Regulators have allowed thousands of nursing homes across America to flout federal staffing rules by going an entire day and night without a registered nurse on duty, a USA TODAY investigation has found.
Then, beginning in 2011, CMS relied on the findings of a different study to determine how much to pay nursing homes for residents on Medicare. Reimbursements are calculated based on the level of staffing a typical nursing home provides for people with similar medical needs. It’s the formula CMS also deploys in its consumer-focused Nursing Home Care Compare tool.
If inspectors “were empowered and interested, able or willing, to enforce this, I think the sufficient staffing requirement would be fine,” said Mollot, executive director of the Long Term Care Community Coalition. “But unfortunately, they’re unwilling or unable to do that.” Cindy Napolitan moved into a skilled nursing facility with her daughter after the death of her husband.The administrator of Cheyenne Medical Lodge and its operating company, Foursquare Healthcare, did not respond to multiple requests for comment.
“I’m diplomatic; I try to be,” Napolitan said. “But there are times when you just have to say, ‘All right, enough is enough.’” Even though Claire participated on the family council at one and filed numerous complaints with the state against both facilities, she said little ever changed. She still was able to do the daily crossword in The New York Times and play along with “Jeopardy,” but she needed help standing up from the toilet. Instead, Claire said, nurses insisted her mother wear a diaper.
When asked if he thought his staffing levels were adequate, Hartstein wrote: “In comparison with other skilled nursing facilities in our immediate proximity, The Riverside’s nurse aide staffing levels are on the same level.” While living at New York's Amsterdam Nursing Home, Grace Campbell fell on Jan. 4 after, her daughter says, she tried to move herself in her wheelchair when no one answered her call light. These photos, from Jan. 10 and Jan. 11, show the bruises that developed.
The inspectors who visited Amsterdam showed how it could be done. They compared daily staffing reports with the facility’s assessment of complete staffing, finding enough caregivers on just four days in January 2022. A new state law that took effect in April requires nursing homes to spend at least 40% of their revenue on staff that provides face-to-face care.
Casey notes that a January report from the Inspector General for the Department of Health and Human Services found inspection agencies understaffed. A quarter of states routinely miss a federal deadline to inspect a home within 10 days of receiving a safety complaint. Dean Lerner, an attorney who oversaw regulatory enforcement in Iowa for nearly a decade, said he once expanded the state’s team of nursing home inspectors because they “were so understaffed.” But, he said, the incoming governor cut those positions before anyone could start.The federal manual given to states to train their inspectors for years told them they should not investigate staffing levels unless the inspector had first found that care standards were not met.
Lovette-Black, the retired California state inspector, recalled seeing the same staffing-related problems – “frequent falls or pressure injuries or infections,” he said – year after year at the same facilities. By submitting paperwork that testifies they had retrained their staff members or had adjusted staffing schedules, he said, the nursing homes would be deemed back in compliance.
Yet only eight staffing citations were issued to any nursing home in Virginia last year. Three of them went to predominantly Black homes. Some are too young for Medicare; others end up there beyond the usual 21 days covered by that benefit.
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