Nurses Say Staffing Ratios In Long Term Care Facilities Are Unsafe

By: Portia Wofford

Few would dispute that safe nurse staffing ratios are necessary. As nurses across the country rally for safe nurse-patient ratios on their units, long term care (LTC) facilities -- also known as nursing homes -- and skilled nursing facilities (SNF) seem forgotten. 

Federal law has few requirements for nurse staffing in long term care facilities. The Nursing Home Reform Law of 1987 requires these facilities to have:

• A registered nurse eight consecutive hours, seven days a week
• Licensed nurses 24 hours a day
• Otherwise “sufficient” nursing staff to meet residents’ needs 

Federal standards haven't updated since the Reform Law was implemented over 30 years ago. The standards in place aren't adequate to ensure a competent, safe workplace. 

The Heavy Workload

SNF and LTC are no longer just for geriatric residents. Residents enter facilities sicker, the acuity level has increased, and the role of the facilities has expanded.  LTC and SNF care for patients with higher-level nursing and rehabilitation needs, including

• Tracheostomies
• Complex wound care
• TPN
• Assisted ventilation
• JP drains
• Life vests
• IV medications

Medically complex residents bring an increase of residents with psychiatric diagnoses and multiple comorbidities. Under the ongoing Centers for Medicare & Medicaid initiative to reduce rehospitalizations -- the Patient-Driven Payment Model (PDPM) -- facilities are likely to treat higher acuity residents. 

In a typical eight-hour shift, a nurse is expected to

• Pass meds at least twice per shift (within a two-hour time frame)
• Monitor blood sugars and give insulin
• Check vital signs
• Manage certified nursing assistants
• Watch mealtimes
• Perform wound care
• Receive and transcribe physician's orders
• Complete incident reports
• Complete documentation
• Arrange transportation, diagnostic testing, and schedule appointments

Ensuring their residents are safe and cared for and notifying physicians and family members of any concerns are additional tasks to a long list of duties! 

Bobbie Bacher, LPN from Illinois stated, "We need to stop using nursing homes as psych facilities. They require special care and training. We need to stop using nursing homes as prison release halfway houses. We need to get back to basic nursing with proper nursing ratios. When treatments are heavy, there needs to be a treatment nurse on the day and PM shifts. This is a safety issue for the staff and the patient/resident."

Unsafe Nurse-Patient Staffing Ratios

The nurse-to-resident ratios at LTC and SNF are so ridiculous that they're becoming unsafe.

New York nurse Karen Montella, LPN states, "The ratios in LTC are ridiculous! I worked hard to get my license and have to give 41 patients meds --twice on my 3-11p shift-- with only three CNAs. I hang IVs, help with ADL's, and have psych and elopements to deal with. It's just too much!" 

Too many nurses are working with unsafe nurse-resident ratios. In a private Facebook group, thousands of polled LTC/SNF nurses responded with the ratios at their facility. 

These numbers reflect these two ratios: 

• Resident: nurse ratio 
• Resident: CNA ratio*

The numbers were insane:

• 32:1 nurse and 16:1 CNA- Ohio
• 44:1 nurse and 44:2 CNA- Tennessee
• 50:2 nurse and 15:3 CNA- New York
• 66:2 nurse and 66:4 CNA- Illinois
• 50:1 nurse and 30:1 CNA- Georgia
• 60:1 nurse and 60:3-4 CNA- Nebraska

Related: NYC Nurses Reach Historic Deal on Safe Staffing - Strike Called Off

On the night shift, some nurses have to split or share a cart with another nurse. Yes, you read that correctly. Two nurses have access to one medication cart! 

When asked if they feel they are staffed to perform their jobs safely, nurses like Dawn Doccola from New York stated, "No! We are expected to do everything and when we complain we’re told we need better time management." 

Even with perfect time management skills, subpar staffing is unsafe! Drumeka Rollerson, RN states, "I think we confuse these staffing guidelines way too often. Just because you are able to do 60:1 doesn't make it safe for the patients."

The Cost Residents Pay

Understaffing is one of the underlying causes of elder abuse and neglect in nursing homes. Nursing staff are unable to give each resident adequate attention, and overworked and stressed staff increases the risk of mistakes and committing abuse. 

Studies prove that residents who live in understaffed facilities are at a higher risk of 

• Malnutrition
• Weight loss
• Bedsores
• Falls
• Infections

Nurses React To Unsafe Staffing 

Nurse Amanda shares a story that she describes as a “wake-up call.” On her fourth med pass during a 12-hour shift, she and another nurse were responsible for sixty residents. As she drew up insulin, she stopped and intervened as a demented resident began attacking another resident. Still distracted, she returned to her cart and continued to draw up insulin. 

After double-checking her dosage, she realized she had drawn up twenty units of insulin --instead of three. Amanda states this was an eye-opener. She realized she was spread too thin trying to safely administer medications and protect residents. She states, “The resident with behaviors should have been a 1:1, but that wasn’t possible with the ratio we had.” 

No harm came to any resident, but Amanda admits it is easy to become overwhelmed. 

Understaffing doesn’t promote a culture of safety for staff or residents. 

Portia Wofford is a nurse, millennial strategist, healthcare writer, entrepreneur, and micro-influencer. Chosen as a brand ambassador or collaborative partner for various organizations, Wofford strives to empower nurses by offering nurses resources for career development--while providing organizations with tools to close generational gaps within their nursing staff. Follow her on Instagram and Twitter for her latest.