A third of Pa. nursing homes are dangerously understaffed: analysis

Story by DANIEL SIMMONS-RITCHIE | simmons-ritchie@pennlive.com

October 27, 2016

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mily Myers got into nursing home care to help the elderly, she quit because she knew she was failing them.

Myers worked for 10 years as a certified nursing assistant, contracting with more than 20 homes in the midstate. She considered her colleagues some of the kindest, most altruistic people she ever met.

The problem was there was never enough of them.

"If you don't have the staff you can't do the job that you need to do," she said. "You can't give quality care."

Myers worked in homes that were so understaffed that they would wait an hour or more for help lifting residents from wheelchairs to beds, forcing them to hoist them alone and risk injuring themselves and the residents.

READ MORE: This is part five in a series. Read part one, part two, part three, part four, and part six.

Myers worked in homes where residents had to wait so long to be taken to the restroom that their diapers would become saturated, leaking to the floor with urine. It was a situation that humiliated residents, caused urinary tract infections, and turned continent residents incontinent.

Myers remembers she was so overworked in one home that she could only reposition bedridden residents once every eight hours, despite requirements that residents be moved every two hours to prevent potentially deadly bed sores.

The understaffing that eventually drove Myers out of the field isn't an anomaly in the Keystone State. An extensive PennLive analysis of Medicare/Medicaid reimbursement data found that 85 percent of homes last year in Pennsylvania were staffed below levels that experts consider safe.

A third of homes were dangerously understaffed based on measures used by national experts.

Those findings are disconcerting amid this backdrop: More than 150 studies have found nursing home staffing has a direct impact on a home's quality. PennLive has documented 46 avoidable deaths in Pennsylvania nursing homes between 2013 to 2015, largely due to issues that appear related to understaffing.

Diane Menio, executive director for Center for Advocacy for the Rights and Interests of the Elderly (CARIE), a Philadelphia-based advocacy group, said PennLive's findings were disturbing, particularly the lack of registered nurse care.

"We know these are frail people just by definition," she said. "So if there's no one there to take care of them, from a medical standpoint, the nurse aides are not prepared to do that."

Find your nursing home's staffing level

PennLive sent its data and methodology to the Pennsylvania Department of Health, which oversees nursing homes in the state, but the department declined to say whether it agreed with the findings or whether it was concerned by them.

In a statement, press secretary April Hutcheson said that the department was examining changes to staffing standards in Pennsylvania regulations.

"We are working to identify best practice for staffing standards in nursing home care," Hutcheson said.

Accurate data

PennLive's analysis uses data from Medicaid/Medicare reports that homes file to the federal government for reimbursement. As PennLive found in a separate analysis, those reports provide a more accurate reflection of staffing than the data on Nursing Home Compare, the federal website that families use to choose nursing homes.

While the national data in that story included Pennsylvania, the analysis in this story provides a more accurate assessment of understaffing in the state. It uses more recent data - 2015 rather than 2014 - and its calculations are derived from wage information that excludes vacation, sick days, and other paid perks, meaning it's a more realistic measure of care provided to residents.

Based on PennLive's analysis of 559 facilities, nursing homes in the state provided residents with an average of only 3.6 hours of care per day - well below the minimum 4.1 hours recommended by researchers for safe care.

The analysis found 477 homes, or 85 percent, provided less than that level.

The analysis further found that 183 homes, or 33 percent, were dangerously understaffed because they provided less than 3.5 hours of care per day and, within that, less than 32 minutes of care from registered nurses. That definition of dangerousness is based on one used by national researchers in staffing.

Russell McDaid, president and CEO of the Pennsylvania Health Care Association, which largely represents the state's for-profit homes, disputed PennLive's assertion that Pennsylvania nursing homes are understaffed.

McDaid said that the 4.1 hours that PennLive defined as its minimum for safe care was not mandated by the federal government. Pennsylvania regulations, he said, only mandated a minimum of 2.7.

McDaid noted that the Centers of Medicare and Medicaid Services (CMS) chose not to impose a minimum staffing standard when it unveiled new regulations this month and that, in response to public comments about staffing minimums, the agency said "we do not necessarily find" the 4.1 standard is right for every home.

"These points and the facts we shared in this email regarding Pennsylvania's mandated minimum staffing standard of 2.7 hours of direct resident care for each resident contradict your assertions about facility understaffing," McDaid wrote.

Charlene Harrington, professor emeritus of nursing and sociology at the University of California, San Francisco, disputed McDaid's argument.

Harrington, a national expert in nursing home staffing, said she disagreed with CMS' rationale for rejecting a minimum standard. She believes it was likely spurred by political pressure from the nursing home industry and the agency's own fear that introducing a minimum would require it to raise Medicaid reimbursement rates.

"The decision not to increase the standards are political and financial and not based on research evidence," Harrington said.

READ MORE: How did PennLive analyze understaffing in Pa.?

Harrington pointed to a 2001 study by the agency that found nursing homes need to provide at least 4.1 hours per resident per day to ensure safe care. That was reaffirmed in independent studies in 2004 and 2011.

