Business and Finance

The 5 vulnerabilities that led to the colossal failure of nursing homes

Patricia Olthoff-Blank thought every little thing was going simply superb at her mom’s nursing dwelling in rural Buffalo Center, Iowa. Virginia Olthoff had lived there for 15 years, and the administration communicated often together with her household about her care.

Then Olthoff-Blank received a 3 a.m. name from an emergency room nurse. She discovered, to her horror, that her mom was severely dehydrated. An ER doctor advised her, “This did not just happen.” He believed her mom had been with out water for 4 or 5 days. 

Several hours later, Virginia Olthoff was useless.

Her daughter recounted the occasions in testimony earlier than the Senate Finance Committee in March 2019, telling them a Department of Inspections and Appeals report revealed her mom had not been consuming or consuming for nearly two weeks and had not obtained IV fluids. She had been crying out in ache and had misplaced appreciable weight. 

Despite repeated pleas by licensed nursing assistants to their superiors about her mom’s situation, “nothing was done,” Olthoff-Blank stated. 

The pandemic has exacerbated and raised consciousness about the poor situations in lots of nursing homes nationwide. But these situations existed earlier than COVID-19 hit the U.S., and they’re possible to proceed except adjustments are made, specialists say. 

“There’s an opportunity right now, because there are a lot of eyes on the nursing home sector,” stated David Grabowski, professor of healthcare coverage at Harvard Medical School. “One of my big concerns is as things return to normal … [people will say] we can go back to business as usual. Business as usual wasn’t working before the pandemic, and it certainly didn’t work during the pandemic. We need to make some real changes here.”

What set nursing homes up to fail so dramatically throughout the pandemic? Experts level to 5 most important elements.

1. Staffing

Chronic staffing shortages in nursing homes stretch present workers to breaking factors. These jobs of frontline employees, like licensed nursing assistants (CNAs), are sometimes as troublesome as retail and quick meals and often pay much less (the average annual income for a CNA in a nursing house is $28,450). The outcome? Employees don’t stick round.

“We found turnover rates of over 100% in a calendar year, meaning basically the entire staff turns over each year — and some nursing homes have turnover as high as three hundred percent,” Grabowski stated, referring to a study he and colleagues printed March 2021 in Health Affairs. 


“We don’t pay those direct caregivers enough,” he stated. “They’re largely women, many are persons of color and immigrants, and they’re overlooked in a lot of ways in terms of where we direct resources in our healthcare system.”

Inadequate staffing has a direct affect on residents, who could not solely get poor care however can not develop relationships with employees when they’re there in the future and gone one other, Grabowski stated.

“You talk to the residents and you ask them, ‘What is it about this nursing home that you liked or didn’t like?’ and it’s always about the staff,” he stated.

Staffing at the skilled nurse degree can be very important, stated Charlene Harrington, professor emerita of social behavioral sciences in the School of Nursing at the University of California, San Francisco.

Harrington joined 21 different nursing specialists in publishing a call to the Centers for Medicare and Medicaid Services (CMS) in March for a federal mandate for a stronger presence of registered nurses (RNs) in nursing homes.

CMS staffing guidelines presently name for one RN on obligation at a nursing dwelling for eight consecutive hours every day. Harrington and her colleagues stated that ought to be elevated to a 24-hour, seven-day on-site RN presence. There aren’t any federal ratios for workers of any degree.

“It’s pure ageism that you can warehouse older people and not have to get adequate staff and pay them so that they’re competent and have experience,” Harrington stated.

Pamela Mickens, a long-term care ombudsman in Dallas, stated she sees the affect of insufficient staffing each day. But a remark by a resident’s member of the family crystallized the difficulty of staffing requirements for her.

The member of the family labored in the jail system and identified that there are staffing ratios for inmates, however not for folks in nursing homes, Mickens recollects.


“That was an epiphany for me,” she stated.

2. Funding

Medicaid covers greater than 60% of all nursing dwelling residents, and Medicaid reimbursements cowl 70% to 80% of nursing dwelling working prices, in accordance to the American Health Care Association, an trade group. It factors to that funding hole as the wrongdoer in “shoestring budgets.”

“Medicaid is not a generous payer,” Grabowski stated. “The way most nursing homes have made things work is to take on these short-stay, post-acute patients who come from the hospital,” since Medicare covers these sufferers for a restricted time and at a a lot larger price.

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That creates incentives to hospitalize long-term sufferers and convey them again, Grabowski stated. “The margins on that side of the business are really quite high.”

Harrington, of UCSF, stated her analysis reveals the nursing dwelling fee mannequin isn’t the downside.

