Improving Registered Nurse Staffing in Nursing Homes Decreases Avoidable Nursing Home Injuries (Pressure Ulcers, Infections, Malnutrition) and Elderly Suffering

In nursing homes, staffing levels of registered nurses (RNs) and the amount of RN direct care time are strongly correlated with avoidable nursing home injuries (“adverse clinical outcomes”), including pressure ulcers/sores, urinary tract infections (UTIs), weight loss, and deterioration in the ability to perform activities of daily living (ADLs). Because RNs influence the quality of nursing homes by providing expertise in direct care and evaluation, nursing homes’ workforce policy should focus on maintaining the recommended staffing level of one RN for every 32 long-stay residents (45 minutes per resident per day) and increasing the proportion of RNs providing “direct resident care” (time spent in hands-on care).

The 2004 Institute of Medicine (IOM) report titled “Keeping Patients Safe: Transforming the Work Environment of Nurses,” recommended that RN time should be 45 minutes per resident per day, including time spent on administrative and managerial tasks and direct resident care. A previous study “RN Staffing Time and Outcomes of Long-Stay Nursing Home Residents: Pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care,” published in the American Journal of Nursing in November 2005, also found consistent results that support the IOM’s recommendation. This observational study showed that RN staffing of 30 to 40 minutes per resident per day (examined in 10-minute increments) was strongly associated with reduced adverse clinical outcomes in nursing homes, including pressure ulcers, UTIs, hospitalization, deterioration in the ability to perform ADLs, and weight loss
Even after taking the severity of nursing home residents’ underlying illness into account, the study found strong and consistent associations between the average RN direct care time per resident per day and better clinical outcomes, including fewer pressure ulcers and UTIs, less weight loss, reduced deterioration of ADLs, less use of catheters, and greater use of nutritional supplements. On the other hand, more licensed practical nurse (LPN) and certified nursing assistant (CNA) time was associated with fewer pressure ulcers–a clinical outcome that is heavily dependent on nurse interventions–but did not improve other adverse outcomes. (The pressure ulcer incidence rate was 16% among residents who had a CNA time of 2.25 hours or more per day, while such rate doubled to 32% among those who had less than 2 hours of CNA time per day.) The authors of the study noted that this difference “highlights the crucial role RNs play in the quality of care in nursing homes” in providing expertise in assessment and prevention of nursing home injuries.

During the twelve-week period of this study, the nursing home residents’ medical records revealed that “one out of three residents experienced a deterioration in the ability to perform ADLs; more than one-quarter developed a pressure ulcer or experienced weight loss. Between 10% and 20% were hospitalized, developed a UTI, were catheterized, or had some combination of these outcomes; 5% died.” The study concluded that these nursing home injuries were preventable and avoidable if nursing homes had adequate staffing levels of RNs, LPNs, and CNAs, which is also legally required under California Health & Safety Code ยง 1599.1(a).

You can check a nursing home’s staffing levels at Nursing Home Compare. However, please note that nursing homes often include hours that do not involve direct care of residents, such as director of nursing time, director of staff development’s time, maintenance personnel’s time, and nurse administrators’ time. When assessing the quality of a nursing home, we advise you to inquire its “direct care time” provided by RNs, LPNs, and CNAs per resident per day.


If your loved one has suffered any of the above injuries in a nursing home in Alameda County, San Leandro, Hayward, Richmond, or Pleasanton, California, or if you believe a nursing home failed to provide adequate care to prevent or treat pressure ulcers, please contact us today so that we can help protect your loved one’s best interests and hold the responsible parties accountable.