Inadequate Staffing and Resultant Poor Patient Outcomes in Nursing Homes

Nursing homes may be known for a lot of things, but stellar patient care might not always be one of them. Nurses working in the Emergency Department will tell you that when they get patients from the local nursing homes, the issues present did not arise in the span of one day. More and more lawsuits are being filed for nursing home neglect and complications that arise during stays in a nursing home. Recent research studies (below) indicate that the problems relating to patient care in nursing homes is mainly due to inadequate staffing.

Approximately 1.5 million Americans reside in almost 16,000 nursing homes across the United States (Gurwitz, 2018). The nursing home patient population has more chronic comorbidities than non-institutionalized elderly individuals, and require assistance with at least four to five activities of daily living (Gurwitz, 2018). Almost 70% of nursing home patients have cognitive impairment, and more than one third have bladder and bowel incontinence (Gurwitz, 2019). These facts might then lead one to believe that there is an appropriate staff to patient ratio, with physicians present at all times to take care of such a high acuity clientele. Unfortunately, this is not always the case.

A research study on registered nurses staffing levels from 2018, found 75% of nursing homes do not meet expected RN staffing levels (Marselas, 2019). The worst staffed days are Saturdays and Sundays. RN to patient ratios increase and double the nurse’s patients when compared to Monday through Friday (Rau, 2018). With less staff and higher patient loads, necessary patient tasks can be overlooked while nurses are frantically trying to medicate up to 20 patients throughout the day, some requiring medications multiple times per day. Patients that require feeding may have their meals cut short, baths are rushed, if given at all, as well as lack of thorough skin assessments as well as frequent turning to prevent or treat decubiti. David Stevenson, an associate professor of health police at Vanderbilt University School of Medicine, is confused about the change in RN to patient ratios on the weekend. “It’s not like the day-to-day life of nursing home residents and their needs vary substantially on a weekend and a weekday. They need to get dressed, to bathe, and to eat EVERY SINGLE DAY.” (Rau, 2018)

The issues and associated complications that can be prevented by adequate staffing, unfortunately lead to avoidable hospitalizations. Gurwitz (2018) writes about adverse drug events within nursing homes and notes a study that shows that these errors are common and preventable. Within the study of large, long-term care facilities, the rate of adverse drug events was nearly 10 per every 100 residents, and 40% were considered preventable (Gurwitz, 2018). Another interesting fact was that when studying residents taking coumadin and requiring PTT blood draws to adjust dosages, the percentage of time spent in the therapeutic range is less than 50% (Gurwitz, 2018).

The Centers for Medicare and Medicaid Services (CMS) do not require certain RN to patient ratios, but they do require an RN to be present for at least eight hours a day, and an LPN must be present at all other times (Harrington & Edelman, 2018). Since 2014, one in eight nursing homes have been cited for noncompliance (Rau, 2018). A CMS audit in 2018 showed that 96% of nursing homes had an RN onsite for eight hours a day only 80% of the year, and on the weekends, 91% of facilities had an RN present less than 60% of the time (Marselas, 2018). A literature review shows that there are two main reasons for inadequate staffing. First, RNs and LPNs in nursing homes have lower salaries than their colleagues in other fields. When understaffed, these RNs and LPNs work harder, and tend to get burned out, and quit faster than nurses in other fields (Rau, 2018). Secondly, about 70% of nursing homes are for-profit, with incentive to lower staff numbers to make more money, even though facilities with the highest profit margins have been found to rank lowest in quality of care, and highest in violations (Harrington & Edelman, 2018).

As Gurwitz (2018) states that “the way in which the financing of nursing home care is currently configured does not incentivize substantial financial investment in interventions that might lead to genuine improvements in the quality and safety of care in this setting”; this is an ongoing area of  significant concern and need for watchful eye for potential future changes.



Gurwitz, J. (2018). Medication Safety in Nursing Homes: What’s Wrong and How to Fix It. Retrieved from

Harrington, C., & Edelman, T. S. (2018). Failure to Meet Nurse Staffing Standards: A Litigation Case Study of a Large US Nursing Home Chain. INQUIRY: The Journal of Health Care Organization, Provision, and Financing55, 004695801878868. doi: 10.1177/0046958018788686

Marselas, K. (2019, July 2). ‘Staggering’ 75% of nursing homes almost never meet expected RN staffing levels, study finds. Retrieved from

Rau, J. (2018, July 13). Most nursing homes are not adequately staffed, new federal data says. Retrieved from