NY’s Nursing Home Staffing Shortages Raise Concerns About Quality of Care

At Peninsula Nursing and Rehabilitation Center in Far Rockaway, a patient had much of his bowel removed after a bedsore developed into a life-threatening case of gangrene, according to a 2016 lawsuit.

At Meadow Park nursing home, a resident sat for hours in a soiled diaper, according to inspection reports.

Also according to inspection reports, residents at Concord Nursing and Rehabilitation Center were needlessly restrained with bed rails, and one told health inspectors he felt like he was “trapped in bed.”

Meadow Park, Peninsula, and Concord are just a few of the city’s many chronically understaffed nursing homes. A City Limits investigation found that almost three-quarters of the city’s skilled nursing facilities are rated “Below Average” or “Much Below Average” for staffing by the Center for Medicare and Medicaid Services, which collects data on nursing homes nationwide.

In New York City’s worst-staffed homes, nursing home residents get fewer than three hours on average of direct nursing care each day—below the 4.1 hours of active care the average resident requires per day to be well taken care of, according to the Long-Term Care Community Coalition. Some of the lowest rated homes reported having no registered nurses on site for multiple days each quarter.

City Limits found that those gaps have serious consequences for residents. On average, an analysis of data from the Center for Medicare and Medicaid Services reveals, New York City’s most understaffed nursing homes have lower health ratings and almost twice as many citations for health hazards as the best-staffed facilities. And as overworked staff struggle to keep up with the workload, residents and their loved ones report humiliating and dangerous episodes of neglect.

“The [nursing assistants] just don’t have the time to take care of everybody,” said Lemuel Carter, who said he often had to change his own wound dressings during his six-month stay at Meadow Park in 2018. “They don’t have the manpower.”

The importance of staffing

Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, says that staffing has always been a problem for nursing homes. Edelman explained that the 1987 Nursing Home Reform Act required nursing homes to have a licensed nurse onsite at all times, but it didn’t set any minimum staff-to-resident ratios.

And until last year, CMS relied on self-reported staffing data, making shortages difficult to quantify.

The result is that for-profit nursing homes see staff as an easy target for budget cuts, said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, an advocacy group for people in long-term care facilities.

“You cut the staff because you can,” she said. “You cut it to the bone, and then what we end up seeing is terrible, terrible understaffing.”

Residents in understaffed nursing homes are more prone to bedsores, malnutrition, and falls, all of which are especially dangerous for older adults, Grant explained. In especially understaffed homes, residents who need assistance may not get that help for hours.

For the gangrene patient at Peninsula, the wait for help lasted 27 days. In a lawsuit filed on the patient’s behalf, his advocates allege that his infected bedsore went untreated even after he developed a high fever and suffered noticeable tissue death around the wound on his lower back—both hallmark symptoms of sepsis, a deadly blood infection. By the time Peninsula staff arranged for a physician to examine him, the sore had deteriorated to the point of giving off a noticeable odor.

The patient needed “a multitude” of surgeries and invasive procedures to save his life, including the removal of a severely infected testicle, portions of his bowel and dead flesh from his abdominal wall and genitals.

The lawsuit alleges that understaffing is at least partly to blame, accusing Peninsula of “failing to have adequate staffing levels in order to ensure prompt and proper care…” An expert in infectious disease testified that preventative measures such as helping the patient turn and reposition his body could have prevented the bedsore altogether.

Asked to comment on the allegations, Michael Schreiber, administrator of the Peninsula Nursing and Rehabilitation Center, said in a statement. “The care and safety of our patients has and will always be our top priority.” Schreiber declined to comment further, citing concerns about patient privacy, but said Peninsula was “vigorously defending” against the allegations in the lawsuit.

Residents in understaffed homes are also at risk of being inappropriately prescribed antipsychotic medications, which are sometimes used by overworked staff to control residents who are acting out, Grant said.

“Dementia isn’t a diagnosis for antipsychotics,” she said. “But when there aren’t enough staff, you don’t have the time. So the quickest way to stop the behavior is to give antipsychotic drugs.”

Connection to overall quality?

Interestingly, according to CMS data, Meadow Park, Concord, and Peninsula all report lower-than-average rates of antipsychotic use among their long-stay residents.

In fact, CMS gave Meadow Park five stars, its highest rating, for quality of resident care, a measure that takes into account residents’ pain levels, independence, and other factors.

Shirley Bouie, a former resident at Meadow Park, said that the facility was clean and the staff was kind during her stay.

“If I ever have to go back to rehab, that would be the place for me to go to,” she said.

Theresa Jacobellis, a spokesperson for Meadow Park, declined to comment on Lemuel Carter’s allegations or the operations of the facility, but highlighted Meadow Park’s above-average scores in categories besides staffing and said changes are in store for the home.

“There is a renewed focus on upgrades to the physical plant as well as commitment to ensuring a high quality and safe environment for the residents,” Jacobellis said.

Representatives from Concord Nursing and Rehabilitation Center did not return a request for comment.

But some experts say CMS’s quality ratings may not be the most accurate way of gauging a nursing home’s actual caliber. Yue Li, professor of public health sciences at the University of Rochester Medical Center, says his team has found such a strong connection between staffing and quality that they use staffing numbers to measure the caliber of a nursing home in their own research.

“There is strong evidence that higher nurse staffing level is leading to better quality,” he said, adding that the number of Registered Nurses on staff is also closely linked to patients’ health and well-being. Asked why CMS’s own quality rating was so consistently high even among the worst-staffed nursing homes, Li said that that score may be driven by patient characteristics like age, gender, and baseline health status, and that his team has found that CMS doesn’t make enough statistical adjustments to fix these factors’ outsize influence.

CMS officials have noticed the connection between staffing and quality of care, too. The agency cited the importance of staffing in recent updates to its scoring system for nursing homes. Now, staffing ratings are based on payroll rather than on what nursing homes themselves report, and nursing homes will automatically receive the lowest possible rating for staffing if they report having no registered nurse onsite for four or more days in a quarter.

“Nurse staffing has the greatest impact on the quality of care nursing homes deliver,” a statement announcing the changes reads.

Despite years of concern in Albany, the state has yet to pass any law officially regulating nursing facilities’ staffing numbers. But in May of this year, the Health Department began an exploratory study to gauge the potential benefits and costs of requiring homes to ensure a minimum number of staff per patient.

The department is expected to present their findings before Dec. 31.