Abstract
Objectives
Staffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.
Design
This study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.
Setting and Participants
15,212 nursing homes.
Measures
The primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.
Results
Between May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.
Conclusion and Implications
Our results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.
Keywords: COVID-19, nursing homes, staff shortages, resident deaths, staffing hours
The COVID-19 pandemic has had an unprecedented and disproportionate impact on nursing homes (NHs) in the United States. As of May 2022, there were more than a million confirmed COVID-19 cases and more than 150,000 COVID-19 deaths of NH residents.1 The COVID-19 pandemic also put significant stress on NH staff, with more than a million recorded COVID-19 cases and around 2500 recorded deaths among the staff.1
Adequate staffing is critical to providing care to NH residents. Prior research has shown that NHs with higher staffing levels provide better quality of care.2, 3, 4, 5 Even before the pandemic, staffing has been a long-term concern in NHs. NHs were plagued with high staff turnover, low retention, staffing below Centers for Medicare & Medicaid Services (CMS) suggested levels, and low wages.6, 7, 8, 9 The pandemic put additional strain on NHs, and staffing problems have only become worse.10, 11, 12, 13, 14, 15, 16, 17, 18, 19 In addition, employment in NHs declined during the pandemic and continues to remain low even when employment in physicians’ offices and hospitals has already reached the prepandemic level.20 , 21
Previous studies have shown the association between COVID-19 cases and COVID-19–related deaths in NHs, controlling for facility characteristics, including past quality measures like star ratings.22 A study noted that deaths due to COVID-19 and non–COVID-19 were associated with past quality measurements but did not include contemporaneous staffing issues.23 Studies have investigated the impact of the pandemic on staffing hours and found that staff hours per patient day did not decrease in the first 9 months of 2020 compared to a similar period in 2019.24 However, other research finds that severe COVID-19 outbreaks were associated with lower staffing hours because of absences and departures.25 There are no studies on staffing shortages and deaths in NHs.
This study aimed to fill these knowledge gaps by examining the association of self-reported staffing shortages with staffing hours and total resident deaths (further divided into deaths due to COVID-19 and non-COVID-19 causes) in NHs during the COVID-19 pandemic. The main research questions were (1) whether self-reported staffing shortages were associated with changes in the staffing hours of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs); (2) whether the staffing shortages on hours per resident had any impact on contract and employee hours; (3) whether staffing shortages during any week were associated with an increase in total resident deaths; and (4) whether staffing shortages during any week were associated with an increase in deaths due to COVID-19 and other causes during that specific week.
Methods
Data Sources
This study uses multiple publicly available data sets. We used data reported by NHs to the Centers for Disease Control and Prevention's (CDC's) National Healthcare Safety Network (NHSN) Long Term Care Facility COVID-19 Module: Surveillance Reporting Pathways and COVID-19 Vaccinations.1 We obtained data reported any week between May 31, 2020, and May 15, 2022. We used information on residents' weekly deaths due to COVID-19 and total deaths, weekly residents’ confirmed COVID-19 cases, and self-reported shortages of nursing staff, aides, and other staff.
We used the Payroll Based Journal (PBJ) Public Use Files that have daily data on NH staffing levels based on data submitted by NHs to CMS through the PBJ system.26 The data include the staffing information each day for each facility submitted by NHs quarterly. Our analysis focused on nursing staff because they provide most of the direct care to residents in NHs. The daily data were aggregated weekly and merged with the NHSN data. We used data for the week ending between May 31, 2020, and March 27, 2022.
We obtained NH characteristics by downloading the data from the Nursing Home Compare website.27 We used information on ownership (profit, nonprofit, and government), in-hospital location, and the number of certified beds. We used state and county codes from Nursing Compare data to get location information.28 , 29
Our study included NHs that reported data to NHSN between May 31, 2020, and May 15, 2022. We dropped NHs for the reporting week if they failed to pass the data quality assurance check performed by CDC and CMS. We also excluded observations if NHs reported higher deaths due to COVID-19 than total deaths in any week.
Variables
Staff shortages and exposure variable
Shortages of any staff, a dummy variable, was defined based on whether NHs reported a shortage of nursing staff, nursing aides, or other staff. Nursing staff included RNs and LPNs or vocational nurses. Aides included CNAs, nurse aides, medication aides, and medication technicians. Other staff included other facility personnel not included in the categories above, regardless of clinical responsibility or resident contact (eg, environmental services). We also created lagged values of shortage of any staff going back up to 3 weeks to capture the impact of persistent shortages on resident outcomes. In NHSN data, RNs and LPNs are categorized under nursing staff, and CNAs are categorized under aides.
