Nursing Home Staffing Violates State StandardJul 29, 2002 | Atlanta Journal-Constitution Jacqueline Johnson's race against the clock begins every day at 3 p.m. That's when she starts her rounds at an east Georgia nursing home, checking to see who's clean and dry, who needs a diaper change and who needs help getting back into bed.
Johnson also begins a day of difficult choices: Whose food will become cold and unappetizing while she feeds someone else? Which resident will have to wait too long in a wet diaper? How many times will she have to cut off conversations with patients who crave human contact?
Staffing at the home is typical in a state where staffing levels are among the lowest in the nation. Aides in dozens of nursing homes across Georgia face even more difficult choices than Johnson does.
Studies say a nurse's aide working an evening shift like Johnson's should be assigned only seven to 10 residents. On a good day, Johnson will be responsible for 12 to 15. On a bad one, when someone else doesn't show up for work, it could be as many as 20.
The demands are constant -- imagine a mother trying to take care of a dozen sick children. That's what Johnson's days are like. After a decade on the job, Johnson knows how to take care of the home's frail and elderly residents, but she's frustrated that she can't do it the way she should.
"I have to pick out who I am going to see about," she said. "It can be a hard decision."
The staffing problem is so severe that nine of 10 Georgia nursing homes operate with staffing levels found in an exhaustive federal study to be harmful to patient care. The study found that people living in lower-staffed homes were more likely to lose too much weight, develop bedsores or end up in the hospital with infections or other problems.
Staffing levels are low in Georgia both for nurse's aides, who do the bulk of the front-line work in nursing homes, and for licensed nurses, who dispense medications and perform other medically oriented duties.
A Journal-Constitution analysis of nursing homes' financial reports and staffing records, as well as federal statistics, suggest myriad related problems:
Only four other states have average staffing levels of nurses and nurse's aides that are lower than Georgia's.
Georgia's nurse's aides earn an average wage of $7.40 an hour, among the lowest in the nation. Fast-food cooks make nearly as much -- $6.56 on average.
Thirty-three homes violated Georgia Medicaid's minimum staffing requirements on average on every day of the year in fiscal year 2001. Spot checks show dozens more homes break that rule on occasion.
Those homes could have been fined, but the state does not enforce the staffing minimum. Medicaid officials promised in December to demand accountability, but have yet to enforce the minimums.
For-profit companies, which dominate the industry in Georgia, tend to have much lower staffing levels than the state's nonprofits. A resident of the typical nonprofit home gets a half-hour more staff time each day than someone living in a for-profit facility.
In the typical U.S. nursing home, most experts agree, the staff is stretched so thin that aides must routinely ignore residents who need help with meals, exercise, grooming and many of the simple tasks that give them a sense of personal dignity.
"They don't get no good care," said Mary Lester Howard, a longtime nursing home worker, who has seen aides on the busy day shift assigned to as many as 24 residents.
"With 24 people, the only thing you can do is wash their face and their bottom and sometimes you don't get their bottoms washed," Howard said. "You can change disposable diapers and sit them in a chair and let them go all day."
Everyone involved in nursing homes -- owners, workers, advocates -- agrees that residents are placed in harm's way when there's not enough staff.
"They do get bedsores, and there are a lot of falls. You just can't be there one on one with all the residents," said a 26-year nurse's aide in Middle Georgia.
"You want to do a good job, but you don't have enough time," the aide said. "You have to go in there praying."
Why staffing is low
It's hard to find workers for a job with enormous demands and the worst pay in the marketplace. "It takes a very special, caring person that's willing to be patient and put up with a whole lot for very little compensation," said William M. Small Jr., owner of the Fountainview Center for Alzheimer's Disease, an Atlanta nursing home.
The pay and working conditions also breed constant turnover, which leads to poor care. Only 80 percent of nurse's aide positions in Georgia are filled, and annual turnover is 95 percent, according to state officials.
But Medicaid, the government program that pays most nursing home bills, will not pay for staffing levels recommended by experts. In fact, Georgia Medicaid encourages poor staffing by offering financial incentives to homes that keep costs low -- even those with perilously low staffing.
Advocates for nursing home residents and for the industry have called on the state to eliminate those payments and offer bonuses instead for those who spend more on staffing.
"Unless you make it a good business practice, it makes it hard for facilities to get the support from the corporate office to do the right thing," said Becky Kurtz, the state's long-term care ombudsman.