“All the nursing homes say they don’t have enough money, but in reality they [for-profit nursing homes] make excessive profits on the backs of their poorly paid staff,” she stated.

3. Corporate construction

Those earnings, Harrington stated, are hidden by the usually Byzantine company construction that undergirds for-profit nursing homes, which make up 70% of the complete.

An article from Kaiser Health News revealed it has grow to be more and more widespread for nursing homes to outsource items or providers to corporations they management or have a monetary curiosity in. Some even lease their buildings again from a sister company. The outcome: the homeowners can siphon off earnings that are usually not mirrored in the nursing homes’ books.

A associated profit for nursing homes is that, if they’re sued, the plaintiffs usually have a tough time accumulating, since the belongings are usually not held with the licensee, Kaiser reported.


“They set up these complex structures, and they’re pulling out so much money from their related party organizations … there’s no money left for staffing and services,” Harrington stated. She advocates for larger transparency and monetary accountability in nursing homes.

4. Lack of oversight and enforcement

Nursing homes agree to comply with minimal requirements of care once they take part in Medicaid and Medicare applications. Federal regulations require that they “provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being” of their residents. That consists of sustaining correct hydration – one thing Patricia Olthoff-Blank’s mom definitely didn’t get.

After Virginia Olthoff’s dying and that of one other resident of the similar nursing dwelling, CMS fined the facility $77,462, and the households sued.

But federal motion in opposition to nursing dwelling neglect is often inadequate, and too many nursing homes are allowed to operate whereas perennially falling under minimal requirements after which bouncing again up.

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“There’s a segment of the industry that has what we call ‘yo-yo compliance,’ because they’re constantly coming in and out of compliance,” and rotating via varied deficiencies, stated Lori Smetanka, government director of the National Consumer Voice for Quality Long-Term Care. “And they’re just not held accountable.”

“We see continued and routine noncompliance” with legal guidelines and rules, stated Eric Carlson, directing legal professional with Justice in Aging, a nonprofit that fights in opposition to poverty amongst older Americans. “There are facilities that have business practices that are inconsistent with the law – for example, they treat Medicaid patients more poorly, and there’s a federal statute that says you can’t discriminate based on reimbursement source.”

Too usually, he stated, CMS “does not recognize the violation, or if it does recognize it, it doesn’t impose a penalty.”

5. Aging buildings

The bodily setting of nursing homes has grow to be one other supply of issues. Traditional nursing homes built 30, 40 or 50 years ago were often modeled on hospitals, with lengthy hallways and small, shared rooms.

“There’s a warehouse mentality that’s communicated by that kind of floor plan and architecture,” Carlson stated. “For most people, our lives are not organized around our beds… we don’t sleep three-feet away from strangers.”


The Green House mannequin of nursing care and others prefer it, in distinction, consists of small-scale, homelike items restricted to teams of 10 to 12 older adults, every with their very own non-public room. These fashions usually function with a “more enlightened” staffing association, with nurse aides working persistently with the similar residents, Carlson stated.

A tradition change

Mickens, the Texas ombudsman, stated one ongoing problem in nursing homes is a scarcity of acknowledgment that residents have rights.

“They have a voice, and their voice and their preferences may be contrary to what the nursing home staff, to include the doctor, is wanting for them,” she stated.

Even if it’s one thing so simple as getting a bathe at night time as an alternative of 6 in the morning, the nursing dwelling should attempt to embody that desire in the resident’s care plan.  

Carlson agreed. He assembled a listing, accessible via Justice in Aging, referred to as 25 Common Nursing Home Problems and How to Resolve Them.

In addition to enforcement, everybody concerned in the system – from hospital discharge planners to workers to relations to the residents themselves – should have larger requirements, Carlson stated.

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That’s the concept behind the information, he stated. If a facility says it isn’t going to honor a request “because it’s going to be too much of a hassle,” Carlson famous, the client can say, “No. Unacceptable.”

It will take a tradition change, he stated. And if the amenities don’t do it themselves, he added, shoppers should say, “We’re going to change your culture for you. Because what you’re doing right now is not good enough.”

Emily Gurnon is the former Senior Content Editor masking well being and caregiving for Next Avenue. Her tales embody a collection of articles on guardianship abuse that was funded by the Journalists in Aging Fellows Program. She beforehand spent 20 years as an award-winning newspaper reporter in the San Francisco Bay Area and St. Paul. Reach her through her website.

This article is a component of The Future of Elder Care, a Next Avenue initiative with help from The John A. Hartford Foundation. This article is reprinted by permission from NextAvenue.org, © 2021 Twin Cities Public Television, Inc. All rights reserved.

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