The third part in the series based on the Star-Tribune's excellent investigation into falls in nursing homes deals with prevention. The key to prevention is proper staffing and training. Inadequate staffing is a common complaint from nursing home workers, industry watchers and families with loved ones in nursing homes. More than 1,000 Minnesotans suffered fall-related deaths in nursing homes from 2002 through 2008, according to a Star Tribune analysis of death certificates.
Every night, after pulling on her scrubs and heading to work for the night shift, the nursing home aide would start to feel tense. Frail people's lives would soon be in her hands. Call lights would blink. Alarms would beep. Sometimes she felt too rushed to care for everyone properly.
"If there's one alarm going off in one hall and there's another one going off in the other hall in the other direction, which one do you go to first?" she said. "One of them you're going to save from falling. The other one is going to fall."
"I think it's really related to the inadequate staffing. Totally related. And, you know, the damage is untold," said Charlene Harrington, a professor emeritus of sociology and nursing at the University of California, San Francisco. She has done numerous studies on nursing home staffing. Though state and federal staffing standards are not precisely defined, 75 percent of Minnesota nursing homes reporting data are understaffed by one federal measure.
In interviews with the Star Tribune, 16 nurses aides at some homes with more than 10 fall-related deaths from 2002 through 2008 frequently complained of insufficient staffing. They requested anonymity, fearing for their ability to get jobs in the industry. The former night shift aide, who once worked at two metro area nursing homes, said it sometimes felt like chaos, even at 2 a.m.
Nurses aides help nursing home residents do the routine things others take for granted: Get out of bed, go to the bathroom, walk, eat. Nursing homes have struggled to find good workers in the past, although the recession has widened the pool of candidates recently. The average hourly wage for a nurses aide in Minnesota is $12.86, according to the state Department of Employment and Economic Development.
The impact of staffing can be profound. At St. Anthony Health Center, a frequent visitor told state inspectors doing a routine survey that she saw residents sit unattended for long periods, get out of chairs on their own and get agitated waiting for help to the bathroom. One nurses aide said she was concerned about residents' safety. Another said it was sometimes difficult to get to beeping alarms when they're busy with other residents. The survey the home for insufficient staffing, at the same time noting multiple falls.
The biggest roadblock to more staffing, by all accounts: greed for profits.
Nursing home care is already too expensive. The homes receive from $3,000 to almost $9,000 a month per resident in Minnesota, according to the state Department of Human Services. The average monthly cost is $4,858. About $1.35 billion was spent on nursing home care in Minnesota in 2007, according to the department. Medical Assistance paid for $813 million in fiscal year 2008.
At a minimum, Minnesota requires that homes provide two hours of nursing care per resident per day. Federal regulations say a nurse must be on duty 24 hours a day. Both say homes must have "a sufficient number of qualified nursing personnel on duty" to meet residents' needs, but give no number or ratio.
The federal Centers for Medicare & Medicaid Services (CMS) regulates nursing homes nationally and contracts with states to enforce the regulations. It calculates expected staffing levels for each nursing home, taking into account the severity of their residents' needs and time needed to care for them. Using those expected staffing levels, 278 of 371 Minnesota nursing homes are understaffed.
One federal study in 2001 found a high staffing ratio helps only to a point. For long-term residents, it found, staffing above 4.08 hours of care per resident each day didn't improve quality of care.
Little Sisters of the Poor nursing home in St. Paul is one of about 90 nursing homes in the state that has higher staffing than CMS expected. Sister Theresa Robertson, the nursing home's administrator, said she believes there is a correlation between staffing and falls. Higher staffing means residents can be watched more closely, she said. That may help the staff figure out when residents are acting differently and understand ways to help them and prevent falls, she and other administrators said.
Nursing home resident Jim Grant, who once lived at Rose of Sharon Manor in Roseville, said it took too long to get a response when he turned on his call light. Grant, a 73-year-old stroke victim, said that once when he needed to go to the bathroom, he got up by himself and fell and cracked bones in his right leg about a year ago.
There are no uniform regulations for timeliness in answering call lights. As Grant sat in his cramped room at Rose of Sharon, his bed surrounded by family photos and knickknacks, a woman down the hall bellowed in a hoarse voice, "I have to go to the bathroom! ... I've got to go. I've got to go ... I've got to go now." "She's got to go bad," Grant said. He noted that yelling to get a staff member's attention wasn't uncommon.
State health investigators and regulators rarely issue citations for staffing levels, data shows. But nurses aides know that, even if they're working short-staffed, they're often the ones who take the blame for falls. In about 60 cases where records showed what happened to the nurses aide, homes fired aides about half the time. In 18 cases, homes issued suspensions or warnings or retrained the aides. In 11 instances, nurses aides quit.
One former nurses aide at Crest View Lutheran Home in Columbia Heights said she got frustrated by staffing levels when she worked there in 2007. She and other former Crest View workers described a lack of teamwork. At 4:30 on a Sunday afternoon this summer, the Crest View dining room came alive as staff members in colorful scrubs helped residents to dinner using wheelchairs, walkers and belts. One hallway was nearly deserted, except for one resident who talked on the phone in her room, another resident who sat near a room window, and a third who quietly ambled down the corridor. Throughout the hallway, a beep echoed repeatedly. There were no staff members in sight. The nurse's station sat empty. Crest View, which had at least 13 fall-related deaths from 2002 through 2008, was cited for insufficient staffing early this year as part of regular nursing home surveys.
