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Nursing home safety during COVID: Staff shortages

Facilities struggled with staffing even before the pandemic; 23 percent reported shortages by year's end

More than 3,000 U.S. nursing homes last month had a shortage of nurses, aides or doctors, and it’s a severe problem that has existed since last May. For most of last year, more than 200,000 people at any given time were in nursing homes that themselves acknowledged they were suffering from staff shortages.

Source: U.S. PIRG Education Fund / Frontier Group analysis of data from data.CMS.gov

In fact, the number of homes reporting shortages of nurses, aides or clinical staff actually increased from May to December, according to an analysis of government data by U.S. PIRG Education Fund and Frontier Group. By early December, 23 percent of homes reported a shortage of at least one category of direct-care staff.

Not only are the shortages a direct result of the COVID-19 pandemic, experts say, but in a circular nightmare, the staff shortages also fueled more COVID outbreaks in nursing homes among residents and staff. More cases mean more stress for workers and more workers who contract the virus or are exposed, which then leads to even more staff shortages. The end result: In many cases, when there aren’t enough workers, patient care suffers.

All of this comes at the same time nursing homes are still grappling with shortages of masks, gloves and other supplies to protect everyone inside the homes from transmitting the virus. And they’re also trying to navigate shortages of COVID tests, a slow vaccine rollout and high levels of community spread in most parts of the country.

Nearly a year into this pandemic, all of these are crises that make every day challenging for nursing home residents and the people trying to care for them.

While there are encouraging signs with the arrival of vaccines, the problems facing nursing homes are snowballing, and the situation may erupt before the pandemic subsides, said Dr. Michael Barnett, assistant professor at the Harvard T.H. Chan School of Public Health.

“It’s a recipe for a collapse in the workforce,” Barnett said.

Source: U.S. PIRG Education Fund / Frontier Group analysis of data from data.CMS.gov
Key findings

It’s not surprising COVID-19 has ravaged nursing homes, given their unique issues: Residents are there 24 hours a day, the living quarters are tight, and people in nursing homes and rehabilitation centers are generally older and in poorer health than the population overall.

While nursing homes contain less than one-half of 1 percent of the U.S. population, they’ve produced 2 percent of the country's COVID cases and 25 percent of deaths. The raw numbers: 522,516 nursing home residents diagnosed with COVID, 101,970 of whom died, as of mid-January. Then there are the workers: 448,389 cases reported among nursing home staff nationwide, resulting in 1,313 deaths.

Since last May, nursing homes have been expected every week to report to Centers for Medicare and Medicaid Services (CMS) nearly 100 pieces of data related to COVID-19, including diagnosed cases, deaths, tests, PPE shortages, and shortages of nurses, aides and clinical staff, which includes doctors.

At any point in time, there are about 1.3 million people with short-term rehabilitation needs or long-term illnesses who reside in the nation’s 15,000 nursing homes. During the period we examined, from May 31 through Dec. 6, shortages of nurses and aides grew more dire as the year went on:

  • Shortages of aides were the most widespread problem, affecting 20.6 percent of nursing homes in December, up from 17.4 percent in May.
  • Shortages of nurses were almost as bad, affecting about 18.5 percent of homes in December, up from 15 percent in May.
  • The number of homes with a shortage in at least one staff category increased to 3,136 in December, up from 2,790 in May. The percentage of nursing homes with a shortage of at least one category of staff was 19.9% in May, rising to 22.8% in December.
  • The number of residents potentially at risk because the homes they were in had direct-care staff shortages stayed around 220,000. But Dec. 6 had the lowest number of these at-risk residents — about 213,000 residents. Why? The total number of residents in all homes dropped by 52,908 from Nov. 22 to Dec. 6, likely in part because families took loved ones home before Thanksgiving and the December holidays.
Consequences of staffing shortages

When homes are short on staff, resident care suffers, workers face even more stress, COVID cases can spread faster and more staff quit.

“It makes everything harder,” said Barnett of Harvard. “There is a long literature documenting that facilities with higher patient/staff ratios have lower quality and worse outcomes, which applies to hospitals too.

“Stress is enormous. There is more work to do. It’s harder and there are fewer people,” Barnett added. “And residents are isolated, depressed and cognitively worsening.”

Rebecca Gorges, post-doctoral fellow at the Center for Health and the Social Sciences at the University of Chicago, said her research found that, among nursing homes with one or more COVID cases, they were likely to have fewer deaths and a lower probability of a severe outbreak if they had higher levels of staffing before the pandemic.

She believes staff shortages contributed to the spread of COVID in many homes and believes more staff means it’s easier for a home to adopt best practices, such as regular testing of residents and staff, and separating residents by COVID status.

At Harvard, Barnett’s research found that nursing homes that reported COVID-19 cases had higher staff shortages and bigger PPE shortages than homes without positive cases. “The magnitude of these shortfalls poses a major threat to public health,” the report said.

The nonprofit Center for Medicare Advocacy in Washington, D.C., said it reviewed four recent studies that used different databases, criteria, dates and states to conclude that “nursing facilities that have more nurses are more successful in containing coronavirus cases and deaths among residents than facilities with lower nurse staffing levels.”

There’s no doubt that staff shortages have negatively affected overall care, said Robyn Grant, director of public policy and advocacy at the nonprofit National Consumer Voice for Quality Long-Term Care of Washington, D.C., a consumer advocacy group. In its new survey, 87 percent of respondents indicated their loved one’s physical appearance had declined last year and 85 percent said their loved one’s physical abilities had declined.

