Snapshot: Staffing and Quality in California's Nursing Homes€¦ · ©2006 California HealthCare...

s n a p s h o t

Staffing and Quality in California’s Nursing Homes

2006

©2006 California HealthCare Foundation 2

Nursing Home Staffing and Quality

C O N T E N T S

Number of Fulltime Nursing Staff in Hospitals and Nursing Homes . . . . . .3

Nurse Staffing Hours . . . . . . . . . . . . . .4

Nurse Staffing Levels . . . . . . . . . . . . . .5

Nursing Hours by Ownership Type . . . .6

Facilities that Meet Staffing Goals by Ownership Type . . . . . . . . . . . . . . .7 by Facility and Ownership Type . . . . .8

Total Deficiencies and Citations by Staffing Level . . . . . . . . . . . . . . . . .9

Top Ten Deficiencies in Nursing Facilities . . . . . . . . . . . . .10

Complaints . . . . . . . . . . . . . . . . . . . . .11

Staff Turnover and Satisfaction in Nursing Facilities, National . . . . . . .12

Freestanding Nursing Home (FNH) Turnover Rates . . . . . . . . . . . . . . . . .13

Nurse Staff Turnover Rate by Staffing Level . . . . . . . . . . . . . . . .14

Deficiencies Among Freestanding Nursing Facilities, by Turnover Rate 15

Turnover and Deficiencies by Ownership Type . . . . . . . . . . . . . .16

Wages in Freestanding Facilities by Nursing Turnover Rates . . . . . . . .17

Authors . . . . . . . . . . . . . . . . . . . . . . . .18

IntroductionStaffing levels in California’s nursing homes are a key indicator of the quality of

care. A study from the U.S. Centers for Medicare and Medicaid Services (CMS)

found that homes with low staff levels have an increased probability of causing

serious harm to residents. In 1999, the state passed a law increasing minimum

staffing level from 3.0 to 3.2 hours per resident day.

Since that time the percentage of nursing homes not meeting the new standard

fell from 41 to 24 percent. Among other findings in this snapshot:

• Seventy-nine percent of hospital-based facilities and 21 percent of

free-standing facilities meet the 1999 standards.

• Homes with more staff have higher staff satisfaction rates, significantly

less turnover, and fewer documented deficiencies in care.

• Nearly half of resident complaints center on poor food and more than

38 percent of complaints concern quality of care.

Although there have been improvements in increasing staffing levels for

California’s nursing homes, this snapshot illustrates that levels are still not at the

recommended level for providing high quality care to nursing home residents

across the state.


2003200020032000

131,293

33,860

10,525

86,908

122,990

30,530

10,332

82,128

59,946

42,334

11,286

6,326

63,990

46,024

12,326

5,640

Licensed NurseNursing Assistant

Registered Nurse

Nursing Home Staff

Hospital Staff


Of the almost 200,000

nursing staff working

in California in 2003,

about a third worked in

nursing facilities and a

majority of those were

nursing assistants.

Number of Fulltime Nursing Staff in Hospitals and Nursing Homes, 2000 vs. 2003

Source: Division of Nursing, Bureau of the Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, Spratley, E., Johnson, A., Sochalski, J., Fritz, M. and Spencer, W. 2000. The Registered Nurse Population March 2000: Findings from the National Sample Survey of Registered Nurses. Washington, DC.

Office of Statewide Health Planning and Development. 2000 and 2003. Long-Term Care Facility Data. Pivot tables. Sacramento, CA.


2003200220012000

3.60

3.96 4.06 4.00


Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using Office of Statewide Health Planning and Development’s long term care and hospital annual financial data for 2000 – 2003.

Nurse Staffing Hours, 2000 – 2003

Average Hours per Resident DayHigher levels of nurse

staffing are related

to better quality of

care. Since legislation

was passed for a

minimum of 3.2 hours

per resident day in

California in 1999,

average nurse staffing

hours for residents in

nursing homes have

increased.


41%56%

3%

24%

71%

5%

Nursing Home Staffing and QualityNurse Staffing Levels, 2001 vs. 2003

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations using the Office of Statewide Health Planning and Development’s long-term care annual financial data for 2001 and 2003; Center for Medicare and Medicaid Services: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Report to Congress, 2001.

Between 2001 and

2003, the number of

homes that failed to

meet state-mandated

staffing standards fell

58 percent. Still, nearly

one in four homes did

not meet the standard

in 2003.

■ Recommended (4.1+ hours)

■ State Mandated (3.2+ hours)

■ Below State Mandated (< 3.2 hours)

Hours per Resident Day

2001 2003


For ProfitNonprofit

6.47

1.68

1.39

3.40

3.49

.40

.70

2.39

Registered Nurse (RN)Licensed Nurse (LVN)Nursing Assistant

Nursing Home Staffing and QualityNursing Hours by Ownership Type,

2003In 2003, 11 percent

of nursing hours in

for profits were

provided by RNs while

26 percent of nursing

hours were by RNs

in nonprofit facilities.

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care and hospital financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.

Total Hours of Care per Resident Day


Nonprofit

TOTALFor Profit

2000 2001 2002 2003

Nonprofit 81% 90% 90% 93%

TOTAL 43% 60% 71% 76%

For Profit 36% 53% 68% 73%


Most (93 percent)

nonprofit nursing

homes meet the

minimum state staffing

standard (3.2 hours per

resident day); staffing

levels have increased

over this four-year

period.

Sources: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.

Facilities that Meet Staffing Goals by Ownership Type, 2000 – 2003


Hospital-based79%

Freestanding21%

Nonprofit62%

For Profit38%


Studies have shown

that a staffing goal

between 4.1 and 4.5

hours per resident

day, depending on the

needs of the residents

in a facility, provides

the most appropriate

level of care. Most

nursing homes that

meet this staffing goal

are hospital-based or

nonprofits.

