AARP Florida Raises Concerns Over Quality of Care in Nursing Homes Amidst Staffing Reductions As Highlighted by Latest Report

AARP Florida continues to express concern over the quality of care provided to nursing home residents in Florida, especially in the aftermath of significant nurse staffing reductions mandated by the state legislature in recent years. Data recently released by federal agencies highlights a mixed record on the quality of care, particularly for short-term nursing home residents who require rehabilitation and care following hospital stays.

“Florida's nursing homes are facing a critical juncture in delivering quality care to our vulnerable residents," said Jeff Johnson, AARP Florida State Director. "The correlation between nurse staffing levels and the quality of care is evident, and we are witnessing the consequences of reduced nurse staffing requirements on both short-stay and long-term residents.

“In our first report, we documented the erosion of nurse staffing standards for Florida nursing homes. Our second report showed that, contrary to the arguments made by the nursing home industry, the reductions in nursing staffing standards haven’t been counterbalanced by a meaningful increase in other nursing home staff; the lower standards have just permitted less care for residents. This new report shows that, as the number of qualified hands providing care have declined, hospitalizations have increased, which is a powerful indicator that these new standards are putting frail lives at jeopardy.”

For example, in the period from 2019-20 to 2022-23, the rate of re-hospitalizations for short-stay residents increased by 12%, with more than one in four residents experiencing a hospital readmission during their nursing home stay. Emergency department transfers for immediate care also rose, with nearly 1 in 10 short-stay residents requiring such transfers in 2022-23, a 28% increase since the peak of the COVID-19 pandemic.

The reduction in nurse staffing requirements, particularly for certified nurse aides (CNAs), has raised concerns about the impact on the quality of care. In 2022, Florida decreased minimum CNA staffing requirements by 20%, a move that AARP reports have highlighted. Federal data also indicates a 30-minute reduction in overall nursing care levels per resident, per day since 2021, with a 16-minute reduction following the enactment of new and reduced staffing standards.

“Research clearly shows that staffing, particularly among the people who provide direct nursing care, is a key aspect of nursing home quality,” said University of South Florida assistant professor Dr. Lindsay Peterson, School of Aging Studies. “And as staffing regulations change in Florida and elsewhere, whether they rise or fall, it is critical to monitor changes in quality indicators to improve our understanding of why staffing and staffing policies matter.”

Shortcomings in Long-Term Care for Permanent Residents

The negative trend is not limited to short-stay residents. Long-term residents, who require ongoing assistance for chronic illnesses, experienced a 20% increase in unplanned hospitalizations per 1,000 person-days in 2022-23. AARP's 2023 Long-Term Services and Supports Scorecard ranked Florida 49th in the nation for the frequency of long-stay hospitalizations, indicating a longstanding issue that may further deteriorate in future assessments.

Florida's long-stay nursing home residents historically had lower emergency department visit rates compared to the national average. Nevertheless, following post-reduced staffing legislation, Florida experienced a 30% surge in emergency visits – climbing from 0.6 to nearly 0.8 visits per 1,000 days in 2022-23. While seemingly modest, this translates to an extra six emergency visits annually for an average nursing home with 75 long-stay residents.

Mixed Bag of Quality Indicators

AARP's analysis of various quality indicators tracked by the Centers for Medicare and Medicaid Services (CMS) reveals a mixed performance in Florida's nursing homes. While there have been improvements in some areas, such as increased functioning of short-stay residents and reduced antipsychotic medication usage, concerning trends emerge in others.

The decline in short-stay residents appropriately receiving pneumonia and flu vaccinations and the worsening rates of clinically significant depression among long-stay residents are alarming. Additionally, the increase in the rate of high-risk long-stay residents experiencing pressure ulcers is cause for concern. These indicators underscore the multifaceted challenges faced by nursing homes in maintaining high-quality care amidst staffing reductions.

Focus on Hospitalizations and Emergency Transfers

Emergency transfers, hospitalizations, and re-hospitalizations remain critical indicators of nursing home quality, given their impact on residents' lives and the associated increase in costs for both residents and taxpayers. The disruptive nature of transitions between nursing homes and hospitals places residents at a higher risk of additional illness or injury, leading to medication errors and hospital-acquired infections.

Staffing Changes and Ongoing Struggle

Recent data highlights substantial changes in nurse staffing across all categories since the reduction in nurse staffing requirements in 2022. Nurse care levels have seen a 12% drop, with CNAs, the largest portion of nurse staffing, experiencing a loss of 20 minutes per resident per day. RNs have also witnessed a decline in the time spent with each resident by nearly 10 minutes since 2020-21.

“The ongoing struggle of nursing homes to hire and retain sufficient numbers of nurses and nurse aides has been a central theme in the debate over staffing standards,” said Johnson. “The evidence from Florida indicates that minimum nurse staffing requirements do make a difference in staffing levels, as prior AARP reports have shown.”

State and Federal Requirements

While Florida has historically maintained its own minimum nursing home staffing requirements, the federal government is now proposing new regulations to ensure a minimum level of care across qualifying nursing homes. Florida's current staffing levels, which fall short of proposed federal minimums, raise questions about the potential impacts of such regulations.

“The debate over federal staffing mandates is complex, but the evidence from Florida indicates that staffing levels directly influence the quality of care,” concluded Johnson. “AARP Florida will continue to advocate for policies that prioritize the health and safety of nursing home residents.”

LINK to Issue III of the Nursing Home Staffing Report.