Effects of understaffing nursing homes

Federal and state laws require nursing homes receiving federal funds to develop a plan of care and employ a sufficient staff to provide all of the care within the plan. Due to understaffing, many nursing homes, however, cannot provide all of the care listed on the plan. As a result, residents may not be fed properly, they may not be given sufficient fluids, they may be over- or under-medicated, they may be permitted to develop pressure sores, they may not be taken to the toilet and therefore may be left in bed all day to lay in their own feces and urine, and they may not be cleaned or groomed.

On July 27, 2000, the United States Senate Special Committee on Aging released some startling findings on the problems associated with the understaffing of American nursing homes.

The bottom line was that understaffing is directly linked to poor nursing home care, including an increase in severe bedsores and malnutrition and dehydration. Such incidents of nursing home negligence or abuse have led to increased hospitalization of nursing home residents.

More than one-half (54 percent) of American nursing homes are below the suggested minimum staffing level for nurse’s aides. These workers are the lowest paid and least trained of all nursing home staff, yet they most often are responsible for feeding and bathing nursing home residents. Turnover among nurse’s aides compromises the quality of care found in nursing homes.

In addition, more than one-third of nursing homes fell below the suggested minimum staffing level for registered nurses, which is only 12 minutes per resident per day. Of total licensed staff, nearly one-fourth of all nursing homes fell below the suggested minimum staffing level.

Sources: The United States Senate Special Committee on Aging News Release, July 27, 2000; National Citizens’ Coalition for Nursing Home Reform

Nursing home facts

  • Today, about 1.5 million Americans live in our nation’s 17,000 nursing homes.
  • More than 90 percent of America’s nursing home residents are over 65.
    88 percent of America’s nursing home residents are white.
  • Three out of four nursing home residents are women.
  • The typical nursing home resident is a woman in her 80’s, who shows mild forms of memory loss and dementia. Although physically healthy for her age, she needs help with about 4 of 5 activities of daily living (eating, dressing, bathing, transferring, toileting). Over her lifetime, she’s saved for retirement, but the average cost of nursing home care is too expensive. She is, therefore, unable to afford the care she needs after six months and will be forced to rely on Medicaid.
  • Two out of every three nursing home residents rely on Medicaid.
    Every 8 seconds, an American baby boomer (those born between 1946 and 1964) turns 50.
  • By 2030, one in every five Americans will be a senior citizen.
    Americans 85 and older are the faster growing segment of the national population. From 1960-1994, that group increased by more than 274 percent.
  • Americans 85 and older are the heaviest users of long-term health care services.
  • Longevity is expected to rise for all ages.
  • More than 15 percent of Pennsylvania’s residents are 65 or older.
  • Two out of every five Americans will need long-term care at some point in their lives.
  • In 1996, the average cost of a stay in a nursing home was $41,000 per year.
  • Only one in four Americans can afford private nursing home care for one year.
  • The average stay in 1995 for a nursing home resident was 2.3 years.
  • On average, 8 out of 10 beds in certified nursing homes in America are occupied.
  • In Pennsylvania, more than 90 percent of beds in certified nursing homes were occupied by March 2000.
  • In 1995, America’s nursing homes were 87 percent full.
  • Most nursing homes (66 percent) are operated for profit and more than half are operated as part of a chain. This has resulted in fewer, but larger, nursing homes.
  • More than half of American nursing homes (54 percent) are below the suggested minimum staffing level for nurse’s aides. Nurse’s aides are the lowest paid and least trained of all nursing home staff, but they most often feed and bathe patients.
  • Nearly one in every four nursing homes (23 percent) are below the suggested minimum staffing level for total licensed staff.
  • Nearly one third of nursing homes (31 percent) are below the suggested minimum staffing level for registered nurses. The minimum staffing level for registered nurses is only 12 minutes per day per patient.
  • Registered nurses in Medicare/Medicaid-certified nursing homes spend an average of 42 minutes a day with each patient. Licensed practical nurses spend the same amount of time per patient per day. Certified nursing assistants spend an average of 2 hours and 6 minutes per day with each patient. This results in 3½ hours of direct and indirect care from all sources per resident in a 24-hour period.
  • Low staffing levels in America’s nursing homes contribute to an increase in severe bedsores , malnutrition, and dehydration, which lead to increased hospitalization.

