The Influence of Nurse Staffing Levels on Quality of Care in Nursing Homes

Choosing a nursing home for a long-term placement is a daunting and emotionally charged task for families. Nursing homes that directly bill Medicare and Medicaid for residents’ services (approximately 96% of all U.S. facilities) must be certified and inspected annually (Castle, Wagner, Ferguson, & Handler, 2011). Data from the inspections are summarized by the Centers for Medicare and Medicaid Services (CMS) through its Nursing Home Compare website, which provides information to consumers about factors related to the quality of care residents receive (CMS, 2011). CMS grades nursing homes based on, among other things, the average number of nursing hours each resident receives and facility violations of federal regulations. By providing details on nursing homes’ average number of nurse staffing hours per resident a day and the deficiency score found during annual inspections of the home, CMS helps consumers consider the quality of care provided as part of their calculus in selecting a specific facility. Deficiency citations are often used as a measure of nursing home quality (Castle & Myers, 2006; Castle et al., 2011; Harrington, Zimmerman, Karon, Robinson, & Beutel, 2000; Kim, Harrington, & Greene, 2009; Kim, Kovner, Harrington, Greene, & Mezey, 2009; Park & Stearns, 2009). When facilities fail to meet federal requirements, inspectors choose from approximately 180 possible deficiencies and cite the home for violating specific standards. Violations are assessed on two dimensions—scope (how many residents are affected) and severity (likelihood of harming residents). Scope is trichotomized into isolated, a pattern, or a widespread practice. Severity has four categories (no harm, no harm and potential for minimal harm, actual harm, and immediate jeopardy requiring immediate corrective action). The 12 possible combinations of scope and severity constitute the grade from “A” (isolated and no harm = 0 points) to “L” (immediate jeopardy and widespread pattern = 150 points). Deficiencies in categories “F” (potential for widespread harm) and “H” (pattern of actual harm) are considered substandard quality of care. Each deficiency is also placed within categories, such as quality of care, resident rights, or physical environment. If the deficiency is issued in a quality of care, quality of life, or resident rights category and the scope and severity denote substandard care, additional points are added. Thus, a deficiency for inadequate care planning (quality of care violation) would receive 40 points (“H”—pattern of harm) but that same pattern of harm would be only 35 points if it were improper food storage. With the introduction in March 2009 of this comprehensive deficiency score methodology, CMS captures both the scope and severity of all violations cited within the facility and reports deficiencies as a total point score; higher points and more serious violations reflect poorer quality (for further details on the scoring methodology, CMS, 2010). Prior studies have examined the relationship of staffing to deficiencies (Castle et al., 2011; Harrington et al., 2000; Kim, Harrington, et al., 2009; Kim, Kovner, et al., 2009; Park & Stearns, 2009). Harrington and colleagues (2000) measured the number and type of nursing home deficiencies cited during survey inspections and reported that fewer registered nurse (RN) and certified nursing assistant (CNA) staffing hours were associated with higher numbers of citations, especially citations for poor quality of care. A later study by Kim, Kovner, et al. (2009) reported that both total nurse staffing and RN staffing levels were negatively related to total deficiencies, quality of care deficiencies, and serious deficiencies that may cause harm or jeopardy to nursing home residents. Another study by Kim, Harrington, and colleagues (2009) indicates that RN to total nurse staffing ratio was negatively related to serious deficiencies in nursing homes, and as the RN to licensed vocational nurse ratios increased, total deficiencies and serious deficiencies decreased. In a study examining the impact of state staffing standards on quality of care, Park and Stearns (2009) also confirmed that total deficiencies declined significantly as states increased staffing standards. Although these studies do show a relationship between staffing levels and deficiency scores, they were based on staffing data from the Online Survey, Certification, and Reporting (OSCAR) database, which has been criticized for its inconsistent reporting of staffing levels (Kash, Hawes, & Phillips, 2007). Research examining the reliability of OSCAR data indicates that audited cost reports contain a more accurate reflection of day-to-day nurse staffing levels. Furthermore, previous studies have used a “count” of deficiencies, ignoring the scope and severity of these various violations. The current study advances the understanding of the relationship between nursing staff ratios and nursing home quality because we are able to analyze a range of nurse staffing levels as Florida implemented new nurse staffing requirements between 2002 and 2005 and because we use two new indicators of deficiencies—CMS’ new comprehensive total deficiency score and also the quality of care deficiency score. Furthermore, previous studies use only the OSCAR database for staffing levels, but this analysis supplements OSCAR with verified staffing reports submitted to the State. We hypothesize that higher nurse staffing levels—both CNA hours per resident day (HPRD) and licensed nurse (RN and licensed practical nurses [LPN] combined) HPRD—will be significant predictors of lower deficiency scores after controlling for facility characteristics. We examine Florida because in 2001, Florida’s State Legislature mandated a one-time increase from 0.6 HPRD RN/LPN staffing to a minimum of 1.0 HPRD in 2002 and a tiered increase in CNA hours from 1.7 HPRD in 2001 to 2.3 HPRD in 2002, and to 2.6 HPRD in 2003 (S. 1202, 2001). Because Florida also rebased the Medicaid formula to ensure full Medicaid funding of these new staffing levels (Hyer, Temple, & Johnson, 2009) and committed $300 million in state and federal funds to implement and enforce the staffing standards, facilities complied with the mandates. Taking advantage of the variability in staffing that existed in 2002 and 2003 (when new monies were allocated to pay for those direct care staff increases) and extending the analysis through 2004 and 2005, the study was able to examine the relationship among staffing levels and deficiency citations in the fourth largest state, a state with the highest proportion of elders and a state with more than 75,000 nursing home residents (Harrington, Carrillo, & Blank, 2008). Furthermore, previous research has indicated that there is variability in citations across states, and therefore, this study will focus on one state, Florida (Harrington et al., 2000).