Here is a sobering statistic: As of March 20, 2022, a total of 151,726 nursing home residents across the U.S. had died with COVID-19.
The grim count does not end here. This figure does not factor in excess non-COVID deaths attributable to the wider effects of the pandemic. According to provisional CDC data, there were 33,755 excess fatalities just among residents with Alzheimer’s through early October 2021.
Countless others have suffered neglect and poor care due to COVID staffing issues, with complications such as bedsores, depression, and significant weight loss reaching unprecedented levels. As a nursing home resident interviewed by the National Consumer Voice for Quality Long-Term Care put it, “Staffing is worse than the pandemic itself.”
However, we cannot put all the blame on the pandemic. COVID-19 only exacerbated staff shortages and other problems that have been plaguing the sector for decades.
The good news is that the Biden Administration recently unveiled a large-scale overhaul of nursing home regulations. The proposed initiatives hold a lot of promise for staff and residents alike.
With this in mind, let’s explore how COVID staffing issues have impacted nursing homes and their residents and what we can expect from the planned regulatory changes.
The Effects of COVID Staffing Issues on Nursing Homes: Isolation, Depression, and Bedsores
On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) announced a package of new measures designed to protect nursing home residents from COVID-19. Among other things, visitations, communal activities, and access of nonessential personnel were significantly restricted.
Nursing home lockdowns likely helped contain the pandemic and averted a larger catastrophe. However, they also took a heavy toll on both staff and residents. This exacerbated pre-existing issues, prompting many to call for sector-wide reforms.
1. Severe Staff Shortages and High Turnover
Research has long shown a strong correlation between higher staffing levels and improved resident health indicators, including functional ability, bedsores, and weight loss. The reverse is also true: High turnover correlates with poor resident outcomes.
Unfortunately, facilities across the country have struggled with inadequate staffing for decades. Inadequate wages, poor training, and the high-stress nature of the job made it difficult to attract and keep skilled workers.
A 2016 study found that one in two nursing homes had low staffing and one in four had dangerously low staffing. In 2017-18, the average turnover reached:
- 140.7% for registered nurses (RNs)
- 114.1% for licensed practical nurses (LPNs)
- 129.1% for certified nursing assistants (CNAs)
In some facilities, annual turnover surpassed 300%.
COVID staffing issueshave only aggravated existing shortages. As nonessential personnel and family members could no longer enter the premises and provide informal care and support, the burden on core staff increased. Job applications for skilled nursing facilities (SNFs) dropped to an all-time low as employers failed to offer adequate pay and personal protective equipment (PPE).
The resulting high attrition and turnover rates were made worse by personnel contracting COVID-19. With 80 deaths per 100,000 full-time workers, nursing home personnel had one of the deadliest jobs in 2020 – surpassing loggers and approaching— and maybe even exceeding— fishers.
In January 2021, the U.S. PIRG Education Fund and Frontier Group reported that 23% of nursing homes across the country experienced staff shortages. That percentage exceeded 50% in some states. As of March 2022, total nursing home employment was at its lowest since 1990.
2. Lowering the Bar for Staff Training
One corollary of the unprecedented staff shortages during the pandemic has been the increased reliance on poorly trained staff.
In March 2020, CMS lowered CNA training requirements from a minimum of 75 to just eight hours of training. As a result, many new personnel entering nursing homes have been inexperienced and inadequately trained to meet the complex needs of residents. The waiver is still in place today.
3. Decline in Residents’ Physical Health— Bedsores and Weight Loss
Quarterly data aggregates published by CMS in its Minimum Data Set (MDS) indicate that nursing home residents’ physical health indicators have dropped across the board during the pandemic.
The condition (also known as pressure ulcers or pressure sores) is caused by repeated pressure on the skin. Bedsores can be hard to treat and are prone to infections that could lead to potentially fatal complications like sepsis.
To prevent bedsores, residents with reduced mobility, such as bedridden or wheelchair-bound people, must be repositioned regularly. Otherwise, the open wounds formed can lead to septic shock and other complications. The rise in bedsore rates suggests that many residents were not receiving adequate care.
In a 2021 survey by the National Consumer Voice, residents’ families repeatedly noted that their loved ones had lost a significant amount of weight during the lockdown. Respondents described their family members as looking “so skinny and weak near death,” “deprived of food [and] drink,” and “declining cognitively due to severe weight loss.”
MDS data confirms this. The number of residents who lost 5% of their body weight in the previous month or 10% in the past six months grew around 46% from Q4 2019 to Q3 2020. These numbers started to decline as restrictions were lifted, and families were once again able to visit their loved ones.
Due to COVID staffing issues, many residents were left without adequate toileting and hygiene assistance. Family members said for the National Consumer Voice that their relatives looked “unkempt” and “disheveled” and wore dirty clothes. Some residents’ teeth and nails had not been brushed and cut in months.
4. Deteriorated Mental Health
The combined effects of staff shortages and the absence of visitors caused residents’ mental health to take a turn for the worse. Separated from their loved ones, many remained confined to their rooms. Doors would often stay closed to the hallway due to COVID rules, and many residents only had human interaction for a few minutes each day when staff entered their room.