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000-2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.

Facilities that Meet Staffing Goals by Facility and Ownership Type

Facility Type Ownership Type


Meets…

Minimum Standard 3.2 hours per resident day

Recommended Goal 4.1 to 4.5 hours per resident day

2000 2001 2002 2003

13.39 14.83 14.81 14.29

8.57 9.62 9.53 9.13

Nursing Home Staffing and QualityTotal Deficiencies and Citations

by Staffing Level, 2000 – 2003Nursing homes that

met the recommended

goal (4.1 to 4.5 hours

per resident day) had

more than one-third

fewer deficiencies than

those that met the

state minimum staffing

standard (3.2 hours per

resident day).

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


Housekeeping

Pharmacy Procedures

Infection Control

Hazards

Incomplete Care Plan

Unnecessary Drugs

Dignity Not Respected

Incomplete Records

Quality Care

Food 46.2%

38.7%

33.7%

30.2%

28.9%

28.8%

28.8%

28.2%

25.4%

24.1%


Almost half of surveyed

nursing facilities

reported food-related

deficiencies; more

than a third reported

deficiencies that were

quality of care-related.

Source: CMS OSCAR Survey Data, updated December 2005. Prepared by CAHF IRC January 2006.

Top Ten Deficiencies in Nursing Facilities, 2005

Percent Reporting


Met Recommended Goal(4.1+ hours)

Met Minimum Standard(3.2+ hours)

1.6

2.8

2.1

1.0

Quality of CareTotal

Number of Complaints

Nursing Home Staffing and QualityComplaints

Total and Quality of Care, 2003


The number of total

complaints and quality

of care complaints

is higher at nursing

homes that meet the

minimum state staffing

requirement (3.2 hours

per resident day) than

those that meet the

recommended goal

(4.1 to 4.5 hours per

resident day).


…High Number of Satisfied Staff

…Fair Number of Satisfied Staff

…Very Few Satisfied Staff

8%

79%

18%

66%

36%

58%

Staff SatisfactionTurnover Rate

Nursing Home Staffing and QualityStaff Turnover and Satisfaction

in Nursing Facilities, National, 2003Nursing facilities with

higher percentages

of satisfied staff have

lower turnover rates.

Share of Very Satisfied Staff in a Facility with…

Source: Tellis-Nayak, V., Customer Satisfaction in Long Term Care: A Guide to Assessing Quality, AHCA, 2003.


2003200220012000

80% 80%

70%

65%

Nursing Home Staffing and QualityFreestanding Nursing Home (FNH)

Turnover Rates, 2000 – 2003Turnover rates for

nursing staff in

freestanding nursing

homes decreased

by 19 percent from

2000 to 2003.

Sources: Janis O’Meara and Charlene Harrington, University of California, San Francisco. Calculations provided using Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003. Employee [percent] turnover rates for health care and social services, NOBSCOT www.nobscot.com/survey/us_voluntary_turnover_0103.cfm.

http://www.nobscot.com/survey/us_voluntary_turnover_0103.cfm


Met Recommended Goal(4.1+ hours)

Below Recommended Goal(< 4.1 hours)

66%

55%


The turnover rate for

nursing homes that

met the recommended

nurse staffing goal

of 4.1 to 4.5 hours

per resident day was

significantly lower than

for nursing homes that

did not meet the goal.

Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.

Nurse Staff Turnover Rate by Staffing Level, 2003


Low Turnover(< 47%)

Medium Turnover(47% to 71%)

High Turnover(72%+)

16.0

14.5

13.2


In 2003, nursing homes

with the highest

turnover rates received

a higher number of

deficiencies than those

nursing homes with

average or low turnover

rates.

Deficiencies Among Freestanding Nursing Facilities, by Turnover Rate, 2003Average Number of Deficiencies

Source: Janis O’Meara and Charlene Harrington, University of California. San Francisco. Calculations provided using California Office of Statewide Health Planning and Development’s long term care financial data for 2000 – 2003, and California Department of Health, Licensing and Certification Program, Automated Certification and Licensing Administrative Information and Management Systems (ACLAIMS) data January 1, 2000 to December 31, 2003.


Average Number of DeficienciesNurse Turnover Rate

55%

66%

15.2

9.7

NonprofitFor Profit

Nursing Home Staffing and QualityTurnover and Deficiencies

by Ownership Type, 2003


Nonprofit nursing

facilities have lower

turnover rates and

fewer deficiencies than

for-profit facilities.


Low Turnover(< 47%)

High Turnover(72%+)

$10.17

Licensed Nurse (LVN)Nursing Assistant

$22.52

$10.76

$23.21

Nursing Home Staffing and QualityWages in Freestanding Facilities

by Nursing Turnover Rates, 2003Wages for nursing

assistants and

licensed nurses were

significantly lower in

nursing homes with

high turnover rates

than in nursing homes

with low turnover rates.

Low wages is one of

the primary reasons

for high turnover rates

among nursing staff.



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Please click here to access our feedback form. Or visit www.chcf.org/feedback and enter Report Code #1090. Thank you.

FOR MORE INFORMATION

California HealthCare Foundation

476 9th Street

Oakland, CA 94607

510.238.1040

www.chcf.org


Authors

Charlene Harrington, Ph.D., Janis O’Meara, M.P.A., and Taewoon Kang, Ph.D.

Department of Social and Behavioral Sciences, School of Nursing, UCSF

http://www.chcf.org/feedback

http://www.chcf.org

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