Federal report says nursing homes are understaffed - and patients endangered
By Robert Pear
The New York Times News Service

WASHINGTON—Federal health officials have concluded that most nursing homes are understaffed to the point that patients may be endangered.
For the first time, the government is recommending strict new rules that
would require thousands of the homes to hire more nurses and health aides.

In a report to Congress based on eight years of exhaustive research, the
Clinton administration says understaffing has contributed to an increase in
the incidence of severe bedsores, malnutrition and abnormal weight loss
among nursing home residents. Many of the patients end up hospitalized for
life-threatening infections, dehydration, congestive heart failure and other
problems that probably could have been prevented if the homes had more
employees, the report says.

Nursing homes with a low ratio of employees to patients are significantly
more likely to have quality-of-care problems, the study says, and
substantial increases in staff may be required to ensure that homes do not
endanger the safety or health of patients. The 200,000-word report is to be
sent to Congress this month.

It recommends new federal standards to guarantee, for example, that patients
receive an average of two hours of care each day from nurse's aides. It says
that 54 percent of nursing homes fall below this proposed minimum standard.

The quality of care depends not only on the number of nurse's aides, the
lowest-skilled workers, who help feed and bathe patients, but also on the
number of registered nurses and licensed practical nurses, who supervise the
aides, the study says.

Accordingly, the report says that nursing homes should have enough
registered nurses to provide at least 12 minutes a day of care to each
resident, on the average. But, it says, 31 percent of nursing homes do not
meet that standard.

The government emphasized that the proposed levels of staff were not the
optimal levels, but the minimum needed to prevent patients from being
exposed to a substantially increased risk of poor-quality care.

The report, from the Department of Health and Human Services, was required
by a 1990 law and was originally supposed to be completed by Jan. 1, 1992.

But health officials experienced many delays, and the scope of the project
grew as they conducted more research and analyzed huge amounts of data from
nursing homes around the country.

Federal researchers said they found that staffing levels were much higher at
nonprofit nursing homes than at for-profit homes. Large nursing home chains
that experienced financial difficulties in the last two years, including
chains that filed for protection under the bankruptcy law, have cut staff to
control costs, the report said.

The cuts come when nursing home residents are typically sicker than in the
past, with more serious disabilities. Hospitals have reduced the length of
stays, releasing patients "quicker and sicker." Many people with less severe
conditions who might have gone to nursing homes 15 years ago now receive
care in their own homes from visiting nurses and aides.

Nursing homes said it was unrealistic for the government to specify minimum
levels of staff when it was providing what they called inadequate payments
under Medicaid and Medicare, the programs for low-income people and those
who are elderly or disabled.

In addition, nursing home executives said it was difficult to attract and
retain good workers in a booming economy, when the unemployment rate is at a
30-year low and other industries offer less demanding, better-paying jobs.
Nurse's aides provide more than 70 percent of the hours of care given to
nursing home residents.

The American Health Care Association, a trade group for the industry, said
it could not support minimum staffing ratios unless the government agreed to
help pay the additional cost, which could total several billion dollars a
year.

About 1.6 million people receive care in 17,000 nursing homes nationwide.
Ninety-five percent of the homes participate in Medicaid or Medicare and are
therefore subject to federal standards. But, the report says, the federal
law and regulations are too vague to guarantee an adequate number of
employees.

The law, adopted in 1987, says nursing homes must have enough staff to
provide services enabling each patient to achieve "the highest practicable
physical, mental and psychosocial well-being."

Neither the law nor the rules indicate the minimum or appropriate numbers of
employees.

Congress could amend the law or health officials could revise the rules to
set tougher, more explicit standards.

Nursing homes, like hospitals and other health care providers, are lobbying
Congress to restore money cut from Medicare in 1997. Sen. Charles Grassley
(R-Iowa), chairman of the Special Committee on Aging, said he would consider
earmarking some of the money to ensure that nursing homes hire additional
workers.

"More than half of the nation's nursing homes don't meet a minimum benchmark
for staffing," Grassley said.

This article appeared in the New York Times on Sunday, July 23, 2000