Among staff, the stress of working in a nursing home during COVID has been crushing for many: There’s illness among residents, phone calls from families who can’t visit, residents who are incredibly lonely and beg for your time, residents who have no one besides you to hold their hand as they die, and the constant fear of contracting the virus, particularly in homes without enough PPE.

“COVID-19 is taking a considerable toll, physically and emotionally, on our health care heroes in long-term care,” said Dr. David Gifford, chief medical officer at American Health Care Association and National Center for Assisted Living (AHCA/NCAL). “Burnout is a real concern for all health care workers during this pandemic.”

The stress likely leads to more staff turnover, said Gorges of the University of Chicago, and then more COVID cases.

Why staff shortages got worse

Worker shortages in nursing homes didn’t start with the pandemic.

To paint the picture of shortages before the pandemic: Experts recommend 4.1 hours of direct care per resident per day, according to Consumer Voice. In the fourth quarter of 2019, it was 3.37 hours.

When the government began collecting data from nursing homes in May, the pandemic was raging and so were staff shortages, with 2,790 homes reporting a shortage in at least one staff category. That grew as the year went on, increasing to 3,136 homes in December.

The pandemic both exposed and made worse the existing problem of staff shortages in nursing homes. The long-standing staff shortage problem is beyond the scope of this report, but there are several ways that COVID made this problem even worse, such as:

  • Workers had to stay home if they were sick with COVID.
  • Workers quit their jobs or took a leave of absence to care for young children whose schools or daycare centers suddenly were shut down.
  • Workers took time off or quit to care for family members who contracted COVID.
  • Widespread testing after CMS started requiring regular staff testing in July meant asymptomatic COVID-19 cases among workers were identified. That required them to take time off, which is good to reduce COVID spread but also reduces staffing levels.
  • Last spring and summer, the worst outbreaks were confined to certain regions of the country. Toward the end of the year and since, the surges have been more widespread geographically. This makes it harder for providers to recruit staff from geographic areas with lower infection rates because most areas are experiencing this surge in cases at the same time.
  • As the pandemic persisted, more workers found jobs that paid more and brought less risk.

Gorges said the statistics among staff are haunting: As of mid-January, there have been 448,389 COVID-19 cases reported among nursing home staff nationwide, resulting in 1,313 deaths.

“Working in a nursing home is now one of the most dangerous jobs in America,” she said.

A big factor: Workers still don’t have enough PPE, according to the Service Employees International Union, which represents many staffers. New research by U.S. PIRG Education Fund and Frontier Group shows shortages of most types of PPE decreased significantly during the fall months, but increased during December.

How nursing homes are coping with shortages

Nursing homes are dealing with staff shortages in a number of ways:

  • Nearly 70 percent of nursing homes have hired additional staff, and 94 percent have asked existing staff to work overtime to cover staff shortages, according to an AHCA/NCAL survey in December. In addition, 86 percent have paid “hero” bonuses to existing staff.
  • Many homes turn to temporary agencies who may work in several homes, Grant said, but that “can be problematic because these individuals don’t know the residents and their particular needs.”
  • Many homes are also hiring “temporary nurse aides,” Grant said, under a waiver approved in March by the federal government that allows people to serve as aides without completing the federally required 75 hours of training. “We have heard from some residents and staff that these temporary nurse aides don’t have the training to equip them to do the tasks that are needed to care for residents,” Grant said.
  • In states where it’s allowed, some nursing homes are permitting family members to enter as “designated support people” to provide assistance to their loved ones.
What needs to be done

This problem is urgent. “Unless these shortages are prioritized by policymakers, long-term care residents will continue to be at a great disadvantage in the pandemic,” the report from Harvard said.

Among the solutions that are needed:

  • Approving temporary emergency COVID funding for nursing homes to hire more staff, as well as pay hazard pay, higher wages or bonuses to get workers through the pandemic. Congress should also approve President Biden’s COVID relief package that includes $20 billion for a national vaccination program, $30 billion for boosting PPE production and $50 billion for testing, and put in priority for nursing homes, given that community spread is the single biggest threat to nursing homes.
  • Prioritizing all long-term care staff and residents for the vaccine. AHCA/NCAL has called on states to prioritize distribution and aim to vaccinate all residents and staff with the necessary two doses by March 1.
  • Requiring all nursing homes to report vaccination rates of residents and staff soon to hold them accountable to families and prospective residents.
  • Getting help with workforce shortages from governors and other state officials, who should encourage medical professionals to volunteer as has occurred for hospitals, and deploy the National Guard to specific facilities with outbreaks to help with cleaning, testing, PPE and staff support.
  • Allowing and encouraging homes to relax visitor restrictions so family caregivers can provide care for their loved ones, as they often did before the pandemic. This obviously would require safety precautions such as COVID screening/testing and PPE, consistent with CMS guidelines. “Family caregivers provide supplemental care to many nursing home residents,” Gorges said, “by regularly checking in on residents, following up with staff about any minor issues before they become major issues and also by providing respite from isolation for nursing home residents.”
  • Solving the long-standing staff shortage problem in nursing homes, even though it may not alter the immediate situation, as noted above. COVID has made this problem much worse, but it was a problem with consequences before the pandemic and needs attention.
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