Outcome Variables
Staff hours
We used the staff hours of RNs, LPNs, and CNAs (total hours and divided by employee hours and contract hours). We calculated the total hours per resident per day for each staffing category and took an average for that week.
Resident deaths
All resident deaths for the week were categorized as deaths due to COVID-19 and non–COVID-19 causes. Deaths due to non-COVID-19 causes were derived by subtracting the deaths due to COVID-19 from the total deaths reported for the week. We estimated total deaths per 100 residents, deaths due to COVID-19, and non–COVID-19 causes per 100 residents.
Additional Variables
The weekly number of residents with new laboratory-confirmed COVID-19 cases and its 1-week lagged values were included in the analyses as additional explanatory variables in multivariate linear regression models. Past COVID-19 cases may impact future deaths in addition to the staffing shortages. We used NH information on ownership, geographic location, the total number of certified beds, in-hospital location, and occupancy rate.
Analysis
We first conducted descriptive analysis that graphed the fraction of NHs that reported staffing shortages and total resident deaths for each week during the study period. In addition, we summarized the NH characteristics that were included in the analysis.
We conducted multivariable linear regressions with NH and county-week fixed effects to examine the association of staffing shortages with staffing hours and resident deaths with SEs clustered at the facility level. The NH fixed effects control for any time-invariant facility-specific variables that may be correlated to staffing shortages, staffing hours, and resident deaths (eg, this could be the process of care that is facility specific). In addition, to control for bias due to region-specific (eg, local labor market conditions or neighborhood COVID-19 cases) shocks that may affect all facilities in a particular week, we included county-week fixed effects in all multivariable regressions. In our regression models, we included current week and 1-week lagged resident confirmed COVID-19 cases among residents as additional covariates. If past COVID-19 cases impact current deaths, not controlling for them would bias the estimate of staffing shortages.
First, we estimated the association between staffing shortages and staffing hours. We used staffing hours of RNs, LPNs, and CNAs per resident as dependent variables and the self-reported shortages of nursing staff and aides as the main independent variables. We further divided the staffing hours into employee and contract hours, estimating the models for them individually.
Second, we estimated the association between staffing shortages and resident deaths. Our models included weekly total deaths per 100 residents and weekly deaths due to COVID-19 and non–COVID-19 causes per 100 residents as outcomes and shortages of any staff as the primary explanatory variable.
Third, we estimated the association between staffing shortages and resident deaths using lagged variables for shortages of any staff. Using lagged values for shortages would capture not only contemporaneous staffing shortages and their impact on resident deaths but also the impact of past shortages on current resident deaths. Our models included total weekly deaths per 100 residents and weekly deaths due to COVID-19 and non–COVID-19 causes per 100 residents as outcomes and the shortages of any staff and their lagged values up to 3 weeks as explanatory variables. We ran separate regression models by the number of lags and calculated the cumulative of the coefficient of lagged values to get the point estimates for long-term effects of staffing shortages on overall deaths as well as deaths due to COVID-19 and non–COVID-19 causes.
Results
Trends in Staffing Shortages and Summary Statistics
Figure 1 reports weekly fractions of NHs that reported staffing shortages to CMS from the weeks between May 30, 2020, and May 15, 2022. The fraction of NHs reporting shortages of any staff ranged from 18% during the week ending on March 21, 2021, to 33% during the week ending on January 23, 2022. Figure 1 also reports the total weekly deaths of NH residents for the same period. Total deaths ranged from 4853 during the week ending on June 20, 2021, to 12,664 during the week ending on December 20, 2020.
Fig. 1.
Staffing shortages and resident deaths in nursing homes, week ending on May 31, 2020, to week ending on May 15, 2022. This figure reports the fraction of nursing homes with staff shortages and total resident deaths by week ending, from May 31, 2020, to May 15, 2022. Shortages of any staff include shortages of aides, nursing staff, or other staff. Nursing staff includes registered nurses, licensed practical nurses, and vocational nurses. Aides includes certified nursing assistants, nurse aides, medication aides, and medication technicians. Other staff includes other facility personnel not included in the categories above, regardless of clinical responsibility or resident contact (eg, environmental services). The total deaths are divided into deaths due to COVID-19 and those due to non–COVID-19 causes. This figure uses nursing home COVID-19 data from the Centers for Medicare and Medicaid Services.