Sources :

American Health Care Association, Facts and Trends ; Health Care Financing Administration, 1996; U.S. Census Bureau 1996; Modern Health, March 10, 1997; the United States Senate Special Committee on Aging News Release dated July 27, 2000; 1999 Census Estimates of the Older Population; U.S. Department of Health and Human Services 1997: An Overview of Nursing Homes and Their Current Residents: Data from the 1995 National Nursing Home Survey; U.S. Department of Health and Human Services: Your Guide to Choosing a Nursing Home; American Health Care Association’s Online Survey, Certification and Reporting Data (March 2000); Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment (National Citizens’ Coalition for Nursing Home Reform, June 2000).

Nursing home reform act

Nursing homes that receive federal funds must comply with the Nursing Home Reform Act. A basic tenet of the Act is that a nursing home must provide services and care to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and that this care must be given based on written documentation for each resident, known as an individualized plan of care.

Under the Nursing Home Reform Act, nursing homes must also do the following in order to meet the basic tenet of the Act :

  • Employ sufficient nursing and other staff in order to provide nursing and related services
  • Be administered in a way that enables the nursing home to use resources effectively and efficiently
  • Within 14 days of admission, perform an initial comprehensive, accurate, standardized, reproducible assessment of each resident’s functional capacity.
  • After significant changes in the resident’s physical or mental status and/or at least once every 12 months, perform such an assessment.
  • Develop comprehensive individualized care plans for residents. Care plans must include measurable objectives and schedules to meet each resident’s medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment discussed above. The care plan must be developed within 7 days after completion of the comprehensive assessment.
  • It must detail the services that are to be provided. The care plan must also be periodically reviewed and revised by a team of qualified persons after each assessment.
  • Provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs of each resident.
  • Provide supervised medical care by a physician. The nursing home must provide or arrange for the services of a physician on a 24 hour per day basis in case of an emergency.
  • Prevent the deterioration of a resident’s ability to bathe, dress, groom, transfer and ambulate, toilet, eat, speak or otherwise communicate.
  • Provide necessary services and assistance in order to maintain good nutrition, grooming, and personal and oral hygiene if the resident suffers from any impairment daily living activities.
  • Ensure that residents do not develop pressure sores. If a resident has pressure sores, the nursing home must provide the necessary treatment to promote healing and prevent infection and development of new sores.
  • Provide treatment and services to incontinent residents to restore as much normal bladder functioning as possible and to prevent urinary tract infections.
  • Ensure that residents receive proper treatment and any devices to maintain hearing and visual abilities.
  • Ensure that residents receive adequate supervision and assistive devices to prevent falls.
  • Ensure that residents maintain acceptable parameters of nutritional status, such as body weight and protein levels.
  • Provide residents with enough fluid to maintain hydration and health.
  • Prevent medication errors.
  • Care for residents in a way that promotes maintenance or enhancement of their quality of life.
  • Promote resident care in a way and in an environment that enhances each resident’s dignity and respect in full recognition of individuality.
  • Ensure that residents can choose activities, schedules, and health care consistent with individual interests, assessments, and plans of care.
  • Maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurate, accessible, and systematically organized.

When a nursing home fails to meet a federal regulation, a deficiency is issued. In 1999, a United States government accounting study found that one-fourth of nursing homes nationwide continue to be cited for deficiencies that either cause actual harm to residents or create the potential for death or serious injury.

In addition to these requirements, nursing home residents are entitled to certain rights.

Source: Post Gazette, Sunday, July 23, 2000 « Nursing Home Staffing Assailed: US Report Suggests Stricter Regulation to Ensure Better Care ».

