The eight Kentucky nursing homes with the highest COVID-19 death tolls — accounting for nearly one-third of the industry’s 593 statewide deaths — entered the pandemic with one thing in common: comparatively few registered nurses.
On average, Kentucky nursing homes reported 45 minutes of RN staff time per resident day during the fourth quarter of 2019, the most recent period for which data is available from the U.S. Centers for Medicare and Medicaid Services. That was close to the national average. But the eight Kentucky nursing homes with the most COVID-19 deaths reported an average of only 24 minutes.
For example, Landmark of Louisville Rehabilitation and Nursing — with 18 deaths so far attributed to COVID-19 — reported just 12 minutes of RN staff time per resident daily, the lowest of the group.
State inspectors in the last three years have cited Landmark of Louisville for 61 deficiencies, including patient abuse, neglect and infection control violations. Among the life-threatening hazards that inspectors last year attributed to insufficient nursing staff at the facility were choking, falls and severe weight loss. Residents also sat in their own feces after their unattended colostomy bags burst.
“The director of nursing stated that she had requested to hire agency staff to help ensure residents’ needs were met. However, the request was declined,” state inspectors wrote in a report last year. “She stated that sufficient staff should be provided to meet the residents’ care needs. However, the facility was having difficulty doing so.”
Most of the eight nursing homes with high COVID-19 death tolls are owned by for-profit corporations or privately run investment portfolios, like Landmark of Louisville, which is owned by a $750 million real estate investment trust. The majority had low quality ratings from the federal government and infection control problems well before the novel coronavirus began to kill large numbers of their residents last spring.
But beyond these other common threads, the link between registered nurse staffing levels and COVID-19 infections and deaths at nursing homes has been identified in several studies at the University of California at San Francisco School of Nursing, the Harvard T.H. Chan School of Public Health and the University of Rochester Medical Center Department of Public Health Sciences.
“Nursing homes without enough RNs find themselves in trouble. It results in terrible quality of care, even when you’re not in the middle of a pandemic,” said Charlene Harrington, nursing professor emeritus at UCSF and lead author of that university’s study, in an interview last week.
Registered nurses usually are the only ones on a nursing home staff qualified to create an infection control plan, spot and assess infections and determine who should see a doctor or go to the hospital, Harrington said. And they don’t come cheap: RNs in Kentucky earn an annual mean wage of $63,750, according to the U.S. Bureau of Labor Statistics.
Lesser trained nurses, known as licensed practical nurses or licensed vocational nurses, can provide basic care for residents, but they are not as qualified as RNs to offer medical care, she said. (They also cost, on average, $21,010 less than RNs a year in Kentucky.)
The real workhorses of a nursing home, certified nursing assistants, tend to have little medical training, if any, and overwhelming job duties that keep them racing from room to room throughout their shifts, she said. (The average CNA in Kentucky earns $13.12 an hour, or $27,280 a year.)
“Many of these places know they don’t have enough RNs,” Harrington said. “But hiring licensed nurses costs money, and these facilities are largely owned by for-profit corporations that are in business to make money, not to spend money. If they don’t have to invest in sufficient staff, then they won’t. So it becomes incumbent on the state and federal governments to require adequate staffing.”
Sherry Culp, Kentucky’s state long-term care ombudsman, oversees small teams who visit nursing homes to monitor the quality of their care. Culp said the recent studies about inadequate nurse staffing did not surprise her. Some nursing home chains rotate nurses between their facilities rather than hire more nurses and assign them to individual locations, she said.
“People need to realize that degree means something,” Culp said.
“These are your infection control experts,” Culp said. “You’ve got to have someone like that in the building at all times. They need to be there so you have someone with the time and expertise to dedicate toward this, and to make sure that people are using the PPE (personal protective equipment) properly.”
The Kentucky Cabinet for Health and Family Services, which oversees nursing homes, did not respond to written questions for this story other than to say: “The Office of the Inspector General recognizes the value that RN staffing brings to facilities.” The cabinet’s inspector general, Adam Mather, is a former nursing home chain executive.
The Kentucky Association of Health Care Facilities, which lobbies for the state’s nursing home industry in Frankfort, did not return a call seeking comment for this story.
Last month, KAHCF President Betsy Johnson told a panel of Kentucky lawmakers that her industry is struggling with staffing issues. In a July survey, 51 percent of her group’s members reported staffing reductions because of the impact of COVID-19 this year, in part because of workers who fear catching the coronavirus.
To fill the gaps in their schedules, some nursing homes are turning to temporary employment agencies rather than permanent hires, Johnson said.
“We don’t have a large pool of people who are wanting to work in long-term care,” Johnson told the lawmakers.
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‘RNs are the linchpin’
Federal law only requires that nursing homes have “sufficient” staff to meet their residents’ needs, including a licensed nurse — an RN, LPN or LVN — on duty at all times.
Some states set their own more rigorous staffing standards for nursing homes, but Kentucky long has resisted such calls, dismissing them as impractical. Instead, legislative leaders are promising to pass legal liability protection in the 2021 session to block certain lawsuits over COVID-19 infections.
“Yes, I agree that it’s critical that we have enough qualified staff. But it’s really hard to hire and retain qualified staff when the salaries just aren’t competitive,” said state Rep. Kimberly Poore Moser, R-Taylor Mill, who is chairwoman of the House Committee on Health and Family Services.
Because of the pandemic, nursing homes are scrambling to cover the cost of personal protective equipment, extra cleaning and overtime for their existing employees, Moser said. The federal government has helped with additional funds through the CARES Act and other sources, she said, but “a mandate — a staffing ratio or a mandate — is just going to be hard for anyone to comply with if you do not have the staff.”
This is not a new problem.
