Category Archives: Staffing

Who Will Work?

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We are getting dozens of phone calls from resident’s families asking what they should do about their loved ones in nursing homes. Several claim that their loved ones are not getting the care they need. Same thing is happenening all over the country.  I read an article from a San Antonio with similar complaints.

“I think we’ve dropped the ball in all nursing homes,” said Stefanie Taylor, who made the tough decision to move her 76-year old mother, Charlotte Wood into a nursing home recently.   “I like I’ve literally thrown her to the lions’ den,” Taylor said.

Taylor says her mother tested positive for COVID-19 and was moved to a designated wing at the Guadalupe Valley Nursing Center. When she called one morning for an update, she spoke with a staff member.

“There was not a nurse assigned to the COVID unit for the day shift,” the staff member told her.  A nurse wasn’t present in the COVID wing from 10 Friday night until 10 the next morning.  The center is clearly understaffed.

“Her words were they were having trouble finding staff that wanted to work with a COVID positive patient,” Taylor said. “I felt like my mother and those other patients were in imminent danger at that point.”

“But they couldn’t spare me five minutes?”

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Thomas E. Comer’s final hours are a mystery to his family. You see, he died and was buried before the family knew he died of COVID-19. Comer lived at the Bayshore Health Care Center until his sudden death on April 13. The nursing home never contacted the family after the Irish expatriate succumbed to the coronavirus.  His son, David Comer, first learned of his father’s death after his daughter called the nursing facility to find out how he was doing.

“We had not heard anything. We knew they were overwhelmed, but I had this false sense nothing would ever happen to him,” Brianna Comer recalled. “The woman who answered the phone said she could not find him.” Then she was told he had expired.  “I went, ‘what? When did he die?’”

“We were told by the funeral home that he was already buried, against his wishes of being cremated, and they also attempted to contact my father, but they were only given an outdated phone number by the nursing home,” Comer remarked.

“Somebody could have told me something,” said his son, David. “He was my dad.”

“I understand what’s going on,” he said of the crisis in nursing homes. “But they couldn’t spare me five minutes?”

Comer, a retired Passaic County Sheriff’s Officer, said it would not have been hard to find him.

“They could have called the Holmdel police and given my name and they would have found me in minutes,” he said.

Born on September 2, 1931 in County Mayo on Ireland’s west coast in the town of Westport, Thomas Comer was a proud Irishman who never lost his brogue, said his granddaughter. He was a veteran of the Royal Air Force. He followed his parents and siblings to the United States, arriving here in 1958. She said he loved math and loved chess and for some reason, dogs always seemed to love him.

“He never got sick. He always said he had Irish immunity,” Brianna Comer remembered. “When we got sick, he said we weren’t Irish enough.”

The family is now trying to obtain his medical records in order to find answers regarding what happened to him and locate his belongings.

“I would have just appreciated his few effects,” said David Comer. “Some pictures. The wristwatch my son gave him. It’s just a $10 watch, but it was his.”

“Poor staffing…was the gasoline to COVID-19’s match.” 

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Consumer advocates and industry experts call for the federal government to address inadequate staffing at nursing homes and long-term care facilities in wake of the coronavirus pandemic and its fatal toll on residents and workers. The pandemic’s toll on nursing homes is a “deadly consequence” of inadequate staffing levels and lax infection control practices, according to Toby Edelman, senior policy attorney for the Center for Medicare Advocacy. She added that CMS must establish and enforce stronger oversight measures.

“The coronavirus pandemic has made all too visible the lethal consequences of poor care and no oversight. We can and must learn from what has gone wrong, and do better in the future,” Edelman said.

“The issues that COVID-19 exploited are not highly technical or complex. They are basic issues of training and adequate staffing,” testified Nicole Howell, executive director for Ombudsman Services of Contra Costa and Solano Counties. “Poor staffing in long-term care facilities was the gasoline to COVID-19’s match.” 

Howell also explained that “within the long-term care industry, direct care workers on average earn only $1 to $2 more per hour over state minimum wage, forcing these dedicated people to work 60 to 80 hours per week at multiple locations.”

“Meaning you can have a caregiver that works at one facility where there are active COVID-19 infections who are forced to work at a second location and may transmit the virus to residents,” she added.