Rights of nursing home residents

When the federal government passed the Nursing Home Reform Act of 1987, nursing home residents were guaranteed certain rights. In Pennsylvania, the Health Care Facilities Act of 1979 (as amended in 1999) requires nursing homes to meet these minimum federal requirements. Pennsylvania law also requires nursing homes to be responsive and adequate to the needs of its citizens, assure that new health care services and facilities are efficiently and effectively used, continue to meet high quality standards, and assure that all residents receive humane, courteous, and dignified treatment. Under the law, nursing home residents have the following rights :

  1. To be free from verbal, mental and physical abuse; corporal punishment; and involuntary seclusion.
  2. To be free from restraints – both chemical and physical – except as authorized in writing by a doctor for a specified and limited time period or when necessary to protect the resident or other residents from injury.
  3. To have safe, decent, and clean conditions.
  4. To be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care of personal needs.
  5. To be fully informed by a doctor of his or her medical condition, unless the doctor decides that informing the patient would be against the patient’s best interests, and to participate in the planning of medical treatment.
  6. To refuse medical treatment as permitted by law and to be informed of the consequences of refusing medical treatment.
  7. To refuse to participate in experimental research.
  8. To have personal medical records treated in strict confidence.
  9. To have established daily visiting hours.
  10. To have visitation by an ombudsman, personal physician, family members, and all individuals that provide health, social, legal, or other services who wish to visit.
  11. To retain personal possessions and clothing as space permits, so long as doing so would not complicate a medical condition or infringe on another resident’s rights.
  12. To participate in and meet with social, religious, and community groups.
  13. To send and receive personal, unopened mail.
  14. To associate and communicate privately with other individuals as desired.
  15. To manage personal financial affairs or to delegate that task to another person of the resident’s choosing.
  16. To be fully informed of available services and related charges.
  17. To be encouraged and assisted to exercise rights as a patient and as a citizen and to voice grievances and recommend changes in policies and services to staff members or outside representatives without interference, coercion, discrimination, or reprisal.
  18. Not to be required to perform services for the nursing home that are not included in the resident’s plan of care.
  19. If married, to be assured of privacy during spousal visits. If both spouses are residents of the nursing home, to be permitted to share a room, if medically feasible.
  20. To be transferred or discharged only for medical reasons, or for the resident’s own welfare or the welfare of other residents, or for nonpayment (except as prohibited by Medicaid), and to be given reasonable advance notice of transfer or discharge.
  21. To be fully informed, as evidenced by a written acknowledgment, prior to or at the time of admission and during the stay, of all these rights and all rules and nursing home regulations that govern personal conduct and responsibilities.

Choosing a nursing home

Choosing a quality nursing home is one of the most important decisions you may have to make. To help you choose a good nursing home for yourself or a loved one, you should consider the following :

Nursing Home Certification

  • Is the nursing home’s state operating license current ?
  • Does the nursing home administrator have a current state license ?
  • If you or your loved one participate in Medicare or Medicaid, is the facility Medicare or Medicaid certified ?

General Nursing Home Operations

How long has the nursing home been in business?
Who owns the nursing home?
Who runs the nursing home; the owner or a manager?
How long has that person run the nursing home?
How can you contact that person?
Can you receive a financial report for the nursing home?
Can you receive a copy of recent inspection reports?
How many residents live in the nursing home?
How many care staff are on duty for all shifts?
What qualifications do the care staff have and what training do they receive?
Is all of the night staff on site, or are some on call?
Does the nursing home have a written policy regarding prevention of abuse and neglect? If so, what is the policy? If not, why?
Is the nursing home a restraint -free facility? If so, what is the restraint policy? If not, is a restraint policy in place?


What is contained in the agreement?
What services are paid by insurance, Medicare, or Medicaid?
What services must the resident pay for? Get a copy of the fee schedule so you can compare it with the fee schedules of other homes.
When must payment be made?
What happens if the resident runs out of money?
Will a bed be available if the resident switches from private insurance to Medicaid?
Is a trial period permitted? If so, how long is the trial period?
What notice must be given if the resident wants to leave the nursing home?
Under what conditions can the nursing home ask the resident to leave?


Does the location suit the resident? Is it close to places and events that the resident wants to attend, like shopping, the hairdresser, or a place of worship?
Are transportation services available so the resident can go where he or she wants and needs to go?
Is the location convenient so that friends and relatives can regularly visit?

