Nursing Home Staffing

Understaffing Is Number One Cause of Harm

Staffing issues are the most prevalent cause of many injuries sustained by residents of nursing homes, such as the dehydration, bedsores, fractures and weight loss. This simply means there are not enough qualified personnel in a nursing home to properly care for all the residents.

Labor costs are the most significant component of a nursing home’s overhead (cost of doing business), and those looking to increase profits generally attempt to cut the cost of labor as much as possible. One of the discoveries I made in my first nursing home lawsuit was that the corporation had set aside over $30 million dollars to pay for lawsuits and settlements. The money they saved on labor costs exceeded the amount they needed to pay injured residents who were the victims of their greed.

Nursing Home Staffing by the Numbers

The primary caregiver of residents at nursing homes, meaning the one who performs most of if not all the tasks needed to take proper care of the resident, is a certified nursing assistant (“CNA”). To understand how understaffing occurs, consider that a CNA typically works a 7.5-hour shift, but with two 15-minute breaks and a 30-minute meal, the CNA only has 6.5 hours of actual time to care for the residents. This allows for 390 minutes for resident care in each shift. Now consider the minutes required for a CNA to complete the responsibilities and tasks that he or she may have on a single shift when responsible for 9 residents (unfortunately, CNAs are often responsible for 12-15 residents on a shift):

  • 4 showers to give (60 min.)
  • 5 baths (75 min.)
  • 5 incontinent residents to clean/change (25 min.)
  • One catheter to empty (5 min.)
  • Document on the resident care charts throughout shift (25 min.)
  • Change 9-bed sheets and make up beds (40 min.)
  • Turn/reposition 4 bed-ridden residents every 2 hours (60 min.)
  • Set up 6 meals (25 min.)
  • Toilet 4 to 6 residents, 2 times a shift (60 min.)
  • Shave/groom/hygiene all residents (135 min.)

Therefore, a CNA with only 9 residents would need approximately 510 minutes to complete these tasks to adequately care for the residents. Yet, the CNA only works for a total of 390 minutes. Thus, the CNA would need 120 more minutes, or two additional hours of non-stop work, to perform the resident care responsibilities. And this is assuming the CNA works diligently during the 390 minutes. However, many CNAs work a double shift at the facility, or have another job at another nursing home, or hold down multiple jobs due to low wages, resulting in many days of 16-hour workdays, and often working six or seven days per week. This kind of taxing work means their 390 minutes at the nursing home are likely to be less than fully productive.

Overly busy CNAs cut back on providing care, and residents suffer.

Senior Man in Wheelchair looking out of a window in a hospital corridor.

When short on time, a CNA comes up with ways to shave off minutes that should go to these basic health care tasks. Some shave some time off feedings. Residents who do not eat quickly will miss some calories.  Over a period of time, the calories add up; an elderly resident slowly begins to feel the effects: losing weight, becoming malnourished, and/or developing pressure sores.  Already with compromised immune systems, residents need of all of their calories to fight off infections and to heal. Shaving time off providing care, therefore, shaves time off of their lives.

Other CNAs may feel forced to cut back on direct care.  Instead of checking, changing, turning, and repositioning residents, they may skip a turn or two. Adult diapers may stay soiled for several hours instead of several minutes. These shortcuts can lead to the deterioration of the skin and the development of rashes (fungal and bacterial infections) and bedsores. Fungal and bacterial infections can get into the bloodstream and cause serious illness, even death. Bedsores and pressure ulcers are painful and just as dangerous.

Another, unfortunately, result of under-staffing or hurried staff is broken bones.  For many residents totally dependent on their caregivers, it takes two CNAs to move a resident from bed to chair and from chair to bed. But there is hardly enough time for one CNA to get residents up and out of bed, much less two. The result is that a single CNA tries to do the task of two, and residents fall or are dropped, resulting in fractured bones.  Simply put: much of the care needed to ensure the residents are safe and healthy is neglected because the CNA cannot perform the work by her- or himself.

How many CNAs should work at a nursing home?

