The Biden administration’s proposed staffing rule for nursing homes would in part require facilities to have a registered nurse on staff 24 hours a day. Susan Sermoneta / Flickr / File

LaWanda Mason admitted her mother to Huntersville Health and Rehabilitation Center, a nursing home outside Charlotte, after she had a stroke in May 2019.

Mason’s mother needed a feeding tube for hydration and nutrition, and could only eat soft foods fed to her by staff. Mason visited often and said she noticed the center seemed short-staffed.

Weeks later, Mason went out of town for a couple days. Once back, she received a call from a licensed practical nurse at the center, who said Mason's mother wasn’t feeling well. When Mason arrived with her son later that day, she got “the shock of her life.”

“It was extremely dark, like no one had been in there,” she said. “When we turned on the light, that’s when we saw my mom, leaning over the right hand side of the bed rail, and she was throwing up. And I just started screaming.”

According to allegations from her later lawsuit against the center, Mason “repeatedly pleaded” to send her mother to the emergency department for two hours while staff waited for a response from an on-call physician. Finally, Mason said her son called 911.

Her mother died the next day. The lawsuit alleges that the cause on the death certificate, hyperkalemia due to acute kidney injury, was from severe dehydration, and the underlying cause of septic shock was from aspiration pneumonia, which is when food or liquid is breathed into the airways or lungs.

The lawsuit alleges that this presumably occurred because facility staff did not spoonfeed her food properly. The lawsuit said the facility was understaffed, which led to “widespread neglect of its residents,” including Mason’s mother.

Mason is still involved in litigation against the facility’s then-owners, Huntersville H&R OPS Limited Partnership, who could not be reached for comment. The center is affiliated with Medical Facilities of America, also named in the litigation, who did not respond to requests for comment. Administrators at the facility also did not respond to requests for comment.

Staffing nursing homes is a national dilemma. North Carolina facilities must follow certain NC DHHS staffing requirements, but advocates say that is far below standards that researchers have outlined.

Still, President Joe Biden’s administration’s proposed staffing rules are a hopeful change for many advocates — while industry supporters argue they won’t be able to meet patients’ needs if the rule passes.

The proposal would require long-term care facilities, including nursing homes or skilled nursing facilities, to have a registered nurse on staff 24 hours a day and at least one certified nursing aide for every 10 patients.

But most facilities in North Carolina fall short, according to analysis from Wmforo, USA TODAY and Big Local News at Stanford University, of the latest federal staffing data in the Payroll-Based Journal from the U.S. Centers for Medicare and Medicaid.

Nursing home in Lillington, NC
Benches sit empty in June 2020 outside Universal Health Care of Lillington, a Harnett County nursing home that was the site of one of the largest COVID-19 outbreaks during the early months of the pandemic. Melissa Sue Gerrits / Wmforo / File

CPP analyzed data from a 91-day period in the second fiscal quarter of 2023 for 405 nursing homes across North Carolina, finding that only nine would have met the proposed RN requirement all 91 days and 14 met the proposed CNA requirement. More than half didn't meet either proposed requirement at least half of the time.

Facilities in Martin County fell short of the RN requirement by an average of 0.35 hours per resident daily, making it the county with the largest potential shortage in the state if these requirements were passed. Nursing homes in Hertford and Perquimans followed. All have populations of less than 23,000, according to 2020 census data.

Root causes

Mandy Johnson and Lori Simpson are regional ombudsmen for Cleveland, McDowell, Polk and Rutherford counties. As advocates for nursing home residents, they said staffing has long been an issue in both rural and urban areas.

“The industry has always suffered from absenteeism and staff turnover and burnout,”Simpson said. “Then with COVID, they saw a huge increase in a problem that was already there.”

Hillary Kaylor is an ombudsman whose region includes Mecklenburg County. She said metro areas can also have “terrible” recruitment issues. A major issue is low pay, she said, as companies like McDonald’s may offer better wages.

The ombudsmen said staffing shortages can lead to a decline in quality of care.

