Some say more staffing, better training would help reduce falls.
Jim Grant, a 73-year-old stroke victim in the room he once lived in at Rose of Sharon Manor. Grant said he gave up calling for help because it took too long to get a response. Grant said when he needed to go to the bathroom he couldn't wait so he moved from his bed to wheelchair and bathroom by himself. In January, he fell and broke bones in his right leg. Here, he moves from the bed he sat and talked on to his wheelchair. Grant has since moved from the Rose of Sharon Manor to a different facility.
Every night, after pulling on her scrubs and heading to work for the night shift, the nursing home aide would start to feel tense.
Frail people's lives would soon be in her hands. Call lights would blink. Alarms would beep. Sometimes she felt too rushed to care for everyone properly.
"If there's one alarm going off in one hall and there's another one going off in the other hall in the other direction, which one do you go to first?" she said. "One of them you're going to save from falling. The other one is going to fall."
Inadequate staffing is a common complaint from nursing home workers, industry watchers and families with loved ones in nursing homes. More than 1,000 Minnesotans suffered fall-related deaths in nursing homes from 2002 through 2008, according to a Star Tribune analysis of death certificates. But would more staffing -- costly as that would be -- actually reduce falls and save lives?
"I think it's really related to the inadequate staffing. Totally related. And, you know, the damage is untold," said Charlene Harrington, a professor emeritus of sociology and nursing at the University of California, San Francisco. She has done numerous studies on nursing home staffing.
Though state and federal staffing standards are not precisely defined, 75 percent of Minnesota nursing homes reporting data are understaffed by one federal measure.
In interviews with the Star Tribune, 16 nurses aides at some homes with more than 10 fall-related deaths from 2002 through 2008 frequently complained of insufficient staffing. They requested anonymity, fearing for their ability to get jobs in the industry.
The former night shift aide, who once worked at two metro area nursing homes, said it sometimes felt like chaos, even at 2 a.m.
"Residents don't sleep. They're up," she said. "They take their naps during the afternoon and they're up. Or there's a resident screaming ... all night long and they're going to wake up everyone."
Working in the homes, the aide said, was nerve-racking because the consequences were life-threatening.
"I get really nervous about that," she said. "I've seen, you know, a lot of, 'oh she fell, so' and then two weeks later, she's gone."
Nurses aides help nursing home residents do the routine things others take for granted: Get out of bed, go to the bathroom, walk, eat.
The residents in their care have dementia, incontinence and all sorts of medical problems. Some try to get up on their own when they shouldn't. Some try to wander away.
The state's 397 nursing homes, which care for more than 30,800 Minnesotans, have struggled to find good workers in the past, although the recession has widened the pool of candidates recently, said Darrell Shreve, vice president of health policy for Aging Services of Minnesota, an industry group representing mostly nonprofit nursing homes.
"You deal with people's, you know, feces and, you know, vomit," said state Rep. Patti Fritz, DFL-Faribault, who was a licensed practical nurse at nursing homes. "Every sort of nasty substance that comes from the body, you deal with it ... you have to clean it up."
The average hourly wage for a nurses aide in Minnesota is $12.86, according to the state Department of Employment and Economic Development.
"The pay is so low because the state sets our [reimbursement] rates," Shreve said.
Nursing home administrators praise their workers, saying many are drawn to the work by an urge to help people and give great care.
"There are a lot of other businesses and industries out there that a nursing assistant could go work in and make more money," Shreve said. "Go work at Best Buy, you know, work at the turkey factory."
The impact of staffing can be profound.
At St. Anthony Health Center, a frequent visitor told state inspectors doing a routine survey that she saw residents sit unattended for long periods, get out of chairs on their own and get agitated waiting for help to the bathroom. One nurses aide said she was concerned about residents' safety. Another said it was sometimes difficult to get to beeping alarms when they're busy with other residents.
The survey, completed Jan. 20, cited the home for insufficient staffing, at the same time noting multiple falls. The home's executive director, Marcia Lindig, wouldn't answer specific questions about the survey. She wrote in a statement that the home is committed to continually improving care, but can't guarantee that elderly and frail residents, often suffering cognitive impairments and other challenges, will never have an accident.
A pricey obstacle
The biggest roadblock to more staffing, by all accounts: money.
Nursing home care is already expensive. Depending on the resident's needs, the homes receive from $3,000 to almost $9,000 a month per resident in Minnesota, according to the state Department of Human Services. The average monthly cost is $4,858.
About $1.35 billion was spent on nursing home care in Minnesota in 2007, according to the department. Medical Assistance paid for $813 million in fiscal year 2008.
More seniors are choosing assisted living and other types of care before going into a nursing home. That means today's residents are more fragile than those who lived in nursing homes years ago.
"We've decreased our reliance on nursing homes. We've increased the severity of patients in them ... and we've not kept up with workforce development," said Dr. Steven Miles, geriatrician and professor at the Center for Bioethics at the University of Minnesota Medical School. "There's not enough training. There's not enough staff. There's not enough nursing supervision. There aren't enough aides."
At a minimum, Minnesota requires that homes provide two hours of nursing care per resident per day. Federal regulations say a nurse must be on duty 24 hours a day.
