Years of high employee turnover and understaffing at the nation’s nursing homes could undermine efforts to implement infection control measures designed to fight the spread of the new coronavirus.
Wide-ranging new guidance from the Centers for Medicare & Medicaid Services updated on March 13, issued in response to the virus, calls for nursing home staff to screen and restrict most non-essential visitors, review and revise patient transportation procedures, increase checks for possible respiratory infections, and increase communications with residents’ families as in-person visitations are curtailed.
The “new guidance will not require more resources or additional employees” even though the regulations call for ill nursing home workers to stay home, said David Gifford, chief medical officer at the American Health Care Association, which represents the nursing home industry.
Connie Steed, president of the Association for Professionals in Infection Control and Epidemiology, agreed, saying the facilities implement similar safeguards each year for influenza.
But 75% of nursing homes have inadequate staffing, said Charlene Harrington, professor emerita at the University of California San Francisco School of Nursing. She said her own research and that of others has found the problem is most serious among registered nurses who supervise the care team and diagnose residents who could be infected.
“I just think that the nursing homes are running so low on staffing that CMS can send out all the guidelines they want, it’s not going to work,” Harrington said. “They’re not going to be able to do it because they just can’t get the basic work done.”
Nursing homes, which care for the 1.3 million Americans, are a high-risk transmission point for the coronavirus, which has proved more lethal among the facilities’ most common residents: elderly people with underlying health issues.
Federal law requires nursing homes to provide “licensed nursing services” that are “sufficient” to meet resident needs. But Medicare only requires nursing homes to have at least one registered nurse on duty for eight straight hours per day.
A recent study by researchers at Harvard University found 91% of facilities met federal staffing levels for registered nurses less than 60% of the time. And staffing levels for registered nurses, licensed practical nurses, and nurse aides typically dropped off at night and on weekends. Overall, 54% of facilities met the expected staffing levels less than 20% of the time.
As of March 16, 29 deaths were associated with the nation’s worst coronavirus outbreak at the Life Care Center nursing home in Kirkland, Wash., according to King County government.
The U.S. now has 4,392 confirmed cases of Covid-19 as of March 16, according to figures from Johns Hopkins University, which also shows 42 U.S. deaths. The World Health Organization on March 11 declared the outbreak a pandemic as cases outside China have jumped 13-fold.
Not a ‘Big Stretch’
Nearly two-thirds of the nation’s nursing homes were cited for one or more infection-control deficiencies over the past three years, according to an analysis by Kaiser Health News. Facilities with fewer nurses and nursing aides were cited more often than those with higher staffing levels.
The novel coronavirus spreading worldwide, however, is “10 times more lethal than the seasonal flu,” Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, told the House Oversight and Reform Committee on March 11.
Steed said nursing homes’ annual influenza precautions already include additional patient screening, visitor restrictions, stepped-up hand hygiene, and other measures similar to the enhanced coronavirus protocols. And if more personnel is needed, many facilities have supplemental employee lists that allow them to beef up staffing when the need arises.
But even with adequate staffing levels, retaining employees—a longtime problem for the nursing home industry—could become even more pronounced as the facilities emerge as a vulnerable and potentially dangerous workplace for a coronavirus cluster.
“If one area concerns me, it would be the maintenance of staffing,” at nursing homes, Steed said.
Morgan Katz, an assistant professor at the Johns Hopkins University School of Medicine who specializes in infectious diseases, said low pay is the problem.
“That’s the bottom line,” Katz said. “It’s very hard work, and they don’t get paid very much.”
Low Medicaid rates make it difficult for nursing homes to be profitable and beef up staffing, when profit margins at most facilities are typically $100,000 to $200,000 a year, Gifford said last year.
Working conditions at the nursing homes are also a challenge.
Harrington said nursing assistants often handle 12 to 15 patients per shift in nursing homes when seven is considered optimal. And nurses can be responsible for 30 patients or more, compared with one nurse for every two to four patients at a hospital, Katz said.
As nursing home staffers leave for better pay and working conditions in hospital settings, infection prevention training becomes harder, Katz said. “Because as soon as you train everybody in the facility, you lose half the people that are working for you. So staying up to date on those education protocols is the challenge,” she said.
A CMS recommendation that ill nursing home workers remain at home to keep from infecting residents will also take a toll, Katz said. Since most nursing home workers don’t get paid sick leave, missing work means means smaller paychecks.
“You have two challenges: You’re giving them more options to not have to come into work and requiring them to do more work. So yes, I foresee issues there,” said Katz, who studies the spread of infectious diseases in nursing homes.
Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, said the vast majority of nursing home staff are are “extremely dedicated” and care a lot about the residents.
“I think that will push them and motivate them, the vast majority of them, to come in,” if they’re healthy, Grant said.