Table 1 summarizes the variables used in the analysis. The mean of shortages of any staff, aides, nursing staff, and other staff were 23.7%, 21%, 19%, and 11%, respectively. The mean RN hours per resident were 0.50. Of these hours, 0.48 were employee hours, and 0.02 were contract hours. The mean LPN hours per resident were 0.84. Of these hours, 0.79 were employee hours and 0.05 were contract hours. The mean CNA hours per resident were 2.11. Of these hours, 1.99 are employee hours and 0.12 were contract hours. The mean total weekly resident deaths per 100 residents was 0.66. The mean of weekly resident deaths per 100 residents due to COVID-19 and non–COVID-19 causes were 0.13 and 0.53, respectively. The mean of weekly confirmed COVID-19 cases among residents was 0.67. In our sample of 15,212 NHs, 70.1% of the NHs were for-profits, 23.6% were nonprofits, and the remaining 6.3% were government owned. NHs in metro areas accounted for 68.9% of all NHs, with the remaining 31.1% located in micro or rural areas. Only 4% of NHs were located inside hospitals. The mean number of certified beds was 106.7, and the occupancy rate was 72.1%.
Table 1.
Nursing Home Characteristics, Week and Facility Level
| Variables | Mean | Standard Deviation | n |
|---|---|---|---|
| Nursing home week level | |||
| Shortage of any staff (%) | 23.71 | 42.53 | 1,538,364 |
| Shortage of aides (%) | 21.03 | 40.75 | 1,538,364 |
| Shortage of nursing staff (%) | 19.03 | 39.25 | 1,538,364 |
| Shortage of other staff (%) | 11.02 | 31.32 | 1,538,364 |
| Total hours for RN per resident | 0.50 | 0.50 | 1,390,995 |
| Employee hours | 0.48 | 0.49 | 1,390,995 |
| Contract hours | 0.02 | 0.09 | 1,390,995 |
| Total hours for LPN per resident | 0.84 | 0.42 | 1,390,995 |
| Employee hours | 0.79 | 0.42 | 1,390,995 |
| Contract hours | 0.05 | 0.13 | 1,390,995 |
| Total hours for CNA per resident | 2.11 | 0.73 | 1,390,995 |
| Employee hours | 1.99 | 0.75 | 1,390,995 |
| Contract hours | 0.12 | 0.28 | 1,390,995 |
| Residents weekly total deaths per 100 residents | 0.66 | 2.40 | 1,538,364 |
| Residents weekly deaths due to COVID-19 per 100 residents | 0.13 | 0.95 | 1,538,364 |
| Residents weekly deaths due to non–COVID-19 deaths per 100 residents | 0.53 | 2.16 | 1,538,364 |
| Residents weekly confirmed COVID-19 cases | 0.61 | 2.80 | 1,538,364 |
| Nursing home level | |||
| For profit (%) | 70.12 | 45.78 | 15,212 |
| Nonprofit (%) | 23.55 | 42.43 | 15,212 |
| Government (%) | 6.34 | 24.36 | 15,212 |
| Located in metro areas (%) | 68.81 | 46.33 | 15,212 |
| Located in micro areas (%) | 13.82 | 34.51 | 15,212 |
| Located in rural areas (%) | 17.37 | 37.89 | 15,212 |
| Located in-hospital (%) | 3.95 | 19.48 | 15,212 |
| Number of certified beds | 106.69 | 60.76 | 15,212 |
| Occupancy rate (%) | 72.11 | 30.81 | 15,212 |
The shortages of staff are self-reported by the skilled nursing facilities. Shortages of any staff include shortages of aides, nursing staff, or other staff. Nursing staff includes registered nurses, licensed practical nurses, and vocational nurses. Aides include certified nursing assistants, nurse aides, medication aides, and medication technicians. Other staff includes other facility personnel not included in the categories above, regardless of clinical responsibility or resident contact (for example, environmental services). Staffing hours are calculated for each day per resident and then averaged over a week to match with staffing shortages and deaths data.
