Staffing Concerns in a Skilled Nursing Facility

by Linda Ray

The number of employees and the mix of specialties and experience on the floor of a skilled nursing facility at any one time can have drastic effects of the quality of care. State and federal guidelines mandate the number of staff members who must be on the floor in relation to the number of occupied beds, which vary from state to state. Administrators face fines and even closure when they fall below those regulations.

Minimum Federal Requirements

Since 1987, skilled nursing facilities have been subject to minimum federal requirements for staffing. The Nursing Home Reform Act covers those facilities that collect reimbursement payments from government funding sources, such as Medicare and Medicaid. Under the act, facilities must provide a registered nurse on staff at least eight hours per day and licensed nursing staff for 24 hours. The federal provisions don't require specific staff-to-patient ratios. Because the federal law does not demand any other minimum staffing requirements, the Department of Health and Human Services and local state regulatory authorities are sometimes concerned that quality of care may suffer, which is why most states have instituted stricter guidelines.

Nurses Vs. Aides

Certified nursing assistants, provide the majority of care in nursing homes, yet increasing the staffing of CNAs does not usually result in better quality of care, according to an article in "Health Services Research." CNAs work under the supervision of an RN or licensed practical nurse but can’t provide necessary technical care. Patients do, however, experience more positive outcomes when licensed nursing staff increases. A reduced incidence of pressure sores is the only outcome increasing CNA staffing produces. Increased licensed nursing staff results in fewer deaths, decreased use of restraints, lower hospitalization rates and less incontinence.

Quality and Profits

The bottom line is that RNs and LPNs cost more than CNAs. To remain competitive and stay open, for-profit skilled nursing facilities must do everything they can to produce and even increase profits. Public companies report to stockholders who demand profits, and privately owned facilities also must remain financially viable. Nonprofit facilities operate under different goals but still must remain viable to keep their doors open. When developing staff levels, administrators must take into consideration the costs of even meeting minimum state requirements. Some facilities choose to pay noncompliance fines rather than beef up staffing levels.

Effective Alternatives

With skilled nursing organizations faced with the financial burdens and public demand for higher quality care, many administrators look beyond basic staffing levels for other, less expensive routes to improve quality. Reducing turnover is one path to improving quality of care. You can increase staff retention by providing ongoing training and regular pay increases to existing staff members, especially for CNAs who already sit at the bottom of the pay scale. Improvements in the organizational structure of the facility often lead to improved patient care that’s not directly related to increased staffing. For example, hiring RNs for human resources, public relations and accounting positions increases the number of available professionals on hand at any one time to deal with emergencies and questions. Administrators may institute admission restrictions to improve quality care standards as well by not admitting patients with needs that require a greater level of medical attention.

About the Author

Linda Ray is an award-winning journalist with more than 20 years reporting experience. She's covered business for newspapers and magazines, including the "Greenville News," "Success Magazine" and "American City Business Journals." Ray holds a journalism degree and teaches writing, career development and an FDIC course called "Money Smart."

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