Are Nursing Home Survey Deficiencies Higher in Facilities With Greater Staff Turnover

ObjectivesTo examine CNA and licensed nurse (RN+LPN/LVN) turnover in relation to numbers of deficiencies in nursing homes.DesignA secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies.SettingThe 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States.ParticipantsThis study focused on the 1151 NNHS facilities with complete deficiency data.MeasurementsTurnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models.ResultsHigh CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10–2.13), Resident Behavior (OR 1.42, 95% CI 1.03–1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12–2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50–2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25–2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies.ConclusionTurnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies.     

Intended and Unintended Consequences of Minimum Staffing Standards for Nursing Homes

Staffing is the dominant input in the production of nursing home services. Because of concerns about understaffing in many US nursing homes, a number of states have adopted minimum staffing standards. Focusing on policy changes in California and Ohio, this paper examined the effects of minimum nursing hours per resident day regulations on nursing home staffing levels and care quality. Panel data analyses of facility‐level nursing inputs and quality revealed that minimum staffing standards increased total nursing hours per resident day by 5% on average. However, because the minimum staffing standards treated all direct care staff uniformly and ignored indirect care staff, the regulation had the unintended consequences of both lowering the direct care nursing skill mix (i.e., fewer professional nurses relative to nurse aides) and reducing the absolute level of indirect care staff. Overall, the staffing regulations led to a reduction in severe deficiency citations and improvement in certain health conditions that required intensive nursing care. Copyright © 2014 John Wiley & Sons, Ltd.     

Staffing Shortages,Staffing Hours,and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

ObjectivesStaffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.DesignThis study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.Setting and Participants15,212 nursing homes.MeasuresThe primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.ResultsBetween May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.Conclusion and ImplicationsOur results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.     

Prevalence and Correlates of Hearing and Visual Impairments in European Nursing Homes: Results From the SHELTER Study

Background

Visual and hearing impairments are known to be related to functional disability, cognitive impairment, and depression in community-dwelling older people. The aim of this study was to examine the prevalence of sensory impairment in nursing home residents, and whether sensory impairment is related to other common clinical problems in nursing homes, mediated by functional disability, cognitive impairment, and depressive symptoms.

Methods

Cross-sectional data of 4007 nursing home residents in 59 facilities in 8 countries from the SHELTER study were analyzed. Visual and hearing impairments were assessed by trained staff using the interRAI instrument for Long-Term Care Facilities. Generalized linear mixed models adjusted for functional disability, cognitive impairment, and depressive symptoms were used to analyze associations of sensory impairments with prevalence of clinical problems, including behavioral symptoms, incontinence, fatigue, falls, problems with balance, sleep, nutrition, and communication.

Results

Of the participants, 32% had vision or hearing impairment (single impairment) and another 32% had both vision and hearing impairments (dual impairment). Residents with single impairment had significantly higher rates of communication problems, fatigue, balance problems, and sleep problems, as compared with residents without any sensory impairment. Those with dual impairment had significantly higher rates of all clinical problems assessed in this study as compared with those without sensory impairment. For each clinical problem, the magnitude of the odds ratio for specific clinical problems was higher for dual impairment than for single impairment.

Conclusion

Visual and hearing impairments are associated with higher rates of common clinical problems among nursing home residents, independent of functional disability, cognitive impairment, and depressive symptoms.     

Quality of Nursing Homes Among ADRD Residents Newly Admitted From the Community: Does Race Matter?

ObjectiveTo examine racial differences in admissions to high-quality nursing homes (NHs) among residents with Alzheimer disease and related dementias (ADRD), and whether such racial differences can be influenced by dementia-related state Medicaid add-on policies.DesignRetrospective cross-sectional study.Setting and ParticipantsThe study included 786,096 Medicare beneficiaries with ADRD newly admitted from the community to NHs between January 1, 2011 and December 31, 2017.Methods2010–2017 Minimum Data Set 3.0, Medicare Beneficiary Summary File, Medicare Provider Analysis and Review, and Nursing Home Compare data were linked. For each individual, we constructed a “choice” set of NHs based on the distance between the NH and an individual residential zip code. McFadden's choice models were estimated to examine the relationship between admission into a high-quality (4- or 5-star) NH and individual characteristics, specifically race, and state Medicaid dementia-related add-on policies.ResultsAmong the identified residents, 89% were White, and 11% were Black. Overall, 50% of White and 35% of Black individuals were admitted to high-quality NHs. Black individuals were more likely to be Medicare-Medicaid dually eligible. Results from McFadden's model suggested that Black individuals were less likely to be admitted to a high-quality NH than White individuals (OR = 0.615, P < .01), and such differences were partially explained by some individual characteristics. Furthermore, we found that the racial difference was reduced in states with dementia-related add-on policies, compared with states without these policies (OR = 1.16, P < .01).Conclusions and ImplicationsBlack individuals with ADRD were less likely to be admitted to high-quality NHs than White individuals. Such difference was partially related to individuals' health conditions, social-economic status, and state Medicaid add-on policies. Policies to reduce barriers to high-quality NHs among Black individuals are necessary to mitigate health inequity in this vulnerable population.     

Hospice in the Nursing Home: Perspectives of Front Line Nursing Home Staff

ObjectiveUse of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes.Design, setting, and participantsWe conducted a survey of 1859 staff from 52 Indiana nursing homes.MeasurementsStudy data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never.ResultsA total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was ‘patient/family appreciate added care’ (84%); the lowest was ‘hospice makes my job easier’ (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively).ConclusionsA majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.     

The Relationship Between Quality of Care,Physical Therapy,and Occupational Therapy Staffing Levels in Nursing Homes in 4 Years' Follow-up

Objectives

To understand physical therapy (PT) and occupational therapy (OT) staffing levels in nursing homes and to examine their relationship with quality of care.

Nursing Home Staffing Requirements and Input Substitution: Effects on Housekeeping,Food Service,and Activities Staff

Objective

To study the effect of minimum nurse staffing requirements on the subsequent employment of nursing home support staff.

Data Sources

Nursing home data from the Online Survey Certification and Reporting (OSCAR) System merged with state nurse staffing requirements.

Study Design

Facility-level housekeeping, food service, and activities staff levels are regressed on nurse staffing requirements and other controls using fixed effect panel regression.

Data Extraction Method

OSCAR surveys from 1999 to 2004.

Principal Findings

Increases in state direct care and licensed nurse staffing requirements are associated with decreases in the staffing levels of all types of support staff.

Conclusions

Increased nursing home nurse staffing requirements lead to input substitution in the form of reduced support staffing levels.     

护理人员职业暴露调查分析及对策

目的 分析护理人员职业暴露情况并寻求减少职业暴露的对策。方法 运用随机抽样的方法,对四家医院211名护理人员进行问卷调查,包括暴露类型、次数,医院是否采取防护措施及其防护效果等。结果 职业暴露类型以锐器伤和意外直接接触血液为主,暴露频繁,大部分医院采取防护措施但效果不显著等。结论 应强化职业安全教育、提高自我防护意识、提倡普及性预防、改进医疗器械、完善和健全防护措施,以减少职业损伤、促使优质护理服务工作持续稳定开展。     

内蒙古自治区护理人员数量变化及其发展趋势预测

目的:分析护理人员的数量变化,发现其短缺的原因,并对护理人员的发展提出意见及建议。方法:选取2010—2018年内蒙古自治区护理人员的数量作为指数平滑法模型的基础,比较模型的不同条件,筛选出最优模型,预测2019—2030年护理人员的发展趋势。结果:护理人员发展呈现上升趋势,预计在2030年达到13.45万人,但护理人员的增长幅度逐渐趋于缓慢,年增长率降至3.40%。尽管护理人员总量上升,但医护比小,不能按时达到规划要求的1∶1.25。护理人员地区分布不均匀,呈现城市多、农村少的现象。结论:内蒙古自治区护理人员的数量仍有较大缺口,需要考虑医护合作和农村人群的需求。     

Health Outcomes of Immigrants in Nursing Homes: A Population-Based Retrospective Cohort Study in Ontario,Canada

ObjectiveOlder adults account for a significant portion of Canadian immigrants, yet characteristics and health outcomes of older immigrants in nursing homes have not been studied. We aimed to describe the prevalence of immigrants living in nursing homes, their characteristics, and their hospitalization and mortality rates compared to long-term residents in the first year of entry to nursing homes.DesignPopulation-based, retrospective cohort study using linked health administrative databases.Setting and ParticipantsWe assessed all incident admissions into publicly funded nursing homes in Ontario between April 2013 and March 2016. Immigrants were defined as those who arrived in Canada after 1985; long-term residents are those who arrived before 1985 or are Canadian-born.MethodsThe primary outcome was all-cause hospitalization and mortality rates within 1 year of nursing home entry. Nested Cox proportional hazards models were estimated to explore the associations of facility, demographic, and clinical characteristics to the primary outcomes.ResultsImmigrants comprised 4.4% of residents in Ontario's nursing homes, compared to 13.9% in the general population. The majority were from East and Southeast Asia (52.2%), and more than half (53.9%) had no competency in either official language on arrival in Canada. At the time of nursing home entry, immigrants were younger than long-term residents but had greater functional and cognitive impairments. Immigrants had a lower rate of mortality [hazard ratio 0.58, 95% confidence interval (CI) 0.51, 0.68; P < .001] but were more likely to be hospitalized (hazard ratio 1.14, 95% CI 1.06, 1.23; P < .001). Adjusting for language ability, the effect of immigrant status on hospitalization was not statistically significant.Conclusions and ImplicationsDespite greater functional and cognitive impairments, immigrants in nursing homes had lower mortality than long-term residents, potentially reflecting the “healthy immigrant effect.” Inability to speak English was associated with increased risk of hospitalization, highlighting the need for strategies to overcome communication barriers.     

Nursing Home Clinicians' Decision to Prescribe Antibiotics for a Suspected Urinary Tract Infection: Findings From a Discrete Choice Experiment

ObjectiveTo determine which nursing home (NH) resident characteristics were most important to clinicians' decision to prescribe antibiotics for a suspected urinary tract infection (UTI), including both evidence-based and non-evidence-based characteristics.DesignWeb-based discrete choice experiment with 19 clinical scenarios. For each scenario, clinicians were asked whether they would prescribe an antibiotic for a suspected UTI.SettingOnline survey.ParticipantsConvenience sample of 876 NH physicians and advanced practice providers who practiced primary care for NH residents in the United States.MethodsEach scenario varied information about 10 resident characteristics regarding urinalysis results, resident temperature, lower urinary tract symptoms, physical examination, antibiotic request, mental status, UTI risk, functional status, goals of care, and resident type. We derived importance scores for the characteristics and odds ratios (ORs) for specific information related to each characteristic from a multinomial logistic regression.ResultsApproximately half of the participants were male (56%) with a mean age of 49 years. Resident characteristics differed in their importance (ie, part-worth utility) when deciding whether to prescribe for a suspected UTI: urinalysis results (32%), body temperature (17%), lower urinary tract symptoms (17%), physical examination (15%), antibiotic request (7%), mental status (4%), UTI risk (4%), functional status (3%), goals of care (2%), and resident type (1%). Information about “positive leukocyte esterase, positive nitrates” was associated with highest odds of prescribing [OR 19.6, 95% confidence interval (CI) 16.9, 22.7], followed by “positive leukocyte esterase, negative nitrates” (OR 6.7, 95% CI 5.8, 7.6), and “painful or difficult urination” (OR 4.8, 95% CI 4.2, 5.5).Conclusions and ImplicationsAlthough guidelines focus on lower urinary tract symptoms, body temperature, and physical examination for diagnosing a UTI requiring antibiotics, these characteristics were considered less important than urinalysis results, which have inconsistent clinical utility in NH residents. Point-of-care clinical decision support offers an evidence-based prescribing process.     

Mapping Sources of Food Safety Information for U.S. Consumers: Findings From a National Survey

This research examines the sources from which U.S. consumers obtain their food safety information. It seeks to determine differences in the types of information sources used by U.S. consumers of different sociodemographic background, as well as the relationships between the types of information sources used and food safety risk perceptions. Analyzing the 2010 Food Safety Survey (N = 4,568) conducted by the U.S. Food and Drug Administration, we found that age, gender, education, and race predicted the use of different sources for food safety information. Additionally, use of several information sources predicted perceived susceptibility to foodborne illnesses and severity of food contamination. Implications of the findings for food safety risk communication are discussed.     

Antibiotic Stewardship in European Nursing Homes: Experiences From the Netherlands,Norway, Poland,and Sweden

Antibiotics are among the most widely prescribed drugs in long-term care facilities, which highlights the importance of antibiotic stewardship (ABS) in this setting. In this article, we describe the experiences with ABS in nursing homes (NHs) from the perspective of 4 European countries: the Netherlands, Norway, Poland, and Sweden. In these countries, a large variety of initiatives to develop and implement ABS in NHs have been introduced in recent years. Among these initiatives are national antibiotic prescribing surveillance systems, NH-specific prescribing guidelines, and national networks of healthcare institutions that exchange information and develop ABS policy. Several initiatives evolved as a result of political prioritization of antibiotic resistance, translated into national action plans. Experiences of the 4 countries with the presented initiatives may inspire other countries that aim to develop or improve ABS in the long-term care setting.