks, known to staff as a risk for falling, was seen on the day of the fall, “ambulating in the hallway with no apparent destination and that she appeared to be confused.”
In the matter of staffing, Brooks’ family alleged that Brian Health and Rehabilitation Center/ Cabarrus’ management knew were not enough staff to properly monitor all the residents and their needs.
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In the matter of staffing, Brooks’ family further alleged in the suit: “At all material times, Defendants were fully aware that the failure to provide sufficient numbers of competent personnel to meet the basic needs of residents jeopardized the health and safety of such residents and would, in all reasonable likelihood, cause serious injury and death to those residents, including Ms. Brooks.”
Attorneys for the nursing home and related entities responded with a filing in federal court, where the case had been moved, that read in part: “Paragraph 45 [charging insufficient staffing] of Plaintiff’s Complaint are legal conclusions and not allegations of fact and, thus, do not require a response from this Defendant; however, should a response be required, they are denied.”
An attorney representing Brooks’ daughter Tawana said the family would have no comment on the lawsuit.
Filed in state superior court and moved to federal court, the family’s suit was recently set for trial a year from October. The attorney for Brian Health and Retirement Center/Cabarrus did not respond to phone calls requesting comment.
High need; low wages
The effect of staffing on the health of nursing home residents has been long established. A 2004 study in the journal Health Services Research found that having enough staff, especially registered nurses, resulted in “lower death rates, higher rates of discharges to home, improved functional outcomes, fewer pressure ulcers, fewer urinary tract infections, lower urinary catheter use, and less antibiotic use.”
The same study found low levels of staffing correlate with residents’ getting inadequate help with eating, developing unhealthy skin conditions, being less active, and having less frequent assistance using the bathroom.
But help is hard to find.
According to health-care analysts Plante Moran, the nation’s health-care employment workforce is growing at twice the rate of other sectors, creating a demand for more than 1.2 million registered nurses, 400,000 licensed practical nurses and half a million nurse aides, or CNAs.
Staffing below average
North Carolina is experiencing double-barreled pressure on staffing: increased demand and stagnant wages. As part of the South Atlantic region, North Carolina wages for direct care workers averaged $12.53, second-lowest in the nation, the Plante Moran report said.
“The other impact that short staffing has is that it makes it harder for other people to do their jobs,” Konrad said. “They get frustrated and they quit.”
Mental health benefits help line NC Dept of Insurance 855-408-1212
People who live at Hillside — which averaged about 122 residents per day as of the end of July — were getting 74 minutes less of nurse aides’ time than the North Carolina daily average of two hours and 18 minutes, according the nursinghomecompare.gov site.
In an odd coda noted in the statement of deficiencies, Hillside staff checked boxes on the medication record for Resident #4 that showed her oxygen tubing had been maintained on the late shift of Nov. 16-17. However, she was already dead when that shift came in.
“That is a problem,” the director of nursing, who wasn’t identified, said in the statement of deficiencies.