David Grabowski, Ph.D., Harvard professor and healthcare policy expert, also stressed the need for providing more resources, such as better wages and more personal protective equipment, to address staffing shortages.

“Staff are frightened given the lack of COVID testing and PPE, and for good reason,” he said. “New federal COVID data suggests that over 500 staff nationally have died from COVID — making nursing home caregiver the most dangerous job right now in America, with a higher death rate than logging workers and commercial fisherman.”

He also emphasized the need for regular testing in nursing facilities and called on the federal government to develop a consistent testing and PPE policies nationwide, and provide resources for facilities to meet those standards.

“Until we get rapid and accurate testing for all staff and residents, we won’t be able to contain COVID. Rather than pushing the logistics and costs of testing and PPE to states and nursing homes, the federal government needs to take ownership of this issue,” Grabowski said.

“If we had testing and PPE in place, we would be able to move safely towards opening nursing homes again to family members,” he added.

Safe Staffing in Rhode Island

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Nursing home lobbyists are trying to trick Rhode Island legislators and citizens that requiring safe staffing at nursing homes will cause the world to collapse and everyone will go bankrupt.  Ridiculous.  Plenty of nursing homes provide staffing higher than what Rhode Island is suggesting as a minimum standard.

The proposed legislation would raise the state’s minimum staffing requirements. The minimum staffing legislation, sponsored by Rep. Scott Slater, requires nursing homes to provide 4.1 hours of direct care daily to each resident. Numerous article have made it clear that 4.1 is the minimum safe staffing for nursing home residents. It would also increase staff pay to a living wage at $15 per hour.

Scott Fraser, president of the Rhode Island Health Care Association, complained without evidence that the minimum safe staffing bill is “unrealistic” and would put many of the state’s nursing homes out of business. “There is no way homes can comply with the provisions of this bill and stay in business. It really is that simple.”

Right now, Rhode Island nursing homes provide an average of 3.6 hours of direct care to each resident, according to the U.S. Centers for Medicare and Medicaid Services. Attorney General Peter Neronha is among those who support the legislation, arguing that Rhode Island “is one of only a handful of states not to have a nursing home staffing standard.”

“Consequently, our state ranks near the bottom of the national average for hours of care provided to nursing home residents,” Neronha testified. “Many falls, infections and other injuries can be prevented by ensuring that health care workers are spending the time we know nursing home residents need to be safe and well cared for.”

The Expendables

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The Washington Post had a great article about the fear and danger nursing home caregivers are experiencing because corporate management refuses to provide proper PPE, staffing, and training to prevent the spread of the coronavirus. More than five months into the pandemic, nursing home caregivers say they have been left to fend for themselves even as outbreaks continue to overwhelm facilities across the country. Tens of thousands of nursing home workers have contracted the coronavirus and at least 600 have died.

“There’s been a lot of talk about essential workers,” said Rob Baril, president of Service Employees International Union 1199NE, which represents nursing home workers in Connecticut and Rhode Island. “They’re treated like they’re expendable workers.”

Lawmakers, industry groups and caregivers say the death count could have been limited if the industry had done more to develop an early, robust and coordinated response for nursing homes and other long-term-care facilities. More than 2,200 nursing homes reported earlier this month that they lacked an adequate number of nurses, and 2,600 reported a shortage of nursing aides, according to the CMS.

Even with sufficient supplies, experts say, years of understaffing and cost-cutting have left nursing homes vulnerable to widespread infection outbreaks. Staff turnover is particularly high among nursing aides, who often earn minimum wage and lack paid sick leave or health insurance, said Charlene Harrington, a nursing home researcher and professor at the University of California at San Francisco.

“They don’t care if they burn through staff,” she said.

Government inspections found multiple instances where nursing staffs were stretched so thin, they did not have enough time to follow proper hygiene practices, such as washing hands in between patients. To address potential staffing shortages, the CMS in March waived the requirement that nursing aides receive at least 75 hours of training. The move, advocates say, could exacerbate unsafe conditions by allowing homes to employ unqualified staff members.

Investigating Nursing Homes

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Kellie Schmitt wrote an interesting article for Center of Health Journalism about how two top journalists explained how to research and investigate nursing homes during the pandemic in a webinar called “Covering Coronavirus”.