State officials say the bonus payments are intended to encourage homes to spend efficiently, not discourage quality care.
A Brunswick home, SunBridge Care and Rehabilitation for the Golden Isles, reported taking in more than $1 million more than it spent on patient care in fiscal 2001. But its average staffing level for the entire year fell below Medicaid requirements, according to an AJC review of staffing records.
SunBridge-Golden Isles has also earned a long list of citations from inspectors, including failure to protect residents from abuse and failure to make sure residents ate and drank enough.
Its punishment was a $14,000 fine in January. Georgia continues to pay SunBridge-Golden Isles about $30,000 a year as an incentive for keeping staffing costs low.
The industry says nursing homes aren't entirely to blame for low staffing levels. Even if the state paid nursing homes more, operators say they would be hard-pressed to increase staffing significantly.
"It's a hard job and you can't find the people to do it," said Gayle Sexton, lobbyist for the Georgia Nursing Home Association.
But those working on the front lines say the industry is responsible for the pay and working conditions that make the job so unattractive. The average full-time nurse's aide in Georgia earned $15,383 in 1999.
Jacqueline Johnson, the aide from east Georgia, has worked in the same nursing home for more than a decade, but she makes just $6.89 an hour. She supports herself and her 2-year-old son with the work.
"My little boy, I have to make sure he gets everything he needs. It takes all of it, trying to get a place to stay and food on the table," she said.
Many aides say managers hit them with unreasonable schedules and simply expect the work will get done.
"They want you to clip nails, clean out dressers and closets and take them to the bathroom every 30 to 45 minutes," said Howard, a longtime nursing home worker from Macon. "You got to have everybody up by 10 a.m. and all the beds made. Even if you have 24 people, they want the same thing as if you only had two or three."
Nursing home operators could find workers if they improved conditions, said Steve Lomax, president of the United Food and Commercial Workers Union, Local 1996, which represents nursing home workers in Georgia.
"For them to put up with what they put up with from the patients, and then get treated like dirt by management and get low pay and the stress of not getting done what needs to be done -- nobody wants to go into that," Lomax said.
Number of hours calculated
As part of a federal study on nursing home staffing, a California researcher used the techniques of fast-food restaurants and assembly lines to see how many aides nursing homes really need.
John Schnelle, professor at the UCLA School of Medicine, developed a list of tasks that aides need to complete and then estimated how long those jobs should take. His study found it would take about 3.5 hours a day to take care of toileting, bathing, feeding and other tasks for residents who make up the largest category of nursing home patients.
Schnelle's model doesn't prescribe luxurious care, just the basics: changing wet linens for incontinent residents; helping patients to eat and exercise; making it possible for residents to dress and groom themselves.
For any aide assigned more than six residents, Schnelle found, this work simply can't get done..
"If you're trying to work hard and I give you 10 patients, you're going to try to speed through the routines as fast as you can and move people around without talking to them and exercising them much," he said.
What about assigning an aide to take care of 15 residents on a day shift?
"That becomes a nightmare," he said. "I don't see how they even get them out of bed."
And yet, nursing home aides in Georgia routinely deal with 15 residents on their own.
Some in the industry argue that too much emphasis is placed on staff-to-patient ratios, without enough focus on staff turnover and whether or not a facility gets the job done.
"Quantity does not mean quality; it never has," said Lynn Blackmon, administrator at the Heardmont Nursing Home in Elberton.
Spot checks have found Heardmont violating Georgia Medicaid's staffing requirements. But the home's inspection reports are far better than the average Georgia facility.
"Regardless of what ratios and all say, Heardmont is an exception to all the rules," said Don Hulme, whose father is a resident. "It's a wonderful, caring place."
Blackmon said she would like to hire more staff, but the state pays Heardmont one of the lower rates for Medicaid residents, making more than minimal staffing virtually impossible. The state would pay Heardmont more money for staffing, but only if the home could carry the extra costs for about 18 months until the state adjusted its rates.
Blackmon says she focuses on keeping turnover low. "I have worked over the years with the very, very best, and I do everything I can to keep them and to terminate those who do not meet our expectations."
Although Blackmon's facility outperforms the average Georgia nursing home, low-staffed homes as a group have worse inspection records. A federal study, ordered by Congress in 1990 and just completed this year, also found a clear link between staffing and quality of care.
It's impossible to know how much Georgia's nursing home residents are suffering because of low staffing. But abuse and neglect often have a link to high turnover and low staffing levels.
