Understaffing in Nursing Homes

Understaffing in nursing homes is one of the biggest factors leading to nursing home abuse and neglect. Understaffing leads to inadequate attention from staff, meaning residents are more likely to get hurt through falls, dehydration, malnutrition, or bedsores. It may also mean that the staff on-duty will feel overwhelmed and underpaid, making them more likely to enact abuse.

Reviewed by Julie Rivers, MBA , Eldercare Advocate & Expert

Why Are Nursing Homes Understaffed?

Understaffing in nursing homes is an ongoing problem that many people are aware of, though the reasons for it are not generally understood.

Sometimes, understaffing is due to unavoidable factors such as not enough people applying to jobs. Other times, nursing home owners and managers intentionally under-staff their facilities. There are several reasons this type of intentional understaffing occurs.

The Cost of Labor

Paying employees in shifts that must span 24 hours each and every day comes at an astronomical cost. This is why owners and managers of nursing facilities have been known to short-staff.

However, when nursing homes are short-staffed, employees can’t deliver meals on time, help bedridden residents to the bathroom, or answer pain medication requests.

Staff Turnover

Sometimes, nursing homes are unable to retain enough trained nurses and certified nursing assistants. This can often be a result of understaffing, not just a cause.

If nursing home employees are being over-scheduled and overwhelmed by their duties, they may be more likely to quit.

False Reports of Staffing Levels

An alarming report came out following the Affordable Care Act of 2010, in which Kaiser Health News analyzed data from more than 14,000 nursing homes.

“On the worst staffed days at an average facility, the new data show on-duty personnel cared for nearly twice as many residents as they did when the staffing roster was fullest.”

– New York Times

Prior to the act, which states that staffing levels must be verified through payroll, Medicare had been receiving staffing level data directly from the nursing homes, which made it possible for them to report false information.

Overtime Pay Issues

Overtime pay is a very common factor that plays into understaffing at nursing homes. Many nursing home employees seek to work overtime because they are paid at a higher hourly rate. Additionally, administrators may encourage staff to work overtime to ensure shifts are covered.

However, working unreasonable hours results in a decreased quality of patient care.

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Effects of Understaffing in Nursing Homes

Understaffing in nursing homes is directly linked with the level of care that nursing home residents receive.

Some effects of understaffing in nursing homes include:

  • Dropped nursing home residents from being moved by only one staff member when two are needed
  • Falls that occur when residents try to go to the bathroom on their own because no one comes when they call
  • Facility closures, especially in rural areas, leaving even more residents without the care they need
  • Painful and infected bedsores caused by inadequate staff available to move or turn patients

Not having adequate staff is the source of an alarming number of nursing home neglect cases. Without enough nurses and certified nursing assistants (CNA) to provide such basics as food, water, bathing, and movement, it is impossible to provide acceptable levels of care.

“The dangers of understaffing have been common knowledge in the U.S. nursing home industry since the 1980s.”

– National Institutes for Health

Understaffing in nursing homes is responsible for injuries, deaths, and innumerable violations of human dignity, which is a basic right of all nursing home residents.

Preventing Staffing Problems in Nursing Homes

Understaffing is a major issue since it is directly related to patient care and instances of nursing home abuse. Nursing home residents can suffer from poor quality of life and even death due to less staff than is required.

Preventing understaffing in nursing homes and assisted living facilities is critical to ensure that the physical, mental, and psychosocial wellbeing of each resident is protected.

Nursing home care should not be seen as having only to be adequate — a high quality of care must be consistently maintained.

The most significant way to prevent understaffing in nursing homes is to demand and enforce enough staff, including minimum nurse and CNA staffing levels.

A guide was published in 2020 by the peer-reviewed journal Health Service Insights to help determine if staff levels at nursing homes are appropriate. By following these five steps, understaffing at nursing homes can be addressed.

1. Determine the collective resident acuity and care needs.

Acuity is the proper distribution of caregiver expertise and resources to ensure a resident’s care is sufficient based on their current health needs.

Since nursing home residents’ care needs vary greatly, a classification system has been recommended to determine appropriate staffing levels.

The system uses six basic categories from highest to lowest care needs:

  1. Extensive services
  2. Special care high
  3. Special care low
  4. Clinically complex
  5. Behavioral symptoms
  6. Reduced physical functioning

Proper staffing levels are needed to protect resident health, safety, and well-being. No matter what condition a nursing home resident is in, family members should not have to worry about their loved one’s care due to improper staffing.

2. Determine the actual nurse staffing levels.

Data collected in the Payroll Based Journal (PBJ) study showed that understaffing in nursing homes is far more common on weekends.

Since nursing home residents require the same care on the weekends as they do on weekdays, these findings show that nursing homes are not staffing according to resident needs.

