Policy Brief: Minimum direct care staffing standard to increase quality of care in Washington

State Long Term Care (LTC) facility residents

The following policy brief is intended for the House Health Care & Wellness Committee,
with the hope that the committees strong influence in policy making will impose minimum
direct care staff to resident ratios for Washington state LTC facilities to improve resident care
quality.

Policy Brief: Minimum direct care staffing standard to increase quality of care in
Washington State Long Term Care (LTC) facilities
Summary
Understaffing is an ongoing issue in LTC facilities. Many studies have shown the
negative impact LTC residents are facing due to lack of minimum direct care staffing, but still
nothing has been done to fix it. As the Journal of Legal Medicine points out, 97% of nursing
homes were found to be severely understaffed according to the 2002 report by the United States
Department of Health and Services (Lenhoff, 2005). The lack of minimum direct care staffing
standards in these LTC facilities decreases quality of care and leads to resident abuse and elder
neglect (Lenhoff, 2005). Not only do we need universal regulations that impose minimum
satisfactory staffing levels, but also more aggressive regular and frequent inspections, and
increased sanctions and penalties (Walshe, 2001). If put in place this will encourage nursing
homes to meet the minimum staffing levels and to provide quality care overall.
Background
According to The National Consumer Voice for Quality Long-Term Care (formerly
NCCNHR) the Federal Law and Regulations on Nurse Staffing Issues states a nursing 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 in
accordance with a written plan of care. (Pg.1). This law does not specify for LTC facilities to
have a minimum requirement for direct staff care to residents. Due to this lack of clarity,
Washington State is among the few states that do not have a minimum requirement for direct
care staff according to the nursing home staffing standards in the United States (Harrington,
2005). With no federal law or state law requirement for minimum staffing ratios in LTC

facilities, the residents continue to suffer. These residents face life threatening pressure ulcers
and other skin injuries, weight loss, infections, avoidable falls and laceration, delayed treatment,
and increased medical errors (Lenhoff, 2005). LTC facilities lacking the quality care for the their
resident are more susceptible to Medicare/Medicaid fraud and resident readmission. Gittler,
(2008) found in his research that nursing homes who do not meet the evidence based quality of
care standard for their residents will be the target point for government enforcement of health
care fraud and abuse laws. To cut costs and improve residents quality of care with minimum
staffing levels, please consider the following:
Recommendations
Our state can adopt the standards proposed by the National Citizens Coalition for
Nursing Home Reform found in The National Consumer Voice for Quality Long-Term website:
FOR EVERY NURSING HOME FACILITY: Minimum Nursing Staff-to-Resident Ratios
Work Shift
Day shift
Evening shift
Night shift

Direct care Licensed Nurses

RN, LPN, or LVN
RN, LPN, or LVN
RN, LPN, or LVN

Staff-to-resident ratios
1:15 residents
1:20 residents
1:30 residents

These minimum requirements are among the many recommended studies for minimum
staffing level that shows a positive relationship between higher nurse staffing levels and better
resident care outcomes (Harrington, 2005). Fewer urinary tract infections, pressure ulcers, less
use of antibiotics, and increased probability of discharge to home were found to be correlated
with higher staffing (Harrington, 2005). Hopefully with these recommendations, will help
ensure the health and safety of the most vulnerable members of our society. As Harrington, 2005
points out in their study, nursing homes with low nurse staffing receive higher numbers of
deficiencies for violating federal regulations than nursing homes with high staffing.

References
Gittler, J. (2008). Governmental efforts to improve quality of care for nursing home residents
and to protect them from mistreatment: a survey of federal and state laws. Research in
Gerontological Nursing, 1(4), 264-284.
Harrington, C. (2005). Public policy. Nurse staffing in nursing homes in the United States: part
II. Journal of Gerontological Nursing, 31(3), 9-15.
Lenhoff, D. (2005). LTC regulation and enforcement: an overview from the perspective of
residents and their families...May 20-21, 2004, Southern Illinois University (SIU) School
of Law, Sixth Annual Health Policy Institute (Institute). Journal of Legal Medicine,
26(1), 9-40.
The National Consumer Voice for Quality Long-Term Care (formerly NCCNHR). Federal law
and regulations on nurse staffing issues (as contained in the Nursing Home Reform Act of
1987). Retrieve from http://theconsumervoice.org//_misc/search_page?
cx=011469937775421039183%3Axqqhuix93jk&cof=FORID%3A10&ie=UTF8&sa=Submit&q=nursing+home+reform+act
Walshe, K. (2001). Regulating U.S. nursing homes: are we from experience? Health Affairs 20,
n0.6: 128-144. doi: 10.1377/hlthaff.20.6.128