Despite the federal rules, one in every seven nursing homes nationwide failed to meet the minimum nurse staffing levels for at least 16 days in 2018, according to a report released last month by the Office of the Inspector General at the U.S. Department of Health and Human Services. Weekends are especially bad, the inspector general wrote.
When there aren’t nurses on duty to provide medical care and oversee the certified nursing assistants, ombudsmen get increased reports of urinary tract infections, bedsores and other serious ailments among residents, the inspector general warned.
And that was before a lethal, highly infectious virus swept through the country, the report observed.
“This review, initiated before the COVID-19 pandemic emerged, focuses on staffing data from 2018,” the inspector general wrote. “However, the 2020 pandemic reinforces the importance of adequate staffing for nursing homes, as inadequate staffing can make it more difficult for nursing homes to respond to infectious disease outbreaks like COVID-19.”
This year’s studies of registered nurse staffing levels at nursing homes concluded that facilities with more RNs tend to have fewer COVID-19 infections and deaths, and vice-versa. The University of Rochester Medical Center study, for instance, focused on Connecticut nursing homes that had varying levels of RN staffing.
“Every 20 minutes per resident day increase in RN staffing was associated with a 22 percent reduction in confirmed cases,” wrote Yue Li, lead author of that study, published in the Journal of the American Geriatrics Society. “Among facilities with at least one death, every 20‐minute increase in RN staffing of the nursing home significantly predicted a 26 percent reduction in COVID‐19 deaths.”
“In most nursing homes, RNs are the linchpin for the assessment and provision of medical care, including early identification of and response to emergencies like life-threatening diseases,” Li wrote. “Increased nursing levels are key to an institution’s ability to respond to outbreaks of emerging infections.”
Not everyone accepts the studies’ conclusions.
“There is no correlation to RN nurse staffing numbers and COVID-related deaths,” wrote Dan Kramer, a spokesman for Pine Meadows Post Acute in Lexington, in a response to questions from the Herald-Leader.
Pine Meadows, with 25 COVID-related deaths so far, had 27 minutes of RN staff time per resident day, according to CMS. It’s owned by Providence Group Inc. of Farmington, Utah.
“The number of RNs did not play a role in the transmission of COVID-19 at Pine Meadows Post Acute,” Kramer wrote. “All nursing staff at Pine Meadows are trained frequently on proper infection control practices, consistent with guidance provided by the CDC, CMS and other federal, state and local health care authorities.”
Watchdog wants changes
Stanford Care and Rehabilitation, a Lincoln County nursing home, reported 23 minutes of RN staff time per resident day ahead of the pandemic, about half the statewide average, with a history of deficiencies over the last three years that includes poor infection control, bedsores, neglect, insects, failure to treat pain and accidental broken bones.
In 2016, a resident with a dangerous bacterial infection was allowed to roam the facility rather than be isolated in his room, as required. That was a failure of the nursing staff, state inspectors wrote in their report.
“Interview with the assistant director of nursing on 8/25/16 revealed it was the nurses’ responsibility to report any abnormal lab results to the infection control nurse. She further revealed she did not know why the abnormal lab result for Resident #4 had been missed,” state inspectors wrote.
So far since March, 18 resident deaths at Stanford Care have been attributed to COVID-19. The facility is owned by Exceptional Living Centers, based in Lexington.
In a written response to the Herald-Leader, Stanford Care executive director Penny Upton said new management took over the facility last November, and it has worked to add more staff, including registered nurses.
But because of delays caused by the pandemic, staffing data reported by the Centers for Medicare and Medicaid Services still reflects the fourth quarter of 2019, Upton said. When CMS catches up, its rating for Stanford Care’s staffing should reflect the improvements by rising from two stars, or “below average,” to three stars, or “average,” she said.
“Our current RN staffing is approaching a three-star level,” Upton wrote.
“The safety and well-being of our staff has always been and remains our highest priority at Stanford Rehabilitation and Care,” Upton wrote in a prepared statement. “We mourn the loss of all lives this disease has taken from us.”
A nursing home watchdog in Kentucky, Wanda Delaplane, said the General Assembly should be shocked enough by the hundreds of coronavirus deaths in nursing homes to finally pass staffing requirements this winter.
Just as the state of Kentucky requires child care centers to keep a certain number of adult supervisors on duty to protect children, it should mandate staffing ratios for nursing homes that house the elderly, ailing and vulnerable, said Delaplane, a former assistant attorney general who lobbies for nursing home reform.
“I would like to see an RN on the floor of every facility around the clock,” said Delaplane.
“The industry tells us, ‘Changes aren’t necessary, we’re giving good care as it is,’” Delaplane said. “But we know that’s not true. How many hundreds of people are dead? The evidence is right there before our eyes. It all comes down to the fact that you can’t give good care if there aren’t enough people on the floor to provide it.”
These 8 nursing homes have the most COVID-19 deaths
Facility, county, COVID-19 deaths, RN staffing per resident/day (state average is 45 minutes)
▪ Rosedale Green, Kenton, 29, 16 minutes
▪ Pine Meadows Post Acute, Fayette, 25, 27 minutes
▪ Florence Park Care Center, Boone, 25, 16 minutes
▪ Ridgewood Terrace Nursing Home, Hopkins, 24, 33 minutes
▪ Mills Nursing and Rehabilitation, Graves, 23, 29 minutes
▪ Essex Nursing and Rehabilitation Center, Jefferson, 21, 37 minutes
▪ Stanford Care and Rehabilitation, Lincoln, 18, 23 minutes
▪ Landmark of Louisville Rehabilitation and Nursing, Jefferson, 18, 12 minutes
Sources: Kentucky Cabinet for Health and Family Services, U.S. Centers for Medicare and Medicaid Services