3. Identify appropriate nurse staffing levels to meet residents’ care needs.

Since resident care needs can be so different, appropriate nurse staffing levels must be determined based on actual patient needs.

Using state or federally mandated minimums to prevent understaffing from occurring is not an effective way to appropriately staff nursing homes. There is no one-size-fits-all nurse staffing plan.

4. Examine evidence regarding the adequacy of staffing.

To prevent understaffing in nursing homes, an analysis of past history should be undertaken to identify any holes or harmful patterns.

This should include examining:

  • Adverse events
  • Federal and state complaints
  • Medicare & Medicaid Services quality measures
  • Missed care
  • Staff turnover

Understaffing may be the underlying problem in contributing to errors and adverse incidents.

5. Identify gaps between the actual staffing and the appropriate nursing staffing levels.

Nursing homes need to meet a minimum level of staffing. Any gaps between actual and appropriate staffing in nursing homes must be identified and resolved.

Nursing home facilities should meet or exceed the basic federal quality requirements to properly handle the needs of each resident.

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How To Report an Understaffed Nursing Home

If a nursing home resident is seriously hurt, it is imperative to call 911 immediately.

If you believe understaffing at a nursing home is an ongoing issue, you may bring the problem to one of the following state and federal groups:

  • Long-Term Care Ombudsman
  • Medicaid Fraud Control Unit
  • National Center on Elder Abuse
  • Protection and Advocacy Network
  • State Licensure Office
  • State Survey Agency

You may also wish to contact Eldercare Locator by telephone at 1-800-677-1116. Specially trained operators will refer you to a local agency that can help.

Is Understaffing Illegal in Nursing Homes?

Those who have witnessed avoidable issues due to not enough staff may wonder whether understaffing is illegal in nursing homes.

Sadly, Medicare has no minimum resident-to-staff ratio to prevent understaffing in nursing homes. The only requirement is that a registered nurse be on-site eight hours a day and a licensed nurse be at the nursing home 24/7.

Seek Justice for Your Loved One

Understaffing in nursing homes is not a minor problem. While some people may think it just means their loved one will have to wait a bit longer to get their needs taken care of, it is actually far more serious than that.

Understaffing can lead to horrible suffering related to falls, dehydration, bedsores, and even death. By filing a nursing home abuse lawsuit, you can get justice for your loved one’s needless suffering.

A successful nursing home lawsuit can get you the compensation needed to pay for:

  • Cost to change nursing homes or caregivers
  • Medical bills
  • Mental health therapy
  • Physical therapy

Pursuing a nursing home abuse claim can be the best way to keep your loved one and other nursing residents safe and free from future harm.

Get a free case review today to learn if you may be eligible for compensation.

You deserve justice. Get a free legal case review now.

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Reviewed by:
Julie Rivers, MBA
Fact Checked

Julie Rivers is an eldercare advocate with over 15 years of dedicated service to victims of nursing home abuse and neglect. Her journey in this field became deeply personal when she assumed the role of an unpaid caregiver during her mother’s battle with Alzheimer’s disease.

ReferencesView References
  1. Harrington, C., Dellefield, M. E., Halifax, E., Fleming, M. L., & Bakerjian, D. (2020). Appropriate Nurse Staffing Levels for U.S. Nursing Homes. Health services insights, 13, 1178632920934785. Retrieved March 25, 2021 from https://doi.org/10.1177/1178632920934785

  2. Harrington, C., & Edelman, T. S. (2018). Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain. Inquiry : a journal of medical care organization, provision and financing, 55, 46958018788686. Retrieved March 25, 2021 from https://doi.org/10.1177/0046958018788686

  3. NBC News. (2023). “Small-town nursing homes closing amid staffing crunch.” Retrieved March 23, 2023, from: https://www.nbcnews.com/health/aging/nursing-homes-small-towns-closing-staff-shortages-rcna66779.

  4. Medicare.gov. (n.d.) Reporting & resolving nursing home problems. Retrieved March 25, 2021 from https://www.medicare.gov/what-medicare-covers/what-part-a-covers/reporting-resolving-nursing-home-problems

  5. Muthara, G. (2018). Gaps in Nursing Home Staffing Underreported. AARP. Retrieved March 25, 2021 from https://www.aarp.org/caregiving/basics/info-2018/nursing-homes-staffing-quality-care.html

  6. The National Law Review. (2019). Nursing Home Residents at Risk: Study Finds Significant Understaffing in 75% of Skilled Nursing Facilities. Retrieved March 25, 2021 from https://www.natlawreview.com/article/nursing-home-residents-risk-study-finds-significant-understaffing-75-skilled-nursing

  7. U.S. Department of Human and Health Services. (n.d.) How do I report abuse elder abuse or abuse of an older person or senior? Retrieved March 25, 2021 from https://www.hhs.gov/answers/programs-for-families-and-children/how-do-i-report-elder-abuse/index.html