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Problems Facing Nursing Homes

Problems Facing Nursing Homes

Funding Shortfalls

The majority of nursing home income comes from government reimbursement. The industry claims that many of its nursing homes are losing money on government payments causing yearly net business losses. As an example, in 2000, 10 national chains sought chapter 11 restructuring, citing inadequate government payments as the reason for seeking bankruptcy protection.

For those homes that make profit, there's not margin enough for improving infrastructure or hiring more or better qualified staff to improve quality of care. Quality of care eventually suffers with inadequate income. On the other hand, critics contend the current revelations of poor care with many nursing homes across the country stem not from lack of income but from greedy owners not willing to apply profits to improvement in care. The national chains, in particular, are accused of retaining profits to bolster stock prices in an effort to fund acquisitions.


A recent report from the Government Accounting Office cites widespread understaffing by nursing homes both in levels of nurses and certified nurse's assistants. Staffing in these cases is below government-recommended adequate standards. Recently states such as California have mandated higher staffing ratios for hospitals and skilled nursing homes. But in most cases, there is not additional money to cover the cost of more staff. So mandated staffing ratios will probably have little effect on the problems facing nursing homes and may actually increase their problems.

Turnover of Aides

There's no question that tight labor markets over the past decade have made it difficult to recruit and retain workers. But turnover of qualified aides is so high, it's hard to even retain any experienced people at all. After all, why would anyone pay for a 6 week CNA course, then hire on for $12 an hour with no benefits, in order to empty bed pans and change diapers or risk permanent back injury from lifting patients. They can make more working for McDonald's or some other fast food chain. Nursing homes claim they can't afford to pay for the higher level of wages and benefits necessary to retain aides who will stay around for a while.

Shortage of Nurses

Next is the problem of nurses. There is currently a nationwide shortage of nurses. Nursing homes are willing to pay the salary to attract nurses but in many areas, there aren't enough nurses to meet demand. Nursing homes, as well as hospitals are using innovative work schedules to meet staffing requirements but, in many cases, nurses are overloaded with too many patients. In other cases, less qualified workers are substituting for nurses. These shortages and high turnover affect the quality of care that a nursing home can provide.

Lawsuits Relating to Abuse and Neglect

It shouldn't come as a surprise with the problems of funding and staffing that reported incidents of patient neglect and abuse are on the rise. Of particular concern is the more frequent occurrence of abuse. Abuse is not only just physical assault or threats, but it can also be such things as improper use of restraints, failure to feed or give water, failure to bathe, improper care resulting in pressure sores or allowing a patient to lie too long in a soiled diaper or bed linen. And lawsuits are increasing in number.

As a result of long-standing complaints with the entire health industry, 36 states have passed "patients' bill of rights" legislation. With regard to nursing homes, 31 of these states' laws allow for bringing suit for violating patients' rights.

There is no requirement under these laws to show negligence, so something as routine as a change in how constraints are used might lead to a violation of rights. For example, suppose a nursing home changed its policy to allow bed rails to be constraints for agitated patients. Suppose a patient climbed over the rail, fell and injured himself severely. This application of constraint might be viewed as violating that patient's rights.

Overall, the number of nursing home lawsuits are rising but in the states of Florida and Texas , they are reaching crisis proportion especially for deep-pocketed national chains who seem to be the principal targets. The Florida Bill of Rights allows for nursing homes to pay uncontained attorney's fees, it allows for unlimited punitive damages, and it establishes a liberal statute of limitations. It appears Florida law firms have taken advantage of the more liberal rules. In 2002, Florida 's 700 nursing homes collectively faced $1 billion in lawsuits from claims totaling 4 times the number of claims in all other states. About 20% of Florida 's nursing homes have filed for bankruptcy protection.

There is great concern at the Federal and state level to control abuse. So far, aside from proposing tougher laws to penalize the industry, there appears to be little effort in finding a way to improve the nursing home system of care delivery.