Association of Staffing Shortages With Staff Hours per Resident
Table 2 shows the association between the RN hours and the LPN hours per resident and the self-reported shortage of nursing staff. Self-reported shortage of nursing staff was associated with a decline of 0.009 (95% CI 0.004-0.013) in RN hours per resident (equivalent to a 1.8% decrease). When divided into employee and contract hours per resident, self-reported shortages of nursing staff were associated with a decrease in employee hours by 0.013 (95% CI 0.009-0.018) and an increase in contract hours by 0.005 (95% CI 0.003-0.006) for RNs (equivalent to 2.9% decline and 20.0% increase, respectively). Self-reported shortage of nursing staff was associated with a decline of 0.014 (95% CI 0.010-0.018) in the LPN hours per resident (equivalent to 1.7% decline). When divided into employee and contract hours per resident, self-reported shortage of nursing staff was associated with a decline in employee hours per resident by 0.025 (95% CI 0.021-0.030) and an increase in contract hours by 0.011 (95% CI 0.009-0.014) of LPNs (equivalent to a 3.3% decrease and a 21.1% increase, respectively). Table 2 also shows the negative association between CNA hours per resident and shortages of aides. Self-reported shortages of aides were associated with a decrease of 0.048 (95% CI 0.042-0.055) in CNA hours per resident (equivalent to a 2.4% decrease). When divided into employee and contract hours per resident, self-reported shortage of aides was associated with a decrease in employee hours by 0.067 (95% CI 0.060-0.075) and an increase in contract hours by 0.019 (95% CI 0.014-0.024) of CNAs (equivalent to 3.6% decline and 15.2% increase respectively). Although these reductions may seem small, we note that there are an average of 77 residents (106.7 × 72) in an SNF, with the total reductions in RNs, LPNs, and CNAs hours summing up to 5.6 hours on average.
Table 2.
Association Between Nursing Staff Shortages and Nurse Staffing Hours per Resident
| Total Hours | Employee Hours | Contract Hours | |
|---|---|---|---|
| Shortage of Nursing Staff | |||
| Registered nurse | −0.009∗∗∗ (–0.013 to −0.004) | −0.013∗∗∗ (–0.018 - −0.009) | 0.005∗∗∗ (0.003 to 0.006) |
| 1.8% change, mean = 0.501 | 2.9% change, mean = 0.476 | 20.0% change, mean = 0.025 | |
| Licensed practical nurse | −0.014∗∗∗(–0.018 to −0.010) | −0.025∗∗∗(–0.030 to −0.021) | 0.011∗∗∗(0.009 to 0.014) |
| 1.7% change, mean = 0.838 | 3.3% change, mean = 0.780 | 21.1% change, mean = 0.057 | |
| Shortage of nursing aides: certified nursing assistant | −0.048∗∗∗ (–0.055 to −0.042) | −0.067∗∗∗ (–0.075 to −0.060) | 0.019∗∗∗ (0.014 to 0.024) |
| 2.4% change, mean = 2.098 | 3.6% change, mean = 1.967 | 15.2% change, mean = 0.132 |
The shortages of staff are self-reported by the skilled nursing facilities. Nursing staff includes registered nurses, licensed practical nurses, and vocational nurses. Aides includes certified nursing assistants, nurse aides, medication aides, and medication technicians. All analyses control for facility and county-week fixed effects. CIs are in parentheses. SEs are clustered at the facility level. ∗∗∗P < .01. N = 1,306,918.
Association of Staffing Shortages With Resident Deaths
Table 3 shows the association between resident weekly deaths and shortages of any staff. The results show that staffing shortages are positively associated with resident deaths due to COVID-19 and non–COVID-19 causes. Shortages of any staff were associated with a 0.068 (95% CI 0.048-0.088) increase in total resident deaths per 100 residents (equivalent to 10.5%). Dividing the total resident deaths, shortages of any staff were associated with a 0.049 (95% CI 0.041-0.058) increase in resident deaths per 100 residents due to COVID-19 and 0.019 (95% CI 0.001-0.036) increase in resident deaths due to non–COVID-19 causes per 100 residents (equivalent to 39.8% and 3.6%, respectively).
Table 3.