An accurate calculation of a facility’s staffing needs can be complex. It requires an assessment of the specific needs of that facility’s residents (for example, the more residents who are incontinent and suffer from dementia, the greater number of staff needed to provide adequate care). But there are a few good rules of thumbs: there should be a minimum of 1 nurse per shift per 20 residents, and the “average” resident needs at least 3 hours of CNA care per day.

To calculate hours of CNA care per day, take the number of CNAs that work on that day, multiply by 7 (hours) and divide by the number of residents. This is the hours-per-patient-per-day of care available. It should be at least equal to 3 hours.

Nursing Home Staffing: Legal Requirements

Federal Law for Nursing Home Staffing

Because nursing homes receive Medicare payments, federal regulations apply to the care these long-term care facilities (LTC) deliver. Consider the actual federal regulations for staffing:

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care.

(a) Sufficient staff.

(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans:

(i) Except when waived under paragraph (c) of this section, licensed nurses; and

(ii) Other nursing personnel.

(2) Except when waived under paragraph (c) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty.

(b) Registered nurse.

(1) Except when waived under paragraph (c) or (d) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week.

(2) Except when waived under paragraph (c) or (d) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full-time basis.

(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

South Carolina Law for Nursing Home Staff

South Carolina’s Department of Health and Environmental Control (DHEC) regulates nursing homes in South Carolina. So, in addition to the federal Medicare regulations, long-term care facilities must adhere to this second set of requirements. These staffing requirements are a minimum.

  1. A. Licensed Nursing Staff. An adequate number of licensed nurses shall be on duty to meet the total nursing needs of residents. Licensed nursing staff shall be assigned to duties consistent with their scope of practice as determined by their licensure and educational preparation.
  2. The facility shall designate a registered nurse as a full-time Director of Nursing. Another registered nurse, who is employed by the licensee, shall be designated in writing to act in his or her absence. In facilities with a licensed bed capacity of twenty-two (22) or fewer beds, the Director of Nursing may be included in the requirements of Section 605.A.2.
  3. There shall be at least one (1) licensed nurse per shift for each staff work area. If there are more than forty-four (44) residents per staff work area, there shall be two (2) licensed nurses on first shift and at least one (1) licensed nurse on second and third shift.
  4. At least one (1) registered nurse shall be on duty in the facility, or on call, whenever residents are present in the facility.
  5. An Administrator who is a registered nurse or licensed practical nurse shall not be included in meeting the staffing requirements of this section.
  6. Nonlicensed Nursing Staff. The required number of nurse aides and other nonlicensed nursing staff shall be determined by the number of residents assigned to beds at the facility. Additional staff members shall be provided if the minimum staff requirements are inadequate to provide appropriate care and services to the residents of a facility.
  7. Nonlicensed nursing staff shall be provided to meet at least the following resident-to-staff ratio schedule:
  8. Nine to one (9 to 1) for shift one (1);
  9. Thirteen to one (13 to 1) for shift two (2);
  10. Twenty-two to one (22 to 1) for shift three (3).

Find Out Staffing Information about a Specific Nursing Home

Nursing homes are required to report staffing information to their states. The states report it to Medicare, and Medicare publishes it. This information is available at Use the information about a nursing home’s residents (such as the number of residents with incontinence) to see if the resident mix is one that will stretch the demands of the staff compared with other nursing homes under consideration.  Moreover, nursing homes are required to post their staffing information.  Ask the Director of Nursing where it is posted in your nursing home or ones you’re considering.

Nursing Home Negligence Lawyers

Too often, staffing decisions are driven by profits and not by the quality of care.  Nursing homes budget for the harm these decisions cause; the calculation is that paying residents for injuring, maiming or killing them is less expensive than paying for the staff needed to provide the care that would prevent the harm in the first place. This is where families and the lawyers who represent them can make a difference.  No one lawsuit will change the calculation, but one by one, making nursing homes pay for the harm they cause can change how nursing homes operate. I am Andy Arnold, and I help families be part of that process by making nursing homes pay for the harm they cause. Let me know if you need help or want to discuss your situation:  864.242.4800