Statement of the New York State Nurses Association before the New York State Assembly Committee on Health, Thursday, May 19, 2005, New York, N.Y.
This statement will focus on two areas of concern: the effectiveness of the Department of Health (DOH) in identifying systemic problems and obstacles to the department’s ability to improve its effectiveness once problems are identified.
Registered nurses (RNs) perform a central role in the delivery of care in nursing homes. In addition to the direct care they provide to residents, RNs are also responsible for the supervision of care delivered by licensed practical nurses (LPNs), who are dependent practitioners and can only practice under the supervision of a registered nurse or a physician. In addition, RNs direct, monitor, and evaluate the care provided by certified nursing assistants (CNAs), who provide the bulk of personal care services, such as assistance in feeding, bathing, and walking.
An RN providing care in a nursing home today struggles with many conflicting and simultaneous demands: assessing residents so CNAs can do their work; checking IVs; completing required paperwork, including comprehensive care plans; and administering medications, tube feedings, and treatments while evaluating residents’ responses to the care that is being delivered. The RN also is responsible for coordinating the residents’ care with family members and other members of the interdisciplinary team. As the needs of nursing home residents have grown increasingly complex, the demands placed on staff have become more unrealistic.
In facilities where there are unsafe staffing levels of both licensed and unlicensed personnel, staff cannot deliver the care that residents need. While some of these incidents are captured during the survey process, the broader systemic problem of understaffing is often not cited. For example, facilities may be given deficiencies for failing to appropriately supervise residents or administer medications in a timely manner. In many of these instances, the staff has performed their duties to the best of their ability but do not have the staffing support needed to provide adequate care. While the resulting failure to deliver a specific service is captured by the survey, the root cause – understaffing – is not. Failure to identify and correct systemic problems, such as unsafe staffing, increases the likelihood that incidents will occur again.
One reason why it is difficult for surveyors to identify systemic staffing deficiencies is that there is no clear staffing standards for nursing homes. There currently is no law in New York state specifying what minimum staffing levels or resident care hours should be. Existing staffing regulations are exceptionally vague and do not provide surveyors with the direction they need to make determinations about whether a facility has safe staffing or whether an indentified problem actually is related to a systemic staffing issue.
Many facilities staff to only the minimum regulatory requirements. Under current regulations, facilities, “must have a full time RN as Director of Nursing,” and “shall use the services of an RN for at least eight consecutive hours a day, seven days a week” (10 NYCRR 415.13(a)(2)(b)). This low standard applies to all facilities, regardless of the number of residents being cared for, and does not include any specific standards for LPNs and CNAs.
Another regulation for staffing levels in nursing homes states that, “The facility shall have sufficient staff to provide nursing and related services to attain or maintain the highest practical physical, mental and psychological well-being of each resident as determined by resident assessments and individual plans of care” (10 NYCRR 415.13).
Vague regulations like these leave too much to the interpretation of individual surveyors, forcing them to define terms such as “sufficient staff.” Varying interpretations of this regulation could contribute to great variations in enforcement standards among surveyors. The enforcement efforts of DOH staff could be strengthened greatly if DOH had clear staffing standards to enforce instead of leaving that to a judgment call by the individual surveyor.
A study by the Center for Medicare and Medicaid Services (CMS), “Report to Congress; Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report,” made specific recommendations on the number of care hours a nursing home resident should receive. It recommended that, depending on the nursing home population, total care hours should range from 4.1 to 4.85 hours per resident per day. The CMS also found that three hours is the absolute minimum number of care hours a resident should receive. When the care hours fall below that amount, a resident’s health and safety are seriously compromised.
To address these concerns, NYSNA urges the passage of legislation to provide clear, enforceable staffing standards for nursing homes. A5347 would prohibit facilities that provide less than three hours of care per day from admitting new residents. Nursing homes that fail to meet this low standard place their residents’ health and safety at risk and must be prevented from further reducing the level of care provided by accepting new admissions. This legislation would provide surveyors with a definition of what the absolute minimum number of care hours should be and would provide DOH with an enforcement tool to prevent the situation from getting worse.
While this legislation would provide some protection for residents from the worst facilities, NYSNA concurs with the CMS findings that three hours of care a day are not enough to meet the increasing care needs of today’s nursing home population.
To ensure that the residents of our nursing homes get the care they need, NYSNA also supports A3263. This legislation would establish staffing ratios in nursing homes for all direct care staff, including RNs, LPNs, and CNAs. Defined staffing ratios would provide surveyors the clear standard they need to ensure safe staffing and would be helpful in identifying systemic staffing problems during the survey process.
Until these measures are adopted, the lack of adequate staffing standards for nursing homes will continue to restrict the ability of surveyors to ensure the safety of our frailest and most vulnerable citizens. Action must be taken now to ensure that those charged with enforcement are supported by laws that should be enforced. Thank you for the opportunity to address this important issue.
For more information, contact Governmental Affairs at 518.782.9400, ext. 283 or by e-mail.