IDPH has cited and fined Generations at Rock Island nursing home after a resident there sustained a fractured hip caused in part by the understaffing of the nursing home.
In this blog, we often discuss the importance of the care planning process in delivering the routine care that is absolutely necessary to assure the health, safety, and well-being of residents (see here, here, here, and here for recent examples). However, even the best care plan is of no use if there is not enough staff around to actually carry it out.
There are two basic regulatory standards that have to be met in terms of staffing levels at nursing homes. One is the state standard which uses a mathematical formula to determine appropriate staffing levels. The second standard is the federal regulation which is more flexible, yet more demanding. It provides that the nursing home must have enough appropriately trained staff on hand to meet the care needs of the residents on a 24/7 basis.
Understaffing has always been a part of the nursing home business model. It is part of why we believe that nursing homes are inherently built to fail and why we wrote a free report with the same name. In essence, nursing homes are one of the few explicitly for-profit sectors in the health care industry. They generate revenue per resident, per day and maximize revenue by filling as many beds as possible with as many ill people as they can. On the expense side, staff is the biggest expense item and to maximize profits, you need to keep staffing expense to a minimum.
The net result of this is that resident suffer poor care because there is not enough staff on hand to meet the care needs of the resident. Residents are not turned and repositioned and do not receive prompt incontinence care, leading to bed sores. Residents don’t get help and/or supervision while eating, leading to malnutrition and dehydration as well as nursing home choking accidents. Nurses get distracted while doing medication pass, leading to medication errors. And finally as here, staff is unable to answer call lights, leading to nursing home falls.
The citation that IDPH issued to this nursing home is long (130 pages) and covered a multitude of issues involving several different residents, but we are focusing here on the staffing issue and how it related to this resident’s fall. As a starting point, one of the things that the nursing home was explicitly cited for was understaffing. Understaffing is a common feature of care in nursing homes and is often the root cause of many unnecessary deaths and injuries to nursing home residents, but it is rarely the explicit subject of a citation issued by IDPH.
How bad was the understaffing that IDPH found? In one portion of the citation, a nurse described having 43 residents to care for with her and one aide. There is simply no way that residents can get the care they need with that kind of resident to staff ratio. The pandemic has clearly made things more difficult for nursing homes, but ending up with staffing levels like that is a failure of management.
What was the impact of the short-staffing on this resident?
She was assessed as being a fall risk due to difficulty walking and dementia. Dementia is a key factor is a resident’s fall risk because residents suffering from dementia cannot be relied upon to follow instructions or make good decisions for their own safety. Before the fall in which she broke her hip, she had a fall in which she suffered a bump on the head. One of the truisms in the nursing home industry is that the occurrence falls tend to beget additional falls, and her care plan was revised to include 15 minute checks on the resident.
Frequent checks on residents who are fall risks is an excellent step for preventing falls – if it is actually done. However, we know that this nursing home was understaffed and this was something that was not feasible for the staff given the staffing levels. However, the care planning process requires more than writing down good ideas on paper; it requires actually carrying them out.
On the day of this nursing home fall, the resident sounded the call light to get help to go to the bathroom. Her roommate told the state surveyor that the call light hand been on for about a half hour. The resident leaned against her table while going toward the bathroom. The table broke and she fell to the ground, suffering a fractured hip.
This is a situation where the is an explicit link between understaffing of the nursing home and a resident injury. The resident was supposed to be checked on every 15 minutes. That didn’t happen, as the roommate told the state surveyor that she had been waiting a half hour after sounding the call light, so the care plan was clearly not being implemented. This was also likely not the first time that this had happened, and when there are repeated instances of not getting a timely response to a call light, the residents are essentially trained that no one is coming when they sound a call light, so they are ever more likely to take risky actions.
The net result for this one resident is that she suffered a serious injury that has real long-term consequences, assuming that this not a case where the hip fracture ends up being an ultimately fatal injury.
Other blog posts of interest: