4.1 Hours of Nursing Care Per Resident Day Are the Bare Minimum
Analyses of nurse staffing levels at nursing facilities during the COVID-19 pandemic find – what all studies of staffing have consistently found for decades – higher staffing levels mean better care for residents and lower staffing levels mean resident harm and death. A study of all 215 nursing facilities in Connecticut found that 20 more minutes of registered nurse time per resident per day meant 22% fewer cases of COVID-19 among residents and 26% fewer resident deaths from COVID-19. The New York State Attorney General’s analysis of staffing levels during the early months of the pandemic reported that the highest rates of resident deaths occurred in nursing facilities with one or two stars in staffing (defined as staffing that is below average or much below average) on a five-point scale. Facilities that self-reported nurse staffing shortages had a 10.5% increase in resident deaths, from both COVID-19 and non-COVID-19 causes, during the coronavirus pandemic.
The Centers for Medicare & Medicaid Services’ (CMS) study of nurse staffing ratios, required by the 1987 Nursing Home Reform Law and issued in a four-volume report in 2001 after many years of research, found that 4.1 hours of nurse staffing (.75 hours per resident day (HPRD) of registered nurses; .55 HPRD of licensed practical/vocational nurses; and 2.38 HPRD of certified nurse assistant) were necessary to prevent avoidable harm and to meet some of the requirements of the Reform Law.
The standards for nurse staffing levels obviously cannot be lower than 4.1 HPRD today, when residents are sicker, more frail, more dependent, and more likely to have dementia than they were 20+ years ago when CMS issued its report. A standard lower than 4.1 HPRD would jeopardize False Claims Act litigation by the Department of Justice in “worthless services” cases and litigation by Medicaid Fraud Control Units (here and here) that cite and rely on the 4.1 standard.
A KFF report issued last week, analyzing how facilities currently staff, finds that 23% of residents nationwide now live in a facility with 4.0 HPRD, or greater, of nurse staffing. Residents in five diverse states live in facilities that already meet a 4.0 HPRD standard – 64% of residents in Maine facilities, 77% of residents in North Dakota facilities, 93% of residents in Oregon facilities, 67% of residents in Hawaii facilities, and 100% of residents in Alaska facilities. These residents would also be jeopardized by a nursing standard lower than 4.1 HPRD.
Unfortunately, KFF also documents how far many other nursing facilities need to go to provide sufficient numbers of nursing staff. Only 23% of facilities would today meet a federal standard of 4 HPRD and even a grossly inadequate staffing level of 3.5 HPRD is today met by only 45% of facilities.
The current inadequacies of staffing levels in far too many nursing facilities only underscore how important it is to enact a meaningful nurse staffing standard now. Since 1990, federal law has required minimal nurse staffing standards – RN coverage eight consecutive hours per day, licensed nurses 24 hours per day, and, otherwise, “sufficient staff” to meet residents’ needs. These minimal standards have not ensured that nursing facilities staff appropriately and residents have suffered and died as a result.
If CMS does not enact meaningful staffing standards now – after the pandemic, when a quarter of the COVID-19 deaths in the country were nursing home residents (although residents are only .004% of the U.S. population) and after President Biden promised meaningful staffing standards in his bold and comprehensive nursing home reform agenda – then it never will. If not now, when?
July 20, 2023 – T. Edelman