Understanding Nursing Home Abuse and Nursing Home Neglect

Nursing home abuse affects thousands of families each year. In 2014 alone, over 14,000 complaints filed with nursing home ombudsmen were about abuse or neglect. Further, in 2013, the National Center for Victims of Crime (NCVC) found that nearly 10,000 nursing home residents filed complaints related to abuse.

The NCVC's breakdown of nursing home abuse complaints is as follows:

  • 27.4% - Physical abuse
  • 22.1% - Resident-on-resident abuse (physical or sexual)
  • 19.4% - Psychological abuse
  • 15.3% - Gross neglect
  • 7.9% - Sexual abuse

Like all other crimes, though, not every case of nursing home abuse gets reported, and researchers are trying to determine exact figures. This is further complicated by the fact that some seniors may be unwilling - or unable - to report their experiences.

"Unfortunately, we simply do not know for certain how many people are suffering from elder abuse and neglect." - The National Center on Elder Abuse

Neglect is the failure to provide an elder's basic life necessities, such as food, housing, health care, or hygiene. While it may not always be intentional, nursing home neglect can have just as serious consequences as abuse.

  • Just as elder abuse is broken up into several types, NAPSA breaks down neglect into subsets. These include physical, emotional, and financial neglect, as well as elder abandonment (where a caregiver leaves an older adult alone) and self-neglect.
  • 12% of nursing home staff members reported neglecting the needs of residents, according to a 2020 report from the WHO. Nearly 12% of residents or their families also reported cases of nursing home neglect in the same study.
  • According to a 2014 review of previous studies, neglect had the highest prevalence out of any other type of elder mistreatment in the United States.
  • Not every state has the same definition of elder or nursing home neglect. The NAPSA recommends checking local definitions with your state's Adult Protective Services (APS) to learn more.

Let the Problem Fix Itself

It can be argued that the current problems are temporary. First, the shift to ever-changing Medicare payments causes temporary dislocation of funds as nursing homes adjust care around the new rules. Eventually as the dust settles, facilities will learn how to make money without sacrificing care. Next, State Medicaid programs will continue to tweak bed ratios and payment systems to help strengthen the industry. In addition, the tight labor market for aides and nurses will eventually correct itself. Trained employees will stick around longer, and quality of care will improve. As a result, neglect and abuse incidents will decline in number.

Another positive nonintervention incentive is a growing trend to publish deficiency ratings for nursing facilities. Using this knowledge, consumers can avoid poorly run nursing homes and eventually market forces will require bad facilities to "clean up their act" or shut down. Despite the possibility for the problem self-correcting, many critics are not willing to wait nor are they optimistic for the future of nursing home care. They want the government more involved.

Extend Government Control

Government could extend more control in several stages of involvement. A first stage might involve the Federal Government unifying the Medicaid reimbursement process by applying the same rules throughout the country. Some states do a poor job of handling Medicaid reimbursement, other states do a fair job and others do a good job. Federal equalization might make it more fair for everyone.

Part of this first stage of Federal involvement might also be codifying national staffing ratios and providing work or study or benefit incentives for nursing home workers. Some states have inadequate staff ratios or work-related incentives for nursing homes while some states have stringent ratios and progressive worker incentives. Federal equalization could help with deficient states and help raise levels of care in those states.

A more involved stage of control might be actual Federal or State management of nursing facilities. The government could lease facilities from current owners. The advantage of this approach would be central management for all facilities, standard labor policies with employees able to transfer from unit to unit to help equalize misallocation of labor and one pool of money to allow redirection of funds to deficient areas of the system. Nonprofit nursing homes would be exempt from this plan since they are currently less dependent on government funding and because much of their support comes from their church or nonprofit organization.

Another part of tighter government control could be implementation of a national nursing home insurance plan much like Medicare Part A. The plan would include deductibles, co-payments and spending limits just like Medicare. Premiums would be paid jointly by beneficiaries, States, Federal Government and employers. Beneficiaries could also purchase additional, private, supplemental, long-term care insurance plans much as with Medicare supplement plans. And like Medicare, these supplements could fill holes with deductibles, co-pays and benefit ceilings. Supplements could also extend coverage to include home care, assisted living, adult day care and hospice. This national insurance plan would finance the government operation of nursing homes.