Both say homes must have "a sufficient number of qualified nursing personnel on duty" to meet residents' needs, but give no number or ratio.
The federal Centers for Medicare & Medicaid Services (CMS) regulates nursing homes nationally and contracts with states to enforce the regulations. It calculates expected staffing levels for each nursing home, taking into account the severity of their residents' needs and time needed to care for them. Using those expected staffing levels, 278 of 371 Minnesota nursing homes are understaffed.
Shreve said those federal numbers have been criticized, in part because staffing numbers are collected only about once a year, reflecting a two-week snapshot, and don't account for turnover or retention -- both significantly related to quality of care.
They don't count activity staff and others with direct contact with residents and don't accurately measure new ways of staffing that some nursing homes have adopted, he said.
One federal study in 2001 found a high staffing ratio helps only to a point. For long-term residents, it found, staffing above 4.08 hours of care per resident each day didn't improve quality of care.
Little Sisters of the Poor nursing home in St. Paul is one of about 90 nursing homes in the state that has higher staffing than CMS expected.
Sister Theresa Robertson, the nursing home's administrator, said she believes there is a correlation between staffing and falls. Higher staffing means residents can be watched more closely, she said.
That may help the staff figure out when residents are acting differently and understand ways to help them and prevent falls, she and other administrators said.
"We try to really focus on continuity of care," Robertson said. "If there is the same caregiver ... they will notice subtle changes."
The wait for help
Nursing home resident Jim Grant, who once lived at Rose of Sharon Manor in Roseville, said it took too long to get a response when he turned on his call light.
Grant, a 73-year-old stroke victim, said that once when he needed to go to the bathroom, he got up by himself and fell and cracked bones in his right leg about a year ago.
"I shouldn't have went to the bathroom by myself, but I did," he said this summer.
There are no uniform regulations for timeliness in answering call lights. Anxious residents often think it takes longer to get help than it does, nursing home administrators point out.
As Grant sat in his cramped room at Rose of Sharon, his bed surrounded by family photos and knickknacks, a woman down the hall bellowed in a hoarse voice, "I have to go to the bathroom! ... I've got to go. I've got to go ... I've got to go now."
"She's got to go bad," Grant said. He noted that yelling to get a staff member's attention wasn't uncommon.
Administrator Kay Schumacher said privacy laws prevented her from talking about Grant. To her knowledge, she said, he had never complained about call lights. "Call lights typically aren't an issue in the facility," she said.
Grant moved to a different nursing home in August and has retained an attorney to consider legal action.
When is staffing short?
State health investigators and regulators rarely issue citations for staffing levels, data shows.
"There isn't an exact science to determining short-staffed," said Darcy Miner, director of the compliance monitoring division at the Minnesota Department of Health. "That's actually a real challenging area because there are nursing homes that do a fabulous job with fewer people."
But nurses aides know that, even if they're working short-staffed, they're often the ones who take the blame for falls.
Cases show homes have avoided citations if they've fired an aide involved in a fall and taken other steps to correct a problem before investigators arrive.
"The home is just reacting because they know the state is going to expect to see some immediate action," said Steve Hunt, internal organizer with the Service Employees International Union Healthcare Minnesota, which represents aides at several homes.
In about 60 cases where records showed what happened to the nurses aide, homes fired aides about half the time. In 18 cases, homes issued suspensions or warnings or retrained the aides. In 11 instances, nurses aides quit.
Stress from low staffing
One former nurses aide at Crest View Lutheran Home in Columbia Heights said she got frustrated by staffing levels when she worked there in 2007. She and other former Crest View workers described a lack of teamwork.
"Some people just don't care," she said of co-workers. "Some were in la-la land."
At 4:30 on a Sunday afternoon this summer, the Crest View dining room came alive as staff members in colorful scrubs helped residents to dinner using wheelchairs, walkers and belts.
One hallway was nearly deserted, except for one resident who talked on the phone in her room, another resident who sat near a room window, and a third who quietly ambled down the corridor.
Throughout the hallway, a beep echoed repeatedly. There were no staff members in sight. The nurse's station sat empty.
Crest View, which had at least 13 fall-related deaths from 2002 through 2008, was cited for insufficient staffing early this year as part of regular nursing home surveys.
Regulators have put it on a list of four "special focus facilities" in the state with "a history of serious quality issues" -- a designation Crest View disputes.
As a result, Crest View is inspected more frequently. Other Minnesota nursing homes on the list are Owatonna Commons Nursing & Rehab, McIntosh Manor in McIntosh and Westwood Health Care Center in St. Louis Park.
Crest View Chief Executive Officer Shirley Barnes said the nursing home is staffed at a higher level than required. "We train, we audit, we continually look to improve," she said, adding that internal audits will show "great improvement."
Nursing homes are constantly working to prevent falls, but haven't come far enough, said Fritz, who has proposed and passed bills for nursing home worker and resident safety.
"You've got to have somebody there to answer the buzzer and somebody there to check on the restraint," Fritz said. "You can have all the wonderful equipment in the world, but if you don't have the staff, it's futile."
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