Charles Ornstein, deputy managing editor at ProPublica, described the devastating and disproportionate toll taken by coronavirus on the country’s nursing homes, and how reporters can better understand, quantify and report on the crisis in their own communities. He was joined by fellow journalist Chris Kirkham, an enterprise reporter at Reuters, who offered a behind-the-scenes look at his own investigation into longstanding staffing shortages that left these facilities especially vulnerable to COVID-19.

Nursing homes had challenges even before the pandemic struck including 82% of nursing homes surveyed from 2013-2017 were cited for infection prevention and control deficiencies.

“This is a perennial problem and our coverage of the issue today needs to have that context of where we’ve been in the past,” he said.

When COVID-19 hit, nursing homes did not have the testing capabilities or the personal protective gear for staff they needed. Other challenges include low-paid staff who often need to work multiple jobs, and a history of deficiencies, particularly for infection control, he said.

The federal government’s searchable database on nursing homes and COVID-19 has been “deeply problematic,” and plagued with inaccuracies and inconsistencies, Ornstein said. As the pandemic has progressed, that information has improved, but it still doesn’t always line up with the information provided on state web sites.

“You need to be really careful about using this data without looking up as much as you possibly can and asking tough questions,” he said.

Ornstein also suggested telling the story of a nursing home in your community that kept COVID-19 at bay or one that got particularly slammed by the virus, and compiled this tip sheet for reporters covering the nursing home story.

Reuters reporter Chris Kirkham, who wrote a special report on nursing home staffing shortages with Benjamin Lesser, was initially interested in figuring out whether nursing homes with COVID-19 outbreaks had histories of deficiencies. But the reporters struggled with the spotty federal and state data.

They also wanted to report on something systemic, so they turned their focus to staffing. They heard from a lot of overworked workers who said staffing had always been a problem, but COVID-19 “has really just blown a hole into that entire system.” While management was publicly calling these workers “heroes,” many insiders did not feel they weren’t getting adequate support, he said.

To get a sense of the staffing situation at nursing homes coming into COVID-19, Kirkham and data journalist Lesser conducted their own analysis to grade staffing. They decided to use California’s minimum staffing requirements as a benchmark since its standards is among the highest and had been recently updated. They calculated that 37% of nursing homes throughout the country would not have met the minimum staffing requirement in California. And, at least 70% of the homes would not meet the higher bar that some experts recommend.

When two nurses who had gone on record about the “nursing home nightmare” faced retaliation,  Kirkham wrote a follow up story and quoted the Massachusetts attorney general.

Those fears of retaliation might scare sources into not talking on the record, a risk that means reporters should approach these situations carefully, he said. Even if someone doesn’t want to be interviewed on the record, listen to their story anyway and stay in touch, as their circumstances may change.

Kirkham emphasized the importance of determination and persistence when searching for on-the-ground voices. For his project, he created a spreadsheet with about 250 names and ended up connecting with 5% to 10% of them.

“It is way past time to have nurses in nursing homes.”

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Nursing homes need to be a priority when personal protective equipment (PPE) is being distributed, and these facilities also need to be required to have a nurse on staff 24 hours a day.

“It’s absolutely critical to have registered nurses 24 hours a day in nursing homes,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy, in Washington. “Right now, the only federal requirement is a registered nurse for 8 consecutive hours a day, but people get sick in the middle of the night.” Without a nurse on duty for nursing home workers to consult, “we’re not going to get good care for people,” she said. “It is way past time to have nurses in nursing homes.”

“The federal government, whose prompt response was so desperately needed, failed to surmount the challenge and make PPE a priority for nursing homes,” said Michael Wasserman, MD, a geriatrician and president of the California Association of Long Term Care Medicine. The nursing home industry “had the ability to leverage their assets to acquire PPE, but many chose to wait for a government response which didn’t happen … As a clinician, I don’t care who takes responsibility for the acquisition of PPE, but without PPE, COVID-19 cannot be stopped.”

Wasserman and Edelman were speaking at a roundtable hosted by the House Democratic Caucus Task Force on Aging and Families. Task force members also heard from Chris Brown, a certified nursing assistant working at a nursing home. “I find the work to be very rewarding but to be truthful, I face many challenges on the job, and many of these challenges existed before COVID-19,” said Brown.  Brown said nursing home workers are being paid “poverty wages” and often don’t get sick leave. “If I become sick, how can I take care of somebody? And who will take care of me? I have to choose between having the lights on and protecting my health.”

