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CaseStudiesofNursingFacilityStaffingIssuesandQualityof Care BackgroundThe results of the Phase 1 and Phase 2 quantitative analyses provide compelling evidencelinking staffing levels to the quality of care provided to residents. The findings indicatethat there are specific staffing ratios for different types of staff that are associated with higherquality of care in nursing facilities for both the short-stay and long-stay populations. Theseresults were based on secondary data analyses that relied on Medicare Claims data and MDSdata to assess quality, and Medicaid Cost Report data to measure staffing. With secondarydata sources it was not possible to study how factors other than overall staffing ratios mightinfluence quality of care. These qualitative case studies were designed to investigaterelationships between quality of care provided to individual residents and staffing levels aswell as other factors relating to nurse staffing.Staffing ratios are only a part of the complex relationship between staffing and quality ofnursing home care. Other aspects of the relationship, such as staff allocation among units andshifts, staff knowledge and training, staff supervision, and management practices are noteasily quantified. The objective of these qualitative case studies was to understand the waysin which these different attributes of staffing influence the quality of nursing home manicapital.com attributes that appear to be very influential ought to be considered in the context ofstaffing regulations and investigations of staffing issues in nursing homes Methods Overview of Data Collection and AnalysisThe study team conducted site visits to seventeen nursing facilities in three states: Ohio,Colorado and Texas. During the site visits, study nurses investigated the quality of careprovided to individual residents in relation to each of the following staffing issues:• Staffing levels on different shifts,• Staffing levels on different units,• Short staffing,• Staff working double shifts,• Use of contract staff,• Nursing staff supervision and management,1Written by Helena Louwe RN, MA and Andrew Kramer MD, Center on Aging, University of ColoradoHealth Sciences Center under subcontract to Abt Associates. Valuable feedback was provided by MaryEcord RN and Marvin Feuerberg PhD as well as TEP members: Charles Phillips PhD, Eric Tangalos MD,John Nyman PhD, and Barbara Bowers PhD. RN data collectors included Sherry Sorenson, KathleenSmith, and Sharon manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

• Staff knowledge, skills and expertise, and• Staff development and training.A balance was struck between structured collection of information and unstructuredobservation. Data collection instruments and questionnaires were designed to collect data ina systematic manner, yet allow the study nurses sufficient freedom to organize theirinvestigation as dictated by circumstances in the visited nursing facilities. They recordedtheir observations of care for specific residents. The study nurses then used theirprofessional knowledge and long-term care experience to interpret their observations andprovide summary evaluations of both the quality of care delivered, and the staffing issues atthe nursing facility they observed. Members of the research team then synthesized theseobservations and evaluations into specific staffing issues The Study NursesThree study nurses were recruited for on-site data collection; one for each of the three manicapital.com research team’s objective was to find data collectors who would be able to independentlyevaluate quality of nursing care and relate it to staffing issues in a nursing manicapital.comore, it was imperative to find nurses with substantial professional experience in thenursing home setting. In addition, since case studies rely heavily on observation andinterviews, it was imperative that the nurses would be able to comfortably use these datacollection techniques. Initially, we sought data collectors with a professional background in anursing facility and background or experience in qualitative research. When this provedunsuccessful in some cases, we sought nurses with professional experience in the nursinghome setting who had a personality amenable to qualitative research. We looked for theability to establish easy rapport with people, good observation skills, and a willingness to bepersistent in uncovering information from informants while not alienating them. One of thethree nurses combined all qualifications including both nursing facility experience and abackground and experience in qualitative research. The other two were registered nurseswith work experience in nursing facilities, who had the required inter-personal manicapital.com three nurses received a one-week training in Denver in February of The trainingconsisted of instruction in the data collection protocols. In addition, they were given anintroduction to qualitative research techniques, taught by J.K Magilvy, PH.D., R.N.,F.A.A.N, Professor ofNursing, and J.G. Congdon, Ph.D., R.N., Associate Professor ofNursing at the University of Colorado Health Science Center in Denver, Colorado. Bothconducted extensive qualitative research in long-term care including ethnographic fieldstudies in nursing homes. The protocols were easily understood by the data collectors, butconsiderable emphasis was placed on the particular techniques of qualitative research. Thetwo guest instructors spent additional time with the trainees to further explain and role-playobservation and interview techniques. As part of the training the study nurses were taken forone and half days to a local nursing home in order to practice their skills and familiarizethemselves with the data collection manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