Association Between Staffing Shortage and Deaths due to COVID-19 and Other Causes
| Weekly Total Deaths per 100 Residents | Weekly Deaths due to Covid-19 per 100 Residents | Weekly Deaths due to Non–Covid-19 per 100 Residents | |
|---|---|---|---|
| Any shortages of staff | 0.068∗∗∗(0.048-0.088) | 0.049∗∗∗(0.041-0.058) | 0.019∗∗(0.001-0.036) |
| 10.5% change, mean = 0.650 | 39.8% change, mean = 0.123 | 3.6% change, mean = 0.527 |
The shortages of staff are self-reported by the skilled nursing facilities. Shortages of any staff include shortages of aides or nursing staff or other staff. Nursing staff includes registered nurses, licensed practical nurses, and vocational nurses. Aides include certified nursing assistants, nurse aides, medication aides, and medication technicians. Other staff includes other facility personnel not included in the categories above, regardless of clinical responsibility or resident contact (eg, environmental services). All analyses control for facility and county-week fixed effects. CIs are in parentheses. SEs are clustered at the facility level. ∗∗∗P < .01. N = 1,423,698.
Association of Staffing Shortages With Resident Deaths (Lagged Shortages)
Table 4 top panel shows the association of resident total weekly deaths and shortages of any staff and its lagged values. The cumulative estimate when including shortages of any staff lagged 1 week was associated with a 0.098 (95% CI 0.0741-0.121) increase in resident deaths per 100 residents (equivalent to 15%). Similarly, when shortages of any staff were lagged by 2 and 3 weeks, it was associated with 0.113 (95% CI 0.0877-0.137) and 0.110 (95% CI 0.0844-0.136) increases in resident deaths per 100 residents, respectively (equivalent to 17.5% and 17%, respectively). Table 4 middle panel shows the association of resident weekly deaths due to COVID-19 and shortages of any staff and its lagged values. The cumulative estimate when including shortages of any staff lagged 1 week was associated with a 0.075 (95% CI 0.065-0.085) increase in resident deaths per 100 residents due to COVID-19 (equivalent to 61.0%). Similarly, when shortages of any staff were lagged by 2 and 3 weeks it was associated with 0.087 (95% CI 0.076-0.097) and 0.086 (95% CI 0.076-0.096) increases in resident deaths per 100 residents due to COVID-19, respectively (equivalent to 71.3% and 71.1%, respectively). The bottom panel in Table 4 shows the association of resident weekly deaths due to non–COVID-19 and shortages of any staff and their lagged values. The cumulative estimate when including shortages of any staff lagged 1 week was associated with a 0.022 (95% CI 0.002-0.043) increase in resident deaths per 100 residents due to non–COVID-19 causes (equivalent to 4.3%). Similarly, when shortage of any staff was lagged by 2 and 3 weeks, it was associated with a 0.026 (95% CI 0.004-0.048) and 0.024 (95% CI 0.001-0.048) increase in resident deaths per 100 residents due to non–COVID-19 causes, respectively (equivalent to 4.9% and 4.6%, respectively).
Table 4.
Association Between Long-Term Staffing Shortages and Resident Deaths in Nursing Homes
| Total Deaths per 100 Residents | Cumulative Estimate | % of the Mean | Mean | n |
|---|---|---|---|---|
| Shortages of any staff lagged 1 week | 0.098∗∗∗ (0.0741-0.121) | 15.0 | 0.650 | 1,423,698 |
| Shortages of any staff lagged 1 and 2 weeks | 0.113∗∗∗ (0.0877-0.137) | 17.5 | 0.645 | 1,403,096 |
| Shortages of any staff lagged 1, 2, and 3 weeks | 0.110∗∗∗ (0.0844-0.136) | 17.0 | 0.646 | 1,382,903 |
| Deaths due to COVID-19 per 100 residents | ||||
| Shortages of any staff lagged 1 week | 0.075∗∗∗ (0.065-0.085) | 61.0 | 0.123 | 1,423,698 |
| Shortages of any staff lagged 1 and 2 weeks | 0.087∗∗∗ (0.076-0.097) | 71.3 | 0.122 | 1,403,096 |
| Shortages of any staff lagged 1, 2, and 3 weeks | 0.086∗∗∗ (0.076-0.096) | 71.1 | 0.121 | 1,382,903 |
| Deaths due to non–COVID-19 per 100 residents | ||||
| Shortages of any staff lagged 1 week | 0.022∗∗ (0.002-0.043) | 4.3 | 0.527 | 1,423,698 |
| Shortages of any staff lagged 1 and 2 weeks | 0.026∗∗ (0.004-0.048) | 4.9 | 0.526 | 1,403,096 |
| Shortages of any staff lagged 1, 2, and 3 weeks | 0.024∗∗ (0.001-0.048) | 4.6 | 0.526 | 1,382,903 |
The shortages of staff are self-reported by the skilled nursing facilities. Shortages of any staff include shortages of aides, nursing staff, or other staff. Nursing staff includes registered nurses, licensed practical nurses, and vocational nurses. Aides include certified nursing assistants, nurse aides, medication aides, and medication technicians. Other staff includes other facility personnel not included in the categories above, regardless of clinical responsibility or resident contact (eg, environmental services). All analyses control for facility and county-week fixed effects along shortages of any staff, number of residents new confirmed COVID-19 cases among residents, and their lagged values. CIs are in parentheses. SEs are clustered at the facility level. ∗∗∗P < .01, ∗∗P < .05.