Wasserman worried about nursing homes allegedly dumping vulnerable residents in order to make room for more profitable COVID-19 patients. “I was worried that this type of behavior could and would occur, so when the story came out, it didn’t surprise me,” he said. “The bad apples highlight a couple of fundamental problems in the industry …. Surveyors can only do so much after the fact; we need to work to prevent this type of behavior” from occurring in the first place.

In addition, “medical directors have been kept out of medical management and decision making. We need to make sure the medical director is fully engaged,” said Wasserman. They’re critically important because “unless you have clinical leadership in the building calling this out, the facilities manage to come up with reasons and excuses for why they’re doing it. We need to be calling it out and recognizing that staff and facilities are under tremendous financial pressure and that drives a lot of this type of behavior.”

Staffing Data

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The Centers for Medicare & Medicaid Services announced plans today to end the emergency waiver and resume requirements for all nursing homes to submit staffing data through the Payroll-Based Journal (PBJ) system. Providers must have second-quarter staffing numbers to the Centers for Medicare & Medicaid Services by Aug. 14. Meanwhile, staffing data submitted for the end of 2019 will be captured for public posting and ratings.

CMS recommends that first-quarter data be submitted but does not require it.  Industry apologist Steven Littlehale, chief innovation officer at Zimmet Healthcare Services Group advises not to submit the staffing data.

“While Q1 data will not be used in Five-Star, if you choose to submit it, it will be publicly accessible and be possibly used by others,” Littlehale cautioned. “I would be careful in sharing data externally that isn’t required, but keep meticulous documentation on your staffing and all your attempts to provide appropriate staff to your residents. Secondly, COVID-19 hit our nation hard, but not equally. Certain markets were severely hit, while others had no cases. Five-Star doesn’t adjust for these geographic variances.

The Industry is a Moral Failure

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Charles C. Camosy teaches bioethics and moral theology at Fordham University.  He wrote an op-ed for the New York Times. Below are excerpts.

We knew it from the beginning. A nursing home in Washington State was the center of the first known coronavirus outbreak in the United States. We knew that institutions caring for the elderly and disabled in close quarters would be particularly vulnerable during the pandemic.

But we did not act. Personal protective equipment, special training and extra staff went almost exclusively to our critical care facilities. Nursing homes got virtually nothing. Well, that’s not entirely true. In New York and other places we gave them patients, and even nurses, infected with the virus.

The result has been a raging wildfire of infection and death. We don’t have full reporting of anywhere close to all the deaths at this point, but the best estimates right now are that about half of those who have died from Covid-19 have been nursing home residents. In some places, it’s much more: Connecticut reported that nearly 90 percent of its Covid-related deaths between April 22 and April 29 occurred in nursing homes.

We tend to see this as a public health failure, but it is also a moral failure. That fact hit me recently, after I went on Fox News’s “Tucker Carlson Tonight” to talk about the plight of nursing homes.

Even before the pandemic, these were places where what I call “throwaway culture” was thriving. The staff aren’t paid a living wage, often have poor training and are hopelessly overworked. The residents face elder abuse, and large percentages of them are desperately lonely. A good number get no visitors at all, which pushes rates of dementia among residents to unbelievable levels.

I suggested to Mr. Carlson’s audience that it was no surprise that throwaway culture kicked into hyperdrive in nursing homes during our current moment. I was excited to be able to make my case to a national audience; afterward, I was exhausted. All I wanted to do was help my wife get our 2-year-old to bed and go to sleep myself.

But that’s when the messages started coming in. Email. Facebook messenger. LinkedIn. Twitter. One after the other after the other. And they were horrifying.
It is one thing for a professor of bioethics to cite abstract numbers and trends and offer a theoretical explanation for them. It is another thing to get message after message detailing the human toll of what you had just discussed.

One of the most moving — and frightening — was from a nursing home staffer. She said she was given inadequate P.P.E. and training, and had likely been exposed to the virus. Her communications with management were ignored. Staff members at her facility were not being tested. She decided to quit her job rather than risk infecting her residents. “I don’t know if you can help me,” she said. “I feel that what you said is true; the elderly need a voice by someone that cares.”

