Care Home Problems Blamed on Staffing

Low staffing levels in California nursing homes are largely responsible for their poor overall quality, depriving residents of basic assistance to use the bathroom, eat meals and walk around, according to a study of California’s nursing homes.

Jose Lopez, 36, couldn’t agree more. “We need more help,” said Lopez, who takes a 45-minute bus ride to his $7.53-an-hour job as a certified nurse assistant, leaving each day stressed and worn out.

“It’s hard to work with 10 patients a day,” he said, refusing to name the Los Angeles home where he works for fear of retaliation.

A review released by the California HealthCare Foundation this week found that many residents received less than five minutes of assistance with eating and were given bathroom help fewer than two times in 12 hours.

“Seventy percent of these residents are incontinent,” said Charlene Harrington, the study’s lead researcher and a professor at the UC San Francisco School of Nursing. “They need assistance to the toilet every two to three hours, and they’re not being given it.”

But industry officials said the Medicare and Medicaid programs, which pay for most nursing home care, are not providing enough money to give elderly residents the attention they deserve.

Nursing homes have trouble attracting and retaining nurse aides, who are in short supply but perform more than 70% of patient-care tasks. The California HealthCare Foundation review found that the average aide earned $9.57 per hour in 2000-01, below the rate paid by hospitals.

“While [aides] are at the bottom of the wage totem pole, they are entrusted with the bulk of care-giving responsibility,” said Collin Wong, director of the Bureau of Medi-Cal Fraud and Elder Abuse in the state attorney general’s office.

“If you look at the scope of their responsibilities, you’ll find that serious injury or death can result if their responsibilities are not discharged competently.”

Lopez, who has been a nursing aide for 11 years, said he feels pressure as soon as he walks in the door at 7 a.m.

“We have to do many things,” he said. “Take their vital signs. Help them walk. Give them showers. Clean them. Sometimes feed them.”

The facility wants to hire more nursing aides, he said, but is having difficulty. “Nobody wants to work under these conditions because they don’t pay enough.”

Certified nurse aide Rocio Rodriguez works at a different Los Angeles home, but shares Lopez’s feelings. She said she often is sad that she can’t spend more time with the elderly patients.

“Sometimes they just want you to sit down and talk to them, but we don’t have time to talk,” said Rodriguez, 20, who earns $7.88 an hour. “I mean, I don’t want to be rude, but sometimes I have to ignore what they are telling me because I have to go to the next patient.”

She is forced at times to cut corners. “A lot of times we don’t do oral care ... cleaning their dentures or brushing their teeth because we’re in such a hurry,” she said. “This place needs more people and higher wages. It’s just too much work for the little bit of pay you get.”

Like Lopez, she declined to name the home where she works.

With the publication of key research, government officials and watchdogs increasingly are stressing the importance of adequate staffing in nursing homes.

In June, the U.S. General Accounting Office concluded that nurse aide staffing -- the hours devoted to an average patient each day -- is a good predictor of the quality of homes, even better than overall spending per patient.

Another report, ordered by Congress and completed last December, found that higher levels of nurse staffing reduced the need to hospitalize residents for treatable conditions and infections. Residents also experienced fewer pressure sores and less weight loss when they had additional help, said researcher Dr. Andrew Kramer of the University of Colorado Health Sciences Center.

“In almost every case, there was a relationship between staffing levels and these quality measures,” Kramer said. Kramer and his colleagues recommended at least 4.1 hours of nursing assistance per patient every day, but said that more than nine in 10 homes don’t provide that level of care. So far, the federal government is balking because that level of care could cost billions of dollars to implement.

California has been more aggressive than most states in setting staffing standards. In January 2000, the state began requiring nursing homes to provide at least 3.2 hours of nursing assistance per day to each patient, on average.

The California HealthCare Foundation found that about 44% of homes were not complying with the state’s nursing staff standards in 2000 and 2001. Because of the shortage of nurses and nurse aides, industry officials said it took some homes extra time to comply.

Last year, the Legislature went a step further, requiring the state to set minimum ratios for nursing assistants to residents. Those ratios, which have not been set, will take effect in 2003.

Democratic Assembly Leader Kevin Shelley (D-San Francisco) said he wants to make it easy for family members to count the employees on a floor and determine if a nursing home is following the law. Shelley, who is running for secretary of state, said the goal is to have enough staff to respond when a resident presses a call button.

Industry officials agreed that more staffing is needed, but they said more money is needed too. Homes that accept high numbers of Medi-Cal patients are at the state’s mercy, they said. “What they pay us in reimbursement is what we have to pass on to the workers,” said Betsy Hite, public affairs director of the California Assn. of Health Facilities.

Officials said they have increased Medi-Cal nursing home reimbursements nearly 20% since August 2000, more than for many other medical providers.

“I don’t think any of us have all of the resources that we could possibly want in these areas, especially with the economy where it’s at,” said Diana Bonta, director of the state Department of Health Services.

“But there have been significant movements” in the right direction, she said.