Low Staffing Levels and High Turnover in California Nursing Homes Contribute to Poor Quality Care

Complaints increased 38% from 2000 to 2002, according to CHCF report


More than one-third of California’s freestanding nursing homes did not meet the state’s minimum nurse staffing standards (3.2 hours or more per resident, per day), according to Nursing Homes: A System in Crisis, a “snapshot” report prepared by the California HealthCare Foundation (CHCF).

Although more homes met the minimum standard in 2002 than in 2001, the low staffing levels contributed to more than two-thirds of the staff in California’s nursing homes leaving their jobs in 2002.

Low staffing and high turnover rates were important contributing factors to poor quality care and a 38% increase in complaints between 2000 and 2002.

The CHCF report found that the most common clinical measures of poor quality — weight loss, time spent in bed, and use of physical restraints — continued to be serious problems in 2002.

“Low staffing led to 78% of nursing homes not complying with federal care and safety regulations during mandatory inspections,” said the report’s author, Charlene Harrington, Ph.D., School of Nursing, University of California, San Francisco. “An additional 11% of the nursing facilities were cited for very serious quality of care problems.”

State monitoring by the Department of Health Services resulted in 43% of nursing homes receiving deficiencies (warnings for minor problems) and 26% receiving citations, which include fines and are indications of more serious violations.

Other findings in the report include:

  • The percentage of facilities with inadequate staffing (according to state requirements) decreased from 46 to 37% between 2001 and 2002.
  • 93% of nursing homes did not meet staffing ratio guidelines of 4.1 hours per resident, per day, recommended in a report to the Centers for Medicare and Medicaid Services.
  • Annual nursing staff turnover rates ranged from 5 to 304%. The majority are nursing assistants who earn an average of $10.35 per hour.
  • In 2002, 10% of nursing home residents experienced substantial weight loss, 9% were in bed all or most of the time, and 17% were placed in physical restraints.
  • Nearly half of the state’s nursing homes reported no profits or net losses in 2002, and 160 were in bankruptcy between 1999 and 2002.
  • Among freestanding nursing homes that receive Medi-Cal reimbursement, the proportion of those that broke even or lost money grew by an average of 26%.

Nonprofit nursing homes, representing just 18% of the state’s total, faired better than for-profit facilities, which had:

  • An average of 3.3 nursing hours per resident per day compared with 4.1 for nonprofits;
  • Staff turnover rates of 70%, compared to 49% for nonprofits; and
  • 37% more violations than nonprofits.

The report found that in spite of an aging population (the number of residents aged 85 and older is expected to double by 2030) there is ample capacity in the state’s 1,400 nursing homes. Occupancy has declined from 85.9% in 1991 to 80.9% in 2001.

“Nursing homes must do a better job of caring for the 110,000 Californians in their facilities, not to mention preparing for a rising tide of elderly citizens who deserve more,” said Mark D. Smith, M.D., M.B.A., CHCF president and CEO. “Nursing homes face difficult challenges — low-paid staff, high turnover rates, low margins, and declining reimbursement from government agencies — but seniors deserve quality care and their families must have confidence that loved ones are in a safe environment.”


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About the California Health Care Foundation

The California Health Care Foundation is dedicated to advancing meaningful, measurable improvements in the way the health care delivery system provides care to the people of California, particularly those with low incomes and those whose needs are not well served by the status quo. We work to ensure that people have access to the care they need, when they need it, at a price they can afford.