Another correspondent, who had worked in health care administration, said that she was “not surprised in the least that the hospitals were trying to discharge their Covid-19 infected patients” back to long-term-care facilities because, in her experience, this has “been happening for quite some time.” It got worse: Agreeing with me about the radical understaffing of nursing homes, she said that it is “increasingly common is to discharge high cost and difficult patients to homeless shelters … Yep, you heard me right … HOMELESS SHELTERS.”

Not every story was coronavirus-specific. One man told me the story of the fatal neglect of his father — after which the nursing home falsified his father’s records and hid behind state laws that nursing home lobbyists had written.

A former director of nursing at a long-term-care facility said that given her terrible professional experiences, she had refused to put her 78-year-old husband, who was suffering from dementia, anywhere outside her own home. Another clearly frightened woman explained that she had just had a horrible experience with her mother in a nursing home; she even gave me, a complete stranger, her phone number, in the desperate hope that I could raise the alarm about how bad things were.

We need to listen to people like this and act on what they are saying. The pandemic doesn’t have many silver linings, but as the number of nursing-home deaths piles up, the news media is being forced to cover a world many of us would prefer to ignore.

It is understandable that we would. Part of the price we pay for living in a death-denying, consumerist, throwaway culture is that we must push these kinds of grim realities to unseen places that afford us plausible deniability. The pandemic forces us to look. If we want to understand the current phase of the coronavirus pandemic, we can no longer look away.

After receiving this waterfall of messages, I expected to fall into despair. But while I do have my bad days, I also have hope. Times like this have produced major cultural changes in our past. If we do take a hard look, we may change more than just the way we treat older Americans. We may, along the way, find a way to push against throwaway culture in all its forms.

Instead of denying the reality of cognitive impairment, aging and death, could our culture begin to embrace it forthrightly in ways which lead us to honor the final years we have with the family members and friends who go before us? To honor the moral and social equality of every human being, regardless of their mental or physical status?

Why not? Many of us are staying home and practicing physical distancing, not primarily for ourselves but for the benefit of our elders and others who find themselves at risk. Let us build on that good and decent impulse by challenging a throwaway culture that, right up until this very moment, has marginalized these populations and made the nursing-home crisis a tragic inevitability.

Living Wage and Short-Staffing

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WGBH News reported a disturbing but not surprising fact–we do not pay nursing home certified nurse aides enough.  PERIOD.

WGBH found a CNA named Shanna LaFountain who has been a nursing assistant for 20 years, but about two months ago, in the middle of the coronavirus pandemic, she stopped working. LaFountain, who has three children, said she made the decision once her children’s schools closed.

“I feel guilty. It eats me away,” she said. “It was an extremely hard decision to make. “The school was calling and emailing me constantly. My son was not answering teachers, not doing assignments. It was just too much. I had to be home with my children,” she said.

Instead of working, she gets unemployment benefits, and she receives $600 extra per week from the federal government on top of typical state unemployment benefits. She is making more now than when she works.

LaFountain is not alone. As part of the CARES Act, the federal government added an extra $600 per week to individuals’ unemployment checks. That means that most CNAs in nursing homes make more by collecting unemployment than they would by working, and some worry that is incentivizing workers to stay home.  Experts say nursing homes and long-term care facilities — which account for 40 percent of COVID-19 deaths in the country — are among the industries most critically affected by this phenomenon. Many certified nursing assistants like LaFountain, who would make more money staying home, say the rates for their work don’t match the risks.

Facilities are battling short-staffing because some staff are required to quarantine after being exposed to the virus, others are going to neighboring states where they can make higher wages, and still others are staying home and collecting unemployment.  Short-staffing causes neglect and abuse.  The understaffing makes it particularly harder for nursing homes and long-term care facilities to implement the protocol necessary to prevent the spread of the virus.

The industry should provide a decent wage so unemployed workers choose to come to work in the healthcare industry.  In a typical nursing home, he said, about two-thirds of the workforce are CNAs. They are often the ones with the closest relationship with patients, who can recognize early signs of health problems in residents and are trained in infection control procedures.