The state is investigating the death of a resident who suffocated at the Centers for Long Term Care of Roberta, near Macon. The body of Fred L. Winkler Jr., a 58-year-old Alzheimer's patient from Chatsworth, was found early on the morning of Feb. 24 with his head on the floor and body wedged between bed rails, according to a police report.
Months earlier, union officials complained to the state that only two nurse's aides were assigned on the night shift to care for 90 residents at the Roberta home. Experts say aides should never be assigned to care for more than 20 residents. Spot checks of staffing at the facility had found it fell short of state staffing requirements, but the facility had not been cited as a result.
A second state investigation is looking at the circumstances of an April death at SunBridge Care and Rehabilitation for Riverdale. After Georgia Gilbreath died from an undisclosed cause, family members complained they had repeatedly found her sitting on soiled sheets, with feces on her body, and said doctors told them she was malnourished.
Spot checks by state inspectors have repeatedly found the facility was staffed below the state's minimum. The Riverdale facility reported a gross operating profit of $891,005 in the 2001 fiscal year.
"Whether it was physically or mentally, she suffered every day she was there," said Kenneth Knox Jr., Gilbreath's grandson.
Other states respond
At least 13 states have increased staffing requirements recently to improve care in nursing homes, and some are finding the additional cost to taxpayers to be formidable.
Florida lawmakers approved higher staffing standards last year as part of a broader plan that would also toughen enforcement and limit lawsuits against nursing homes. The goal is to increase nurse's aide staffing by 25 percent between 2002 and 2004.
But the improvements will cost taxpayers dearly -- an additional $110 million a year by 2003 (about a 6 percent increase), and even more the following year.
Florida already had pumped more money into nursing homes. The state increased the amount it pays to care for a nursing home resident by 50 percent between 1993 and 2000, but the staffing levels for nurse's aides stayed the same at the average Florida home, according to government statistics.
Advocates say Florida's experience shows why staffing minimums are crucial. "When you get increases in Medicaid rates, you don't necessarily see increases in staffing levels," said Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform, a Washington-based lobbying group.
The debate has also raged at the federal level, where the Bush administration has rejected advocates' push to require minimum staffing levels nationwide.
Instead, Health and Human Services Secretary Tommy Thompson said the government will encourage better care by letting consumers know how well or how poorly nursing homes are run. A pilot program using a federal government Web site (www.medicare.gov) allows consumers to look up information about the condition of residents in any nursing home in six states.
The intent is to let consumers choose homes that achieve better results and let market forces prevail.
The National Citizens' Coalition for Nursing Home Reform strongly criticized Thompson's response to the staffing study.
"Secretary Thompson is ignoring an overwhelming body of evidence that there is a relationship between nurse staffing levels and quality," said Donna R. Lenhoff, the group's executive director. "While good management practices, training and other factors can improve care, there is no substitute for having enough qualified workers available."
Private pay helps
Nursing homes such as the Fountainview Center for Alzheimer's Disease in Atlanta say they have to be creative to staff at the levels recommended by experts.
Each resident at Fountainview gets more than four hours of staff time a day from nurses and aides. Small, the home's founder, opened it in 1995 with a goal of providing care that would preserve the dignity of the growing number of people with Alzheimer's disease.
The staffing levels mean that nursing aides such as Lenore Holland don't have to race through their tasks. After four years at the home, Holland knows what her residents like and what they don't. She knows their families. And she knows their needs.
"I sing to them and they go to smiling," Holland said. "I know they know who I am because I make sure to speak to them and hold their hand."
And, unlike most aides in Georgia, she has time to pay attention to putting together their outfits for the day and getting their hair just right. "I'm really particular on how my people look, and everybody knows that," she said.
Small said he can afford higher staffing because 60 percent of the home's residents pay for their own care. MediÂcaid paid Fountainview $109 a day last year for each patient, but the facility spent more than $126 a day on care.
"We could not run this type of facility with a major Medicaid population," he said.
What's needed, Small said, is an honest public discussion of how much the government is paying for care and what the public expects in terms of quality. Now, the system simply dictates requirements to nursing homes, but it doesn't study how much care should cost or examine whether it's paying enough to get the job done.
"It's a conversation that's just beginning to happen," Small said.
But it's a conversation that may soon be center stage.
"It's going to come to the forefront quickly when baby boomers realize it's an issue for them personally," he said.