Discussion
Within the context of the COVID-19 pandemic, this study examined the association between staffing shortages and resident deaths in NHs and the association between staffing shortages and staff hours in NHs. We found that self-reported staffing shortages were associated with declining staffing hours for RNs, LPNs, and CNAs. The decrease was concentrated on the employee hours rather than the contract hours. Our results also showed a slight increase in contract hours associated with staffing shortages. Recent work has found that overall per-resident staffing levels were not lower than prepandemic levels.24 , 25 However, overall trends may hide variations across NHs. We found that staffing hours decreased for NHs with reported shortages. This finding also raises the question of the suitability of per-resident staffing hours for capturing staffing problems during the pandemic, as they may not accurately capture the stress and pressure placed on staffing.
Our study also found that the self-reported staffing shortages were associated with an increase in total resident deaths and deaths due to COVID-19 and non–COVID-19 causes individually. We found that past staffing shortages were associated with resident deaths, suggesting that long-term staffing shortages lead to poor outcomes for residents. Overall, results suggest that staffing shortages were associated with increased deaths among residents.
A positive association between staffing shortages and deaths due to non–COVID-19 causes suggests that the quantity and quality of care in NHs may have decreased during the pandemic. Previous work has shown that CNAs tend to provide most of the direct care in NHs.4 We found that staffing hours per resident were the largest for CNAs compared to RNs and LPNs, and the decrease was also the largest for CNAs. This finding implies that the shortage of CNAs may have affected not only the care for residents who tested positive for COVID-19 but for all residents in NHs. So, the association between staffing shortages and resident deaths due to non–COVID-19 causes could be consistent with the overall worsened resident health owing to inadequate staffing.
To fully understand the impact of self-reported shortages in NHs, future work needs to determine how the staffing shortages impacted the day-to-day care of residents. This work will also need to account for how informal care changed during the pandemic, as NHs severely limited resident interaction with family members living in the community who may have provided some help before the pandemic.
This study has limitations. First, our measure of staffing shortages is self-reported. NHs might report shortages if their residents had poor outcomes to deflect poor quality of care to staffing shortages. However, because we found that self-reported staffing shortages were consistent with separately reported daily staffing hours, this may not be a concern. Second, our outcomes of deaths due to COVID-19 and non–COVID-19 causes may be misclassified. Because we found an increase in total and both types of deaths, this misclassification should not be an issue per se. Third, this research does not identify if staffing hours decline because of absences or departures of staff. Finally, we did not have complete weekly data for all NHs because some of the NHs did not provide reports or the reported data did not pass the CDC and CMS quality check.
Conclusion and Implications
In this study of NHs during the COVID-19 pandemic, self-reported staffing shortages were associated with declining staffing hours for RNs, LPNs, and CNAs and with increased deaths due to COVID-19 and non–COVID-19 causes. Policies aimed at improving access and quality of care in NHs, especially in times of major health crises such as the COVID-19 pandemic, must consider ways to increase staffing, either through interventions aimed at retaining the existing staff or by attracting additional staff.
Acknowledgments
I would like to acknowledge Alice Chen, Teryl Nuckols, and Neeraj Sood for their comments and suggestions.
Footnotes
Funding sources: This research did not receive any funding from agencies in the public, commercial, or not-for-profit sectors.
The author declares no conflicts of interest.
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