As a result, self-reported depression rates skyrocketed. MDS data shows that the number of residents who said they felt down, hopeless, or depressed for a minimum of two days in the past two weeks grew by over 40% between Q1 2019 and Q4 2020.
Eighty-six percent of the family members interviewed by the National Consumer Voice reported changes in their loved ones’ demeanor. They seemed “completely disengaged” and “angry and upset most days.” Many experienced a decline in long-term memory, others would repeat the same things over and over again, and some would beg to be taken home, describing the facility as a “prison.”
A Suspicious Rise in Schizophrenia Diagnoses
In September 2021, The New York Times reported a startling 70% increase in nursing home residents diagnosed with schizophrenia since 2012. Today, one in nine residents has a schizophrenia diagnosis, compared to just one in 150 in the general population. These rates seem odd considering that the condition rarely develops later in life. It is typically diagnosed in people in their 20s.
MDS data confirms that in Q1 2021, the numbers of residents diagnosed with schizophrenia and receiving antipsychotic medications rose by 54% and 77.5%, respectively, compared to the average increase for Q1 2018 through Q4 2019.
This sudden jump has led many to suspect that “phony” schizophrenia diagnoses and antipsychotics are used to sedate or control residents and make up for inadequate staffing. Research suggests that understaffed nursing homes are more likely to use antipsychotic drugs to manage troublesome behaviors.
Residents’ family members surveyed by the National Consumer Voice reported a significant decline in their loved ones’ mental health and demeanor. Some appeared “drugged, head hanging down” and showed little or no response when spoken to.
5. Little to No Scrutiny of Care
Compounding the problems of COVID staffing issuesand poor training in nursing homes was the absence of regulatory and financial scrutiny.
Complex Corporate Structures Breed Lack of Transparency
Over half of nursing homes in 2016 were run by corporate chains. In 2020, MarketWatch reported that private equity firms own around 11% of nursing facilities nationwide, with total investments reaching $5.3 billion since 2015, up from $1 billion in 2010-2014. Real estate investment companies have also entered the scene after the Housing and Economic Recovery Act of 2008 allowed them to buy healthcare facilities.
As complex ownership structures proliferate, financial transparency has dwindled, leaving regulators with poor insight into how facilities spend Medicare and Medicaid funding. Many nursing homes have detached their operating entities from their asset and property companies to reduce oversight and shield parent companies from liability.
Some corporations contract for services such as management, nursing, therapy, loans, and lease agreements with third-party providers owned by the same parent company. This enables them to pull capital out of nursing facilities in the form of expenses and hide profits in transactions with related third parties.
As a result, the profits of many nursing homes remain unclear. According to the Medicare Payment Advisory Commission, the average Medicare margin for freestanding SNFs was 10.3% in 2018 and has stayed over 10% for nearly two decades. Yet, the margins attributed to all payers range from just 0.6 to 3.8%. These are not likely to be the actual margins as nursing homes can hide profits in third-party deals.
Existing Regulations Are Insufficient
In an attempt to rein in the impact of private equity and complex ownership structures on nursing homes, policymakers introduced Section 6101 of the Affordable Care Act (ACA), which requires investors to disclose their identities and report to CMS. Section 6104 of the ACA and CMS then expanded requirements for SNFs reimbursed by Medicare to disclose both direct and indirect ownership down to 5%.
That said, CMS has yet to set up a mechanism to audit the ownership reporting system and ensure that all parent companies and related owners and corporations are fully and accurately disclosed. The federal government also does not have financial and quality standards for approving ownership and management changes.
The Future of Nursing Homes: New Regulations on the Way
On February 28, 2022, the Biden Administration announced plans for a radical overhaul of nursing home regulations. The government acknowledged COVID staffing issues, noting that they predated the pandemic. To address this problem, the Administration will conduct a study on staffing standards with a view to implementing a national federal minimum.
This is much-awaited good news for many in the industry.
These findings build on a large body of academic research showing that better staffing drives better resident outcomes. Yet, CMS has not set a minimum staffing standard to date.
In addition to establishing minimum staffing requirements, the Administration announced other planned initiatives aimed at:
- Reducing resident room crowding: Shared rooms are the default option in most facilities. Phasing out rooms with three or more residents and offering more single-occupancy rooms can help lower the risk of infectious diseases and protect residents’ privacy and dignity.
- Strengthening the SNF Value-Based Purchasing (VBP) program: The SNF-VBP program distributes nursing home funding based on performance indicators. CMS has recently added staff turnover and weekend staffing levels to the tracked metrics and plans to start factoring in staffing adequacy, resident experience, and staff retention rates in the near future.
- Reducing unnecessary medications and treatments: Despite existing measures, inappropriate diagnoses and prescriptions still occur. An upcoming CMS initiative will renew efforts to identify suspicious diagnoses and prevent the inappropriate use of antipsychotics.
Have You or a Loved One Developed Bedsores Due to COVID Staffing Issues?
At Bedsore.Law, we have over 35 years of combined experience protecting the rights and dignity of nursing home residents who develop Stage III and IV bedsores due to neglect, abuse, or inadequate care.
We are the leading experts in bedsore litigation representing victims and their families across the country.
If you or a loved one has suffered from bedsores due to COVID staffing issues, get in touch today to discuss your options. We will make sure that you get the compensation you deserve.