Nursing Home Staffing: What Do You Do?

I was recently having a conversation with a family member over nursing home staffing.  He was very frustrated that the facility his mother was in would not put another CNA on her hall during the day.  He said that the staff was leaving because they were overloaded.

This is a common concern with many families and many nursing home staff members and administrators as well.  What do you do when your budget doesn’t allow you to add more employees but the ones you have just can’t get everything done?

Unfortunately, there’s not a magical answer to that question.  Until our government creates mandatory direct care staffing ratios for nursing homes and funds a revenue source so that we can pay for the staff, things will not change.

One of the first things that you can do now until the future looks brighter for nursing home staffing is to take a look at each CNA’s assignment to determine if their caseload is manageable.  One method you can use is to score out each resident using their ADL score and put them in a category of 1=light care, 2=moderate care, and 3=heavy care.  Add up the scores of each resident on each CNA’s assignment to see if the assignments are balanced.  If one CNA has a lighter assignment, it should be adjusted with another CNA whose assignment is all heavy care residents.  Adjustments like this can make a big difference is easing up someone’s workload, thereby reducing their stress level and hopefully retaining the staff member.

I have been known to take my best staff and place them on the most difficult unit in order to determine if the problem was in the quality or education of the staff who were previously having problems getting things done on that uit or did we place too many heavy care residents on one unit.  This also allows our under-performing staff to be shifted to a slower-paced unit where they can be reviewed by a different manager to see if they’re salvagable.

Something else you can do is to get all the administrative staff involved in passing trays, making up beds, answering call lights, etc.  Anything that frees up our CNAs to concentrate on more direct care.  I mean, really, anyone can answer a call light.

Nurses need to be involved with the meals.  Some of the residents who require assistance with feeding take a long time to eat.  Let’s assign some of our nurses to help manage the work load here.  The more nurses who are assisting with meals, the more time our CNAs have to get people toileted and cleaned up.

You might want to take a step back and make sure you are maximizing your rates.  What this means is to take a look at your cost reporting system and what type of Medicaid reimbursement methodology your state has.  While many states are case mix, there are still cost-reimbursed states or variances thereof.  Currently (2011), Alabama is a cost-reimbursed state.  This means that there is basically an incentive to spend up to your financial “ceiling” in direct care staffing because your future Medicaid rate will be higher as a result.  As a result, many of the smaller, independent nursing home operators have maximized their staffing and have the highest Medicaid rates in the state.  Some of the multi-state chains just haven’t caught on to this methodology, so there direct care staffing lags behind significantly.

How do you manage your nursing home staffing levels against your budget to ensure adequate coverage to care for the needs of your residents?  Let me know, I’d really like to hear different ideas.

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4 Responses to “Nursing Home Staffing: What Do You Do?”

  • Kent Walton on

    I have enjoyed your website a great deal but, you comment about “until the goverment mandates minimum staffing ratios” is in my opionion way out of line. More goverment mandates! That is never a good idea, don’t we get painted with the same brush often enough in this industry? I think we should concentrate on who we are admitting, and increase/decrease staff based on the acuity of the residents. Thanks

  • Mark on

    Hi, Kent. Thanks for dropping in! The way I look at it is like this – some mandates are actually beneficial. I certainly wouldn’t want to paint any of us with that old brush again. Believe it or not, many facilities are chronically understaffed because corporations set the staffing budgets based off of what makes financial sense rather than seeing what actually works in the facilities. While I agree with your view of looking at who we admit and increase/decrease staff based off of the acuity, I don’t know if that approach will work longterm for the whole facility. My census fluctuates with the week and the types of referrals fluctuate as well. If I flex my staffing too much, I would have a hard time building a foundation of stable staff members because I’d be sending people home based off a light acuity week. I do believe minimum staffing should be put in place along with a way to pay for it – and, actually, minimum staffing based off of average acuity levels may be a healthy compromise. However, I welcome your views as well. Thanks!

  • Keith on

    I am a nurse and an LNHA and started as an STNA. My philosophy is a little more generous budget for STNAs on the front end can (if managed properly) yields huge dividends/savings in the long run. Improved clinical care, cleaner facility, fewer skin issues, better customer service, improved job satisfaction, less turnover and burnout, less falls, a marketable uniqueness (“we staff at a ___ ratio”)….etc. The key is management. You can have extremely generous budgets and poor outcomes – so it is not a given. Tight controls, accountability, and a DON that keeps the bar high is crucial. Thanks for the good post.

  • Mark on

    Right on the money, Keith! Thanks for your excellent input!


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