The article reproduced below, by Jordan Rau of Kaiser Health News, is an excellent one in which Rau adds some perspective for a directive issued by Centers for Medicare & Medicaid Services (CMS) about monitoring of weekend nursing home staffing.
Lack of a nurse on duty on weekends, night shifts, or otherwise, raises a sometimes overlooked question: In the absence of a nurse, who is administering medications?
In my book, Mary Regina’s Nursing Home, I discuss a situation in which I visited my mother’s nursing home at 5:30 one morning in 2011 in an attempt to find out why my mother was being heavily drugged, or “zonked.” It appeared that possibly a nurse assistant, who would not be allowed to administer medication in a nursing home setting in Pennsylvania, had been doing so, with serious adverse consequences for my mother. I suspect this situation occurred because a nurse or nurses called off for the night shift on a weekend, or possibly no nurse was scheduled at all to administer medications.
When I complained in writing about this situation to the nursing home’s director of nursing, she confirmed in a phone call to me that the staff person should not have administered the medications — morphine and klonopin — and should have consulted a supervisor. When the state health department conducted an abbreviated onsite investigation of my complaint, the director of nursing was not present that day, and the health department refused to follow-up by revisiting the nursing home or even calling the director of nursing. The DOH instead declared that no medication error had occurred.
During the year of their investigation of my complaint, 2012, the DOH took only two enforcement actions statewide against nursing homes, compared to a high of 171 in 2003, and an average of 63.5 for the period 2002-2015.
Feds Order More Weekend Inspections Of Nursing Homes To Catch Understaffing
The federal government announced plans Friday to crack down on nursing homes with abnormally low weekend staffing by requiring more surprise inspections be done on Saturdays and Sundays.
The federal Centers for Medicare & Medicaid Services said it will identify nursing homes for which payroll records indicate low weekend staffing or that they operate without a registered nurse. Medicare will instruct state inspectors to focus on those potential violations during visits.
“Since nurse staffing is directly related to the quality of care that residents experience, CMS is very concerned about the risk to resident health and safety that these situations may present,” the agency said in a notification to state inspection offices.
The directive comes after a Kaiser Health News analysis found there are 11 percent fewer nurses providing direct care on weekends on average, and 8 percent fewer aides.
Residents and their families frequently complain the residents have trouble getting basic help — such as assistance going to the bathroom — on weekends. One nursing home resident in upstate New York compared his facility to a weekend “ghost town” because of the paucity of workers.
Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group in Manhattan, welcomed the new edict but said it was only necessary because state inspectors have not been properly enforcing the rules already on the books.
“The basic problem is the states don’t take this seriously,” Mollot said. “How many studies do we have to have, year after year, decade after decade, saying it all comes down to staffing, and there are very few citations for inadequate staffing and virtually all of them are identified as not causing any resident harm?”
CMS said it will identify potential violators by analyzing payroll records that nursing homes are now required to submit. Those records, which became public this year, showed lower staffing than what facilities had previously told inspectors during their visits, according to the KHN analysis.
“CMS takes very seriously our responsibility to protect the safety and quality of care for our beneficiaries,” CMS Administrator Seema Verma said in a statement.
The nursing home industry criticized the heightened scrutiny.
“Unfortunately, today’s action by CMS will enforce policies that makes it even more difficult to meet regulatory requirements and hire staff,” said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, an industry trade group, in a written statement. “Rather than taking proactive steps to address the national workforce shortage long-term care facilities are facing, CMS seems to be focusing on a punitive approach that will penalize providers and make it harder to hire staff to meet the shared goal of increasing staffing.”
Currently, a tenth of inspections must occur during “off hours,” which can be either a weekend, or during a weekday before 8 a.m. or after 6 p.m. But for facilities that Medicare identifies as having lower weekend staffing, half of those off-hour inspections—or 5 percent of the total — must be performed on Saturdays or Sundays.
Medicare requires nursing homes to have a registered nurse on site for at least eight hours every day, but according to the payroll records, a quarter of nursing homes reported no registered nurses available at least one day during a three-month period. Since July, Medicare’s Nursing Home Compare website for consumers has highlighted homes that lack sufficient registered nurses and lowered their star ratings. Nursing Home Compare has downgraded ratings for 1,402 of 15,600 facilities for gaps in registered nurse staffing, records show.
The new directive instructs inspectors to more thoroughly evaluate staffing at facilities Medicare flags. The edict does not mean a flurry of sudden inspections. Instead, Medicare wants heightened focus on those nursing homes when inspectors come for their standard reviews, which take place roughly once a year for most facilities.
But what may appear to be staffing scarcities in payroll records may instead be clerical problems in which nurse hours are not properly recorded, say some nursing home officials.
Katie Smith Sloan, president of LeadingAge, an association of nonprofit providers of aging services, said in a statement that some homes are still struggling to adapt to the new data collection rules.
“We’ve been voicing our concerns to CMS and will continue to do so,” she said.
KHN’s coverage of these topics is supported by John A. Hartford Foundation and The SCAN Foundation
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.