The Building Facility

Is there sufficient room in all areas for a person in a wheelchair or one needing a walker to get around?
Are wheelchair ramps provided for easy access into and out of the nursing home?
Are there features in the facility to prevent falls, such as handrails in the hallways and grab bars in the bathrooms?
Is the facility on one floor or more than one floor? If there are multiple floors, are elevators large enough, easily accessible, and easy to use?
In the case of an emergency, are call bells in bathrooms, bedrooms, and communal areas?
Is the entire facility, including rooms, hallways, elevators, stairs, and communal areas, suitably lit?
Are exits clearly marked and are paths to the exits free of clutter and obstructions?
Are there smoke detectors and fire extinguishers? Is the nursing home in compliance with fire codes?
In the case of an emergency, is there an evacuation plan? Are regular evacuation drills conducted?
Is there a safe and easily accessible outdoor area where residents can enjoy the outdoors?
What are the security arrangements?
Are telephones readily available, easily accessible, and private? Do the telephones meet the special requirements of the hearing impaired?

General Appearance of the Nursing Home

Does the nursing home look comfortable, clean, safe, and friendly?
Does the nursing home smell good?
Is the nursing home noisy? Are televisions blasting and call bells ringing?
Is the inside temperature comfortable for the residents?
Do the residents seem happy? Do they smile and laugh?
Is there clutter in the hallway?
Are dishes visible long after mealtimes?
Are the care staff members friendly, caring, and attentive?
Do the staff members seem happy? Do they smile and laugh?
Do the staff members treat the residents with respect?
Does there appear to be enough staff members to meet the needs of each resident?
How long have staff members, such as nursing assistants and nurses, worked at the nursing facility?
Are the nursing stations organized?

Resident Accommodations

Can the resident have a private room?
If the resident has to share a room, can he or she meet the other person before they become roommates? If the two don’t hit it off, can other arrangements be made?
If rooms are shared, are screens or other separators provided for each resident’s privacy needs?
Does each bedroom have its own bathroom? If not, is a bathroom easily accessible?
Are toilets, baths, and showers easy to use while still maintaining privacy?
Can the resident bring some of his or her own furniture or other personal belongings?
Is there a place where the resident can lock up personal and/or valuable items?
Can the resident have a TV and/or private telephone in the room? If private telephones are not permitted, is a telephone readily available, easily accessible, and private? Does it meet the needs of the hearing impaired?
Is the room air conditioned? If so, can the resident control heating and cooling? If not can the resident install an air conditioning unit?
Do the bedrooms open into a corridor and have windows?
Is the room cleaned at least once a week?
Is the resident’s bed made by a staff member on a daily basis?
If married, can spouses share a room?

Communal Rooms and Activities

How many communal rooms are available?
Can the resident choose which communal rooms to visit?
Are the communal rooms easily accessible?
Are toilets within easy access of all communal rooms?
Is the furniture comfortable and clean?
What entertainment is provided? For example, is there a television, radio, piano, and/or board games?
Is there a quiet communal room where a resident can read or make crafts? Are books, magazines, newspapers, or crafts made available?
Are activities planned for communal rooms, such as movies, theme parties, crafts, or low-impact aerobics? If activities are planned, is a schedule posted or is a schedule delivered to the resident’s room?
How frequently are social events and/or outings organized?
Are you or your loved one interested in the planned activities?

Dining Halls and Meals

How many dining halls are available?
Are dining halls easily accessible?
Are toilets easily accessible from all dining halls?
Is the furniture comfortable?
Are the tables compatible for people in wheelchairs?
Is the dining hall and kitchen clean?
Is the kitchen separate from the dining hall?
How many residents sit at a table?
Can the resident choose where to sit and with whom?
When are meals served? Is there an early and late seating for each meal? Can the resident choose the preferred seating time?
Can the resident have input into menus?
Is the food attractive, at the proper temperature and palatable?
Can family members or friends sample the food?
Does the food taste good?
Do the menus include food that the resident likes?
Are there several choices on the menu?
Are the menu selections well balanced and nutritious?
Can menus be altered to accommodate special diets?
Can the resident eat meals other than at set times?
Are snacks and drinks made available at all times?
Can meals be eaten in the resident’s room?

Personal Care

Does the resident have a say in the manner he or she is cared for or helped?
Is a qualified person of the same gender readily available if the resident needs help with bathing, dressing, or toileting?
Can relatives or friends help the resident with bathing, dressing, or toileting?
Does a barber or hairdresser visit the nursing home? If not, how are hair dressing needs met?
Does the facility launder the resident’s clothes, pajamas, and underclothes? How often? Is the service available on demand?
Who provides nail care and how often?