NursingFacility Selection and RecruitmentThe state selection was based to some extent on whether states participated in the quantitativeanalysis and also by the search for qualified study nurses. We knew a qualified nurse datacollector who could work in Ohio, were readily able to recruit a person in Colorado, andTexas was the first of several states under consideration where we found a qualified manicapital.com objective in the selection of nursing facilities was to include facilities with a range ofstaffing levels, based on Oscar data. Other facility characteristics that were consideredincluded: urban/rural location, hospital-based vs. freestanding, and for profit vs. non-profitownership. The seventeen visited nursing facilities had the following characteristics: twohospital-based facilities (15 free standing); eleven for-profit facilities (6 non-profit); tworural facilities (15 urban).In each state, twenty facilities were randomly selected so that we could begin recruiting froma large pool. Each of the twenty nursing facilities was initially contacted by telephone by aresearch nurse from the UCHSC. During the initial conversation, most often with the facilityadministrator, issues of confidentiality, the facility selection process and data issues werediscussed. During this initial contact, the research nurse emphasized that: 1) the nursingfacility was selected from a number of eligible facilities on a random basis; 2) the facility’sidentity would be protected in all documentation; 3) the data collection would be conductedby one nurse with experience in nursing facilities; and 4) the duration of the data collectionperiod if the nursing facility were to participate would be between six to ten manicapital.com this stage, eight nursing facilities declined to participate any further. A follow-up fax wassent to all nursing facilities that agreed to be considered. The research nurse contacted thenursing facilities again a few days to a week later to answer any questions and elicit aresponse. Several repeat phone calls were made to a nursing facility if no contact could bemade with the administrator at this time. When required, a letter from CMS that stronglyencouraged participation was sent to the facility. In Texas, where refusal rates were high, thestate agency also made contact with selected facilities endorsing their participation. In theend, twenty-nine nursing facilities refused to participate or failed to respond, including ninefrom Ohio, eight from Colorado, and twelve from manicapital.com facilities were not aware until just before the visit whether they would be included in thestudy, nor the exact dates they might be visited. The general time frame in which the studywould take place and the name of the study nurse was divulged at the time a nursing facilityagreed to participate. A nursing facility was then informed that the study nurse wouldcontact the facility one or two days prior to arrival, if the facility was selected for a visit. Thestudy nurses received the name and location of the nursing facility selected for their next visita few days to a week before their anticipated visit. This procedure was established in orderto keep an element of surprise and avoid special preparation on the part of the manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Two facilities declined to participate at the time the study nurse contacted them to confirmher arrival. Both facilities were located in the state of Ohio. Attempts to persuade the facilityadministrators to change their refusal failed On-site Data CollectionIn order to investigate the relationship between quality and staffing in the selected nursingfacilities, the data collectors focused on selected quality concerns for specific residents inparticular units. In each facility, six residents distributed over no more than three differentunits were selected for the case studies.Quality AreasSeven quality areas were selected for examining the relationship between staffing and qualityof nursing care in nursing homes. The quality areas included Rehospitalization, ResistingCare, Hygiene, Significant Weight Loss, Incident Pressure Ulcers, Functional assistance inEating, and Functional assistance in Toileting. These particular quality areas were selectedbecause these areas were investigated in the quantitative analyses in Phases 1 and 2, and werefound to be associated with manicapital.com different quality areas also targeted residents requiring various types and intensity ofnursing care. Rehospitalization focused on the short-stay population primarily composed ofMedicare patients who required skilled nursing care. Of interest were those who were eitherdischarged to the hospital, or at high risk for discharge to a hospital. The remaining qualityareas focused on residents requiring long-term nursing care. These quality areas providedinsight into staffing for the long-stay manicapital.com quality areas were chosen for study in each nursing facility. The seven quality areaswere arranged into four sets, each containing three quality areas. Each of the setsincorporated the quality area related to hospitalization for potentially avoidable causes,assuring that the case studies included the examination of skilled nursing care. Quality areaswere grouped into these sets to maximize data collection efficiency. The quality areas withinthese sets are listed in Table In some cases, it was also possible to investigate additionalcare areas based upon a selected resident’s comorbid conditions. The selection of a qualityarea set occurred on-site. As a rule, the nurse researcher selected the sets sequentially foreach subsequent manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Table Quality Area SetsSet # Quality Area Sample PopulationRehospitalizationAdmissionSet 1Functional assistance with ToiletingLong-StayIncident Pressure UlcersLong-StaySet 2Set 3Set 4RehospitalizationFunctional assistance with EatingSignificant Weight LossRehospitalizationResisting careUnclean / UngroomedRehospitalizationSignificant Weight