Create a Better Environment with Holistic Care Strategies

A number of people in the nursing home industry feel that changing the caregiving environment is the right approach. A friendlier, supportive environment between staff and residents produces happier employees, healthier residents, less worker turnover and overall, generally better care. To do this requires abandoning part or all of the hospital model of nursing home care.

The hospital model for nursing homes is easy to administer because results can be quantitatively measured. Quantitative measurement simplifies accounting because it allows cost and reimbursement to be tied to performance standards. So-called case-mix pricing is based on measures of the time aides and nurses spend per patient. The amount of time spent caring for and assisting residents and dispensing medication is carefully documented for each resident. Under this system, sometimes patients are regarded as a commodity rather than a human being.

It's not to say that administrators and workers don't care about the emotional and social needs of their charges and so all facilities have TVs, exercise activities, reading rooms, craft projects, field trips and so forth. But these activities are usually designed and implemented by staff with little or no input from residents. These activities are planned so that they can be measured in time spent per resident in order to remain consistent with the hospital model. The staff is patronizing and centered on a day care philosophy of keeping people busy but ignoring their needs for self-direction and self-worth.

In essence, the hospital model results in a facility where residents are simply waiting to recover and leave, or they are being entertained in a day care environment awaiting their eventual death. Nursing home residents lose the opportunity to be an influence on their environment which is so vital to our purpose as human beings.

Because of this forced detachment, many nursing home workers are only punching time clocks whereas closer involvement in "humanizing" the environment would probably be a strong incentive for many aides to stick with their jobs and not seek work elsewhere. With better retention, quality of care would improve, and residents would be healthier. Studies show that this outcome is indeed the case with nursing homes that have tried to introduce this kind of care system.

A holistic or "whole person" approach to nursing care provides an atmosphere where residents feel they have a reason to keep living. Dignity and self-worth replace despair, loneliness, boredom and helplessness. Workers have a sense of empowerment and feel like they are "making a difference". But to make the system work requires employees to accept nontraditional work roles not learned under the hospital care model. It also requires more effort on the part of administrators and workers to make it work. Additional staff meetings, encounter groups and training sessions are a necessary requirement.

The Eden Alternative

One successful example of this shift to holistic care is the Eden Alternative. Since 1992, over 250 nursing facilities in the US and Canada have "edenized" and new ones join just about every month.

The Eden Alternative had its beginnings in 1991 in Chase Memorial, a small-town nursing home in upstate New York . The new medical director, Dr. Bill Thomas and his wife Judy, felt they had a better vision of what a nursing home should be and they set about to put their plan in action. With more than 200 birds, four cats, two dogs, dozens of plants, a child care center, a garden and a regular schoolchildren visiting program, Bill and Judy created what they called a "holistic" environment.

Dr. Thomas designed the program to defeat what he calls the three demons of nursing home care: loneliness, helplessness and boredom. By empowering residents to care for animals, plants, children and even each other he gave these people dignity and purpose. In the process, residents began showing marked improvement in their need for care. The need for restraints declined, drug bills diminished, death rates and incidence of illness declined, and formerly stoic patients began to communicate. Workers as well were given new freedom to set their own schedules and to specialize in newfound activities such as caring for pets. Employee morale soared producing an improved work ethic.

Converting an existing nursing home to an Eden Alternative is not that costly. The challenge is changing entrenched mindsets and eliciting a firm commitment from owners, administrators and staff to make it work. If it were easy, we would probably have many more than 250 facilities doing it after 10 years.

Recently, Dr. Thomas has further extended his reform through the "Green House Project", a new approach to deinstitutionalize care through newly constructed, communal living environments. Click here for more about Green House.

"Edenizing" only works with facilities that rely less on government funding. These are typically private-pay only or nonprofit facilities. The reason for this is that government funding does not reward the facility for residents improving in health or taking fewer medications. On the contrary, government reimbursement is based on sicker residents receiving more care and lots of medications.