Health Care

Will all health care needs be met, including needs associated with special medical conditions like dementia, End-Stage Renal Disease, or Alzheimer’s Disease?
Can the resident keep his or her current physician?
Is a physician on call 24 hours per day, 7 days per week?
How often does a physician visit the nursing home?
Do other health care professionals, such as dentists and physical therapists, regularly visit the nursing home? If so, how often?
If the resident’s current health care needs change, can he or she continue to live in the nursing home?

Day-to-Day Living

Can the resident get up and go to sleep when desired?
Is there a place to buy small items, like postage stamps and stationery?
Are newspapers and mail delivered daily?
Is there an independent residents’ and relatives’ group?
Is there a safe place for valuables?
Who takes responsibility for insuring possessions?
Can the resident freely practice his or her religion?
Does a practitioner of the resident’s religion visit regularly?
Have the staff members been cross-culturally trained?
Do an adequate number of staff members speak the same language as the resident?


Can family and friends visit without restriction?
Are there places where the resident can privately meet with guests?
Can visitors dine with the resident?
Can visitors stay overnight?
Can the resident offer guests snacks or beverages?

When do you need a nursing home abuse lawyer ?

No one ever expects someone they care about to be injured, abused or neglected in a nursing home, but unfortunately abuses do occur, every day and in many ways. When someone you care about has been a victim of nursing home abuse, the problems can be overwhelming. An attorney can help to advise you of your loved one’s legal rights, tell you what they are entitled to, and what action to take.

In Pennsylvania, there is a specific time limit that a victim of nursing home abuse or neglect has to file a suit against the nursing home. This time period varies based on the type of claim; however, the general rule is two (2) years from the date the abuse or neglect occurred. Since the time limits may vary, we recommend that you consider having an Attorney represent your loved one’s interests. We say « consider, » because not every claim requires an attorney. At Edgar Snyder & Associates, we will give you a free, no obligation consultation and advise you of your legal rights. If we don’t think you need an attorney, we will tell you so.

Attorney Edgar Snyder and his firm have represented over 30,000 injured people. If you decide to become our client, you will benefit from the combined knowledge and experience of our team of professionals . Your team at Edgar Snyder & Associates will work hard to relieve the stress of dealing with the incident of abuse or neglect so that you can concentrate on helping your loved get better.

Nursing home information

Making the right nursing home decision can be difficult. Nursing home information is available for a wide array of subjects including: How do you choose a nursing home? What laws govern the nursing home industry? What are the rights of elderly nursing home residents? How do you make sure that elderly residents are receiving the best possible care? What are the signs of nursing home abuse or nursing home neglect? What type of injuries can result from nursing home negligence or abuse? When may you, or your loved one, need assistance from a personal injury attorney ?

Nursing homes have become big business. America is aging and more and more elderly people are residents of nursing homes. To increase their profits, some companies cut staff or other programs for elderly residents.

Despite state and federal regulations such as the Nursing Home Reform Act of 1987, nursing homes do not always provide the standard of care mandated by law. As a result, elderly residents find themselves the victims of abuse and/or neglect.

Examples of nursing home negligence

  • Failure to provide food or water and failure to prevent malnutrition or dehydration
  • Failure to assist in personal hygiene
  • Failure to provide safe, clean, and decent living conditions
  • Failure to provide appropriate supervision and assistive devices to prevent falls or other accidents
  • Failure to provide adequate medical care and acquire and dispense proper medications, as well as failure to ensure that residents are free from serious medication errors
  • Failure to prevent a resident from developing pressure sores; or, if a resident already has pressure sores, failure to provide proper treatment to promote healing

Signs of Nursing Home Abuse

  • Bedsores or pressure sores, also known as decubitus ulcers
    Skin rashes
  • Feces, urine, or body odor
  • Unkempt appearance, such as long nails, and dirty hair
  • Bruises, contusions, or lesions
  • Weight loss, which may be indicative of malnutrition and/or dehydration .
  • Disorientation or confusion
  • Fear or anxiety
  • Unexplained mood changes and unexplained refusal or ability to communicate
  • Presence of unjustified restraints – physical or chemical.

Often, neglect and abuse by a nursing home can result in injuries to the elderly residents.