As a nursing home lawyer who has represented hundreds of families, I am constantly thinking of ways that the industry can improve. The one issue that has remained a problem for decades is the failure to provide safe, sufficient, and competent staff. The only way to do that is invest in training, benefits, competitive wages, and enough staff to prevent burnout.
The stunning death toll from the industry’s failure to prevent and contain the coronavirus has brought new scrutiny to an industry that is due for a major overhaul. Questions about reimbursements, staffing levels, adequate training for staff, effective regulations and oversight all are raging as states battle to control the ravages of the pandemic.
There have long been ideas among people who study nursing homes — or work in them — for ways to make them safer, increase quality, and be more humane. The pandemic exposed the weaknesses of the nursing home system. Facilities were short of PPE. Tales abounded of nursing home staff wearing rain ponchos and goggles from hardware stores because they couldn’t get proper gowns and face shields.
“There’s lots of hubbub” around nursing homes, says Dr. Louise Aronson, a geriatrician, professor of Medicine at UC San Francisco, and author of Pulitzer Prize finalist Elderhood. And it’s important, she says, that the public keep that focus. “The way we’ve created nursing homes,” she says, “they’re so separate from real life that it’s altogether too easy for people to go back to their lives and just kind of forget about it and not make a difference.”
Infection control is the most frequently cited deficiency by health inspectors. Annually, well over a million nursing home residents contract preventable infections and as many as 400,000 die from them. Even after the pandemic began, nursing home inspectors found that 34% of nurses and nursing assistants did not wash their hands properly and at least 25% were using personal protective equipment (PPE) incorrectly. Good grief.
Expert Charlene Harrington, a professor of Nursing and Sociology at the University of California San Francisco says that “The fines are so small that they don’t really have an impact on the nursing home. It’s just the cost of doing business.”
Professor Charlene Harrington of the University of California, San Francisco, says a “better way” would be to refocus the inspection system on the fundamental problem of nursing homes, which she says is inadequate staffing. Nursing assistants, she says, are “running from one resident to the other without hand washing,” which she says is one of the main reasons that nursing homes are so often cited for poor infection control.
So many of the citations that nursing homes receive — from poor infection control, to patients with bed sores, to nutrition problems — can all be traced back to insufficient staff, says Harrington, but it’s something they’re almost never cited for directly.
Harrington blames nursing home owners for the low staff levels.
“Over 70% of nursing homes are for-profit,” she says, contending they reduce staff to lower their costs. “That’s the primary way that for-profit companies can save money.”
“The financial interests of for-profit nursing homes are too often in conflict with their mission to care for older adults,” Harrington says. And the only way to fundamentally change that is to change the ownership structure, she says, regulating them like a utility.
“You would have very tough financial requirements, you would have stricter requirements of who could become an owner. Only owners with good track records would be allowed,” Harrington says. “And you would have very strict standards around their staffing and the way they pay their staff and treat their staff.”
People never picture themselves in a nursing home, Harrington says. But they should. And they should think about what they would like for themselves.
“Until we start doing that,” she says, “we’re going to allow them to continue to operate on a sub-par level.”
“I’ve been teaching nursing homes and studying this area for 20 plus years,” says David Grabowski, professor of Health Care Policy at Harvard School. “I would really think about smaller home environments where we value the caregivers and we value the residents,” Grabowski says. He imagines houses with just eight to 12 residents living together. “I think in general, we’ve had way too much focus in terms of regulation on quality of care and not enough on the quality of life in these homes.”
“There’s under-investment in care generally and in staff in particular,” Grabowski says. “And why can’t we pay more for these services and value the people that provide care for all of us in these settings? You know, we’re getting what we pay for right now. And it’s unfortunately not a very good outcome.”
Limiting occupancy can also help control the spread of infection, says Daniel Ruth, CEO and president of the San Francisco Campus for Jewish Living.
“I absolutely believe that all rooms should be single rooms,” Ruth says. Currently, many nursing homes house residents two or three or even four to a room, all sharing one bathroom, making it easier for infections to spread.
There might be better outcomes if most nursing homes weren’t designed to make money, says Daniel Ruth of the Jewish Home. “If I was the king of the world, there would be a much greater proportion of nursing homes run by not-for-profits.”