A nursing shortage and aging population have combined to create a crisis situation in skilled nursing homes, where residents need high levels of around-the-clock care.
Hundreds of nursing homes nationwide have inadequate staffing levels, according to payroll data collected by Medicare and analyzed by Kaiser Health News. In Missouri, 112 skilled nursing homes have staff levels below or well below the national average. There are 280 facilities with low staff levels in Illinois, the data show.
Federal inspection reports show several local nursing homes with low staffing rates have been cited recently for neglect, putting their Medicare funding at risk:
- Between May 31 and June 7 at Northview Village in St. Louis, three residents overdosed on illegal drugs, including one who died in the facility. The drugs were supplied by a fourth resident.
- Normandy Nursing Center “failed to provide protective oversight” for a resident with a history of wandering and falls who was hospitalized in June with a brain bleed after falling from a third floor stairwell to the first floor.
- A resident died at the Quarters at Des Peres after staff failed to start CPR or call 911 for a resident in March who did not have a “do not resuscitate” order.
- On Christmas Day 2017, paramedics were called to Integrity Healthcare of Wood River where a man was found unresponsive with a temperature of 104.1 and was taken to the hospital in a coma. A nurse told paramedics that staff members had not seen the man awake in five days, according to the Medicare report.
- All of the nursing homes satisfied inspectors’ concerns about the incidents. Administrators at the homes could not be reached for comment.
Normandy Nursing Center and the Quarters at Des Peres are run by MGM Healthcare, which also owns St. Sophia Health and Rehabilitation Center in Florissant, where Medicare funding was temporarily suspended for new residents last year after inspectors cited the home for neglect in the deaths of two patients.
Medicare recently lowered its star ratings for staffing levels in 1 in 11 of the nation’s nursing homes — almost 1,400 in all — because they either had inadequate numbers of registered nurses or failed to provide payroll data that proved they had the required nursing coverage, according to federal records released in July. Medicare’s Nursing Home Compare program gives each skilled nursing facility a score between one and five stars for staffing, health inspections, quality of care and overall rating.
The Missouri Veterans Home, which is not rated by Medicare, also has staffing problems. As recently as March, there were 100 vacant positions, including 70 nursing jobs at the home. The Missouri Veterans Commission reports spending $20,000 a week on temporary staffing.
The annual turnover rate for registered nurses in skilled nursing homes is 50 percent, according to a 2012 study by the American Health Care Association.
“It’s demanding work, and if you go work in the hospital, you get paid a lot more than nursing homes,” said Chien Hung, director of the long-term care ombudsman program at Voyce, a local nonprofit that offers education and advocacy for nursing home residents. “In Missouri, every nursing home has a shortage on their staff.”
The medical needs of people in skilled nursing facilities can include wound dressing, chemotherapy, catheter maintenance, oxygen therapy, feeding tubes or dialysis, among other types of complex care.
Medicare only recently began collecting and publishing payroll data on the staffing of nursing homes as required by the Affordable Care Act of 2010, rather than relying as it had before on the nursing homes’ own unverified reports.
The payroll records revealed lower overall staffing levels than homes had disclosed, particularly among registered nurses. Those are the highest-trained caregivers required to be in a nursing home, and they supervise other nurses and aides.
There are 23 nursing homes in Missouri that reported one nurse for every 100 or more residents on their worst staffed days. Six homes in Illinois reported the same ratio, according to the Medicare data.
Medicare generally considers adequate nursing care as 30 to 45 minutes of staffing per resident each day. At least 70 percent of nursing homes nationwide fail to meet that standard, according to a 2017 analysis by the Long Term Care Community Coalition, a New York-based nonprofit.
Nursing home industry officials have acknowledged that some facilities are struggling to meet Medicare’s new payroll reporting requirements. Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services, including nearly 2,000 nursing homes, said the lowered star ratings were disappointing and attributed them largely to a workforce shortage.
“Our members are battling on multiple fronts to recruit and retain all types of qualified staff, and nurses in particular,” she said in a statement.
The homes’ failures to either keep the facilities consistently staffed with registered nurses or to provide the data to prove they were doing so led the government to give its lowest rating for staffing to 1,387 of the nation’s 15,616 skilled nursing facilities, according to the Kaiser Health News analysis.
In the St. Louis area, 31 facilities received the lowest rating for registered nurses.
While the Kaiser Health News analysis found substantially lower average staffing of nurses and aides at for-profit facilities than at nonprofits and government-owned homes, the number of downgraded nursing homes was roughly proportionally divided among the three categories, indicating an industrywide issue with staffing by registered nurses in particular.
Medicare concedes that because the payroll system is geared toward reporting hourly work, salaried staff may not always be reflected correctly, especially if they were working overtime. But Medicare had warned the nursing homes in April that the downgrades would be coming if facilities continued to show no registered nurses on duty. The agency noted it has been preparing nursing homes since 2015 for the new payroll system.
“We’ve just begun to leverage this new information to strengthen transparency and enforcement with the goals of improved patient safety and health outcomes,” the Centers for Medicare & Medicaid Services said in a statement.
Jordan Rau and Elizabeth Lucas of Kaiser Health News contributed to this report. Kaiser Health News is a national health policy news service. Its work is supported by the John A. Hartford Foundation and the SCAN Foundation.