"CMS' own research confirms the need to increase the federal minimum staffing levels," she said.

Harrington said that Pennsylvania's minimum staffing requirement of 2.7 hours of care per day, set in 1999, was far too low to ensure safe care.

Myers, the former certified nursing assistant, knows that too well. She still remembers the words her director of nursing told her on the day she quit.

Myers told the director she was concerned that understaffing was imperiling the health and safety of residents.

"The response that I got was that they met the standards that the state requires," she said.

Frailty of residents

While researchers recommend that nursing homes provide an average of 4.1 hours of care per resident, they recommend even higher levels for residents based on their frailty and sickness.

For instance, a healthy resident might require relatively little care each day. A resident with severe dementia, on the other hand, might require near constant supervision.

The Centers for Medicare and Medicaid understands this difference. It maintains data on "expected" staffing levels for each home based on the a nursing home's population.

PennLive acquired that data and matched it to 535 homes in its analysis. It found the average Pennsylvania home should have provided 4.5 hours of care per day.

That means, when frailty is considered, understaffing in Pennsylvania is more severe than it initially appears. While 85 percent of homes didn't meet the recommended level of 4.1 hours of care, 93 percent didn't met that frailty-adjusted 4.5 hours of care.

For some understaffed homes that gap between their actual staffing and their expected staffing is particularly concerning.

For instance, Forest Park Health Center, a for-profit home in Carlisle, was already considered dangerously understaffed under PennLive's analysis because it provided only three hours of care and, within that, only 13 minutes of registered nurse care. That's well below the recommended 4.1 total hours and 45 minutes of registered nurse care.

But based on the frailty of its residents, federal data shows that its recommended minimums were much higher: The home should have provided at least 4.3 hours of total care and 1.2 hours of registered nurse care.

Asked whether it was concerned by that seeming level of understaffing, Guardian Elder Care, the home's owner, said its staffing met state and federal regulations.

"We believe our staffing levels are appropriate for our structure and our resident population and are consistent with the goals of CMS and the Department of Health," said CEO Eddy Inzana via email.

Asked why he believed those levels were appropriate, Inzana declined to answer.

"Since we have a pending lawsuit against the [Office of the Attorney General], counsel has advised us that we should not comment further," Inzana said via email.

READ MORE: The 18 most understaffed nursing homes in Pa.

McDaid, the president and CEO of the Pennsylvania Health Care Association, disputed PennLive's use of "expected" staffing data.

McDaid said "expected" staffing levels used by the federal government are intended to calculate ratings on Nursing Home Compare and aren't intended to mandate or suggest a minimum staffing level.

"The purpose of the calculations you cite is for the 5 Star Rating System for differentiating among facilities for public reporting, and not to establish a minimum number of hours per resident day that is used to define an 'expected' level of staffing for nursing facilities," McDaid said in a statement.

But John Schnelle, a professor of medicine at Vanderbilt University who has researched nursing home staffing extensively, said that's inaccurate.

Schnelle said expected staffing levels were developed by the government to appropriately reimburse nursing homes for the staffing time needed to take care of residents depending on their level of sickness.

While Schnelle said it's true homes aren't mandated to reach those expected levels, it's fair to interpret them as the level of staffing required by a home to meet its residents' needs.

"Otherwise what are you going to use?" Schnelle said. "It's the only national acuity system out there. While you can't say they are violating the law by not meeting it - because there's no law that says they have to meet it - you can't say that it doesn't provide a frame of reference for what their staffing should be."

Homes that are staffed far below those expected levels, he said, should justify how they can provide adequate care to residents.

Is Pa. the worst in the nation?

Particularly alarming, however, is that other states may have even higher rates of understaffing than Pennsylvania.

Because the federal government doesn't provide Medicaid/Medicare reimbursement report data that excludes sick days, vacations, etc., PennLive can't easily compare its 2015 analysis to other states. But PennLive's separate 2014 analysis, using slightly more conservative data, allows state-by-state comparisons.

That analysis shows Pennsylvania homes provided an average of four hours of care per day in 2014, ranking it 27th lowest in the nation for staffing (PennLive excluded Alaska from its rankings because of limited data).

The worst-staffed states in the nation tended to be in the south. Texas and Louisiana, for instance, provided an average of only 3.6 hours of care per day in 2014.

But although Pennsylvania might not be the worst in the nation for understaffing, Menio, the executive director for Center for Advocacy for the Rights and Interests of the Elderly (CARIE), said that shouldn't give Pennsylvanians solace.

"Just because someone is doing a worse job doesn't mean we are doing a good job," Menio said. "I think we have to strive for excellence. I mean, these are people's lives we are talking about."

READ PART SIX: 3 ways Pa. can radically transform nursing home care

About the author: Daniel Simmons-Ritchie

Daniel Simmons-Ritchie is an investigative reporter with PennLive and the Patriot-News. He has earned state and national awards for work on a variety of subjects, including health care, criminal justice, and the environment.