By Melissa Patrick
Kentucky Health News
Several speakers at the Oct. 4 Health Watch USA Healthcare Transparency and Patient Safety Conference in Lexington talked about the importance of adequate staffing in nursing homes and hospitals to maintain and improve safety for patients and staff.
Sherry Culp of the nonprofit Nursing Home Ombudsman Agency of the Bluegrass said that while regulations issued in 2016 by the Centers for Medicare and Medicaid Services have offered some positive changes, such as requirements for improved training and “appropriate competencies and skills,” and better provisions for planning of care, it didn’t do enough with staffing.
“The final rule really fell short on nursing staffing standards,” she said. “We wanted there to be registered nurses in the building 24 hours a day. . . . We know that an RN level of nursing is the level that has the competence to deal with some of the significant changes in conditions that occur in this vulnerable population.”
Culp said the rules only require an RN to be in the building eight hours a day, and that person is often “locked up in an office doing paperwork,” while 90 percent of the care is provided by nurse aides, who have less than 100 hours of vocational training. Her agency monitors living conditions at nursing homes and informs residents of their legal rights.
She said the agency gets calls from overwhelmed aides who tell her they have been put into “impossible situations” to care for as many as 40 people with little orientation and no help. “I think a lot of nurse aides are just thrown to the wolves,” Culp said.
As part of a three-part, in-depth report on the dismal state of Kentucky’s nursing homes, John Cheves of the Lexington Herald-Leader reports about the staffing issues in Kentucky’s nursing homes, noting that collectively Kentucky’s nursing homes rank as some of the worst in the country.
As of Aug. 7, he reported that Kentucky had 52 “one-star” nursing homes (18 percent of the state total), which are considered to be “much below average” and 71 “two-star” homes (25 percent), which are “below average.” These ratings come from CMS’s five-star rating system, which looks at a facility’s staffing, health inspections and quality of resident care.
Hospitals have staffing issues, too
Staffing issues are also an issue in hospitals, said Christine Pontus, associate director of health and safety for the Massachusetts Nurses Association.
Pontus pointed out that registered nurses are vital to the care of patients because they are the front line person to recognize and react to a patient’s ever-changing health status. She called this process “surveillance” and said that basically, “That’s what nurses do.”
She shared research to support the importance of nursing surveillance, which found that “greater nurse surveillance capacity was significantly associated with better quality of care and fewer adverse events,” and the ability of nurses to provide appropriate surveillance is largely dependent on adequate staffing.
Culp said RNs are needed 24 hours a day because it is imperative that someone with appropriate training be able to to determine if further care is needed when residents fall and hit their head. She said some of these fall victims have injuries that go unnoticed, “sometimes ever, or until their death or weeks later.”
One study of staffing in hospitals, found that RNs who work in an environment that supports their physical and emotional safety are more able to provide better surveillance, which ultimately leads to improved patient outcomes, more positive patient experiences and higher RN engagement rates.
“National, peer reviewed studies show higher patient assignments are associated with more patient deaths, complications, medication errors and readmissions,” Culp said.
Pontus noted that while Medicare requires “adequate” numbers of nurses at all levels, it doesn’t define the term or who determines the numbers. Similarly, she said the Joint Commission that accredits hospitals calls for the “number, competency and skill mix of staff in relation to the provision of needed care and treatment,” but does not clearly define or offer a formula to determine this mix.
“These ambiguous statements allow health care facilities to continue to operate at or below minimum [staffing] levels,” she said. “Something is not working. Regardless of all the regulations and the Joint Commission, it’s not working and we need to do something.”
Jonathan Rosen, safety and health consultant for AJ Rosen & Associates LLC, cited another study that looked at nurse staffing and hospital deaths: “We estimate that the risk of death increased by 2 percent for each below-target shift and 4 percent for each high-turnover shift to which a patient was exposed.”
So far, California is the only state to pass a nurse-to-patient ratio law. Rosen said a study found that since the requirements took effect, nurses’ occupational injuries have dropped one-third.