While many facilities in North Carolina are struggling to recruit workers, Adam Sholar, CEO of the NC Health Care Facilities Association, wrote in an email, that doesn’t mean patients are suffering.

Current employees are asked to work overtime and facilities are hiring temporary agency staff as well as limiting new residents, he wrote.

Most nursing homes are trying to hire, but the workforce isn’t there, even though “wages have increased significantly in recent years,” Sholar wrote.

The consequences in nursing homes

Elizabeth Todd, founder of Todd Law Offices in Raleigh and Morganton, focuses on nursing home and assisted living negligence. She said: “Understaffing is by and large the cause of all major injuries and deaths in nursing homes.”

Most facilities are for-profit institutions, and staffing is often the highest cost, she said. Registered nurses are the most educated so their hours are more expensive, Todd said, but they are vital to assess a patient’s medical condition.

“When we see too few RNs in the building, that's an alarm,” she said. “That’s when things can go wrong quickly.”

Carma Henson is a lawyer in Raleigh who also focuses on nursing-home abuse and neglect cases. She said many facilities will argue that they don’t have the money to pay higher wages, but that often isn’t true.

Remembering that staffing is a structural issue and not the fault of individual staffers, who are often overworked and underpaid, is important, Henson said.

Asked whether facilities prioritize profit, Sholar wrote: “There are a lot of businesses that provide much less risk and much more profit than operating a nursing home. As recently as 2018, median operating margins for NC nursing homes were negative (-1.1%), meaning more than half of all nursing homes were losing money.”

Advocates on Biden administration’s proposal

Simpson said the proposal is “a step in the right direction.” But she pointed out that the staffing requirements are still lower than what a 2001 landmark study by the federal Centers for Medicare and Medicaid Services found to be optimal.

A spokesperson for CMS wrote in an emailed statement that the study’s findings were not determining a legal requirement, but focusing on the level beyond which safety and quality would no longer improve with higher staffing.

The spokesperson also wrote: “CMS sought to identify minimum standards that, when applied across all long-term care facilities, would significantly lower the risk of unsafe and low-quality care for residents, while being implementable.”

The Centers for Medicare and Medicaid is an agency within the U.S. Department of Health and Human Services. WEBN-TV / Flickr / File

Johnson pointed to a measure that exempts facilities from the rules, saying she worried facilities could continually be exempted.

To qualify for an exemption, facilities must partly demonstrate “meaningful efforts to hire workers at prevailing wages” and investments in staffing. Most nursing homes would get three years before they must meet the new standard for RNs and CNAs, while those in rural areas have five.

Simpson said residents in rural areas shouldn’t have to wait longer for more staff.

A spokesperson for CMS wrote in an emailed statement: “CMS proposed that the temporary hardship exemption would be good for one year, and a facility would need to be reassessed for eligibility if they were found noncompliant with the minimum staffing standards after. CMS is currently reviewing public comments on this proposal.”

Implementation for nursing homes

Nursing homes can meet these requirements, Johnson said. She’s seen nonprofit facilities that staff adequately for how sick their patients are, she said.

Sholar wrote that the proposal would make it harder for people to access care because facilities will have to reduce their number of patients, as it will likely be too difficult to hire the workers needed.

He also wrote that nearly half of N.C. nursing homes have waiting lists for new residents.

CMS is currently reviewing comments on the proposed rule, according to a spokesperson.

Editor's note: This article is part of the project “Falling Short: Rebuilding elderly care in rural America” from news organizations across the United States. Rural nursing homes nationwide, already understaffed, face significant new federal staffing requirements. With on-the-ground reporting from INN’s Rural News Network, and data analysis assistance from USA TODAY and Big Local News at Stanford University, Wmforo is one of eight newsrooms exploring what the rule change would look like for residents in communities across America. Support from The National Institute for Health Care Management (NIHCM) Foundation made the project possible.

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Grace Vitaglione is a reporter for Wmforo. Send an email to [email protected] to contact her.

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