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Articles Posted in Staffing

In the January issue of the Journal of American Medical Directors Association, an article titled “When is a Chronic Wound Infected?” studies various methods of determining when a chronic wound is infected and judges which of these methods is most accurate. The article begins by explaining that the skin is a major barrier against infection, and therefore, the risk of a wound becoming infected is extremely high when skin starts to break down. The criteria for a wound to be considered infected requires that bacteria be present in the wound, and that this bacteria is producing tissue damage. There are many different types of wounds, but this particular article studies chronic wounds, such as pressures sores.

Physicians and wound care specialists use colony forming units (CFU) per gram of tissue to measure the presence of bacteria in a wound. They have established the “10^5 Rule,” which asserts that in the surgical closure of ulcers, spontaneous healing will occur at bacteria levels lower than 10^5 CFU. This rule implies that once spontaneous healing occurs, the possibility of infection is diminished and caretakers can conclude that the chronic wound is not infected. However, according to the American Medical Directors Association, the “10^5 Rule” may be inaccurate because there are factors other than the quantitative measure of bacteria that contribute to the development of infections. One such factor is the virulence of the bacteria. For example, certain infections, such as staphylococcus aureus, pseudomonas aeruginosa, and Bacteroides fragilis are so virulent that even at levels below105 CFU, infection is highly likely and requires treatment.

The article determined that a tissue biopsy is the most accurate method of determining whether or not a patient is suffering from an infected wound. However, most skilled nursing facilities do not perform biopsies. Instead, they obtain a surface swab of the wound and test the sample for the presence of infectious bacteria because this process is less costly and much simpler than a tissue biopsy. Despite its practical benefits, the use of surface swabs to determine if a wound is infected can be misleading. Often, the infection is incorrectly diagnosed and consequently, patients do not receive proper treatment and are unable to make a full recovery.

However, laboratory tests are not completely at fault when an infected wound is incorrectly assessed. In nursing homes that are understaffed, as well as in those that employ unqualified nurses, infected wounds are often overlooked, ignored, or inaccurately diagnosed. In fact, pressure sores are usually preventable and it is therefore the responsibility of the nursing staff to take these preventative measures, so that your loved one may avoid the pain and suffering that is caused by an infected wound. In the case that a pressure sore becomes infected, it is the duty of the nursing staff to ensure proper treatment. In addition to the usage of medications, some treatments include pressure relieving techniques, such the use of special mattresses and the repositioning of the patient, as well as the cleaning and dressing of the wound.

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On December 14, 2011, Modern Healthcare reported the dangers of extended hours and long shifts in healthcare facilities. While the correlation between exhaustion and increased error may seem obvious, many nurses have difficulty accepting this truth and determining the point at which their fatigue may lead to fatal consequences. The effects of fatigue include, but are not limited to, confusion, memory lapses, and impaired judgment. Many healthcare facilities fail to comprehend the seriousness of the consequences that can be caused by staffing errors. Often, these careless errors are fatal and lead to the death of a patient.

Nurses are often forced to work long hours because health facilities are understaffed. Even when they are well-rested, nurses who work in inadequately staffed facilities are more likely to make careless errors because they are constantly pressed for time, as they need to attend to more patients than they are able to handle alone. Factoring in exhaustion, in addition to the problem of understaffing significantly increases the chance of error, while decreasing quality of care of patients.

Inadequate staffing has many consequences including an increased risk of falls and incontinence, as well as dehydration and malnutrition. In both cases, patients require one-on-one assistance and individualized care plans. However, when nursing homes are understaffed, nurses simply do not have the time to meet the specific needs of each resident. Not only is understaffing a serious problem because of the health and safety risks it poses, but it is also illegal.

When staffing errors or inadequate staff lead to the death of a patient, a Wrongful Death claim may ensue. If nursing home neglect is directly responsible for a resident’s death, the successors of the patient may demand compensation for the personal losses that they have suffered.

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On December 14, 2011, Modern Healthcare reported that the Department of Health and Human Services is implementing an incentive program to award up to $216 million to health agencies in an attempt to reduce preventable injuries. Despite the honorable intentions of the program, the truth of the matter is that health agencies will now be receiving awards for following procedures that they should have been following all along. A similar problem can be found in nursing homes. Often, skilled nursing facilities are careless in their caretaking processes due to a lack of incentive. Unfortunately, most of the injuries that occur in nursing homes are usually avoidable, but nurses are just too understaffed or unmotivated to take measures to prevent them.

Most injuries in nursing homes occur when patients fall. Common injuries include, but are not limited to, hip fractures and head trauma. Even when elderly adults survive these injuries, they often are unable to make a full recovery. Because one injury has the ability to trigger a gradual decline in the overall health of elderly adults, it is extremely important to take every measure possible to prevent an injury from occurring in the first place. Nursing homes need to create individualized care plans for all their patients, especially those that have conditions that increase their risk of falling. Even more important is that these care plans are carried out by nurses every day.

Unfortunately, it is not rare that these care plans are drafted and then completely disregarded by nurses in their daily caretaking procedures. When nurses are unable to follow care plans, it is usually because they are understaffed and simply do not have the time to provide each patient with the specialized, one-on-one care that they need.

Sometimes, in an attempt to prevent falls, nurses will justify the use of physical restraints. This is, however, a direct violation of Patients’ Rights, which assert that a patient is not to be restrained in any way, except for when medical reasons require it. However, even under these circumstances, patients have the right to refuse treatment. Physical restraints actually incur more harm than they do benefit. In fact, a recent study has confirmed that the use of physical restraints does not decrease the likelihood of falls in nursing homes. However, the use of physical restraints is linked to incontinence, depression, isolation, pressure ulcers, and an overall decline in mobility.

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Nursing homes that get reimbursed from Medicare and Medicaid for residents’ services- approximately 96% of all U.S. nursing homes- must be certified and inspected annually. If a nursing home fails to meet federal requirements, inspectors cite the nursing home for violating specific standards (deficiency citations). Violations cited are first assessed by the scope of their effect on residents and the severity of harm to residents and then placed within categories, such as quality of care, quality of life, or resident rights. Under this methodology, both the scope and severity of deficiencies are evaluated and reported as a total point score, and such deficiency score is a reliable indicator of the nursing home’s quality of care.

Given that deficiencies have significant implications for the quality of care and the quality of life of nursing home residents, many studies have used nursing homes’ deficiency scores in measuring their quality of care. A recent study titled “The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes,” and published by The Gerontologist in May 2011, also used Florida nursing homes’ deficiency scores to find a strongly correlated relationship between the quality of nursing homes and nursing staff levels.

According to this study, higher nursing staff levels are “associated with lower scores on both total deficiencies and deficiencies related specifically to quality of resident care.” Specifically, the findings of this study demonstrate that “with every 6 minute increase (tenth of an hour) in [CNA hours per resident day], there is a 3% reduction in the quality of care deficiency score.” This means that if the nursing homes increase the average nursing hours per patient per day by hiring more CNAs or RNs, they would provide better quality of nursing services in compliance with federal requirements and thus receive lower deficiency scores. The study concludes that higher nursing staff levels would also benefit the nursing home providers because by increasing nurse staffing levels, providers subsequently will receive lower deficiency scores and “thereby improve their quality score and marketability to attract residents.”

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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 § 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.

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