LossIncident Pressure UlcersAdmissionLong-StayLong-StayAdmissionLong-StayLong-StayAdmissionLong-StayLong-StayResident SelectionIn each facility, the study nurses identified the particular units in operation at the time of thesite visit and then selected a maximum of three units: if possible a long-term care unit, aMedicare/sub-acute unit, and an Alzheimer/dementia unit. If more than one unit of aparticular type was in operation, the study nurse selected the unit with the highest residentcensus. On each selected unit, lists of twenty eligible residents were generated for either theAdmission Sample or Long-Stay Sample. The Admission Sample list, compiled for theMedicare/sub-acute units, was restricted to those residents who were admitted to the nursingfacility in the past days from an acute care facility. The Long-Stay Sample list wascompiled for each of the remaining long-term care units consisting of residents who hadresided in the nursing facility for more than days. Based on the quality areas set chosenfor that facility, different resident selection criteria were manicapital.com each selected quality area, residents were classified into an 'at-risk' category or a'treatment' category. An at-risk resident was one whose condition placed him/her at anincreased risk for developing a negative outcome. A treatment resident was one who had thecondition pertaining to the quality area, and was receiving care for this condition. The studynurses obtained information regarding the criteria through individual record review, staffinterviews and resident observations. The final selection of two residents on each unit, fromthose meeting the quality area criteria was determined by the study nurses, such that residentsat greatest risk for quality problems were sampled in each quality area (see Appendix D).Case Study Protocol SummaryThe study nurses spent between six and ten days in each of the visited nursing manicapital.com days were spent either consecutively or with several days separation. The duration ofthe on-site visit varied between six to ten days for several reasons: 1) the resident census andthe number of units varied among nursing facilities; 2) the nurses were at liberty to organizeAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

their days according to the needs of the facility and their own personal needs; 3) sometimesthey stayed through multiple shifts and conducted the reviews in more concentrated manicapital.com study nurses spent time on each of the selected units during three shifts (day, evening,weekend), with a maximum of nine shifts in each facility. The night shift was observedduring either the early morning or late evening manicapital.com all of the visited facilities accommodated the study nurses for the full stay. Only oneTexas facility objected to the duration of the data collection once the study nurse had arrivedon-site. Fortunately, the study nurse was informed about the facility’s expectations for arelatively short stay at the onset of her stay. The study nurse focused her attention on oneparticular unit only and selected two residents. The sub-acute unit was chosen in this facilityand data collection focused on the two case study residents on this particular manicapital.com data collection in each of the visited facilities consisted of a review of individual residentrecords, general and resident-specific observations, and staff interviews. Resident interviewswere not mandated but the study nurses were free to interview residents if they deemed thisnecessary and manicapital.com individual resident record review for each of the case study residents assisted the studynurses in targeting particular care areas for further investigation. For each case studyresident, the study nurses selected a minimum of three nursing care practices for manicapital.com resident-specific observations were conducted during the three shifts that the studynurse spent on a unit. In addition, the study nurses made general observations during thesetimes including the administration of preventive care such as repositioning and toileting ofresidents, the response time to call lights, and the interactions among staff and between staffand residents. The general observations were not restricted to the case study residents, butincluded any resident present on the unit during the time of observation. Brief interviewswere conducted with all direct care nursing staff present on the unit during the observationshift, in order to obtain information regarding work assignments, number of hours worked,tenure etc. In-depth interviews were conducted with the direct care nursing staff observedduring the administration of care to the case study residents focusing on their knowledge andfamiliarity with the resident's care. Additional interviews were conducted with managementstaff and administrative staff to understand policies, procedures, management approaches,and supervisory roles AnalysisThe collected materials were delivered to the UCHSC for analysis. Initial data abstractionconcentrated on observational data relating the care received by a particular resident to theprevailing staffing conditions at the time. Examples of both poor and good quality wererelated to staffing issues. This initial review pertained primarily to the care received by theresidents selected for the case studies, but other residents appeared in these observations manicapital.com findings for each site were recorded in a table format organized by staffing manicapital.comties and case study residents appear under their study identification number, otherAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

esidents were simply referred to as 'a resident' or were identified under a combination of theletters X and/or manicapital.com process of relating quality of care to particular staffing variables required someinterpretation. A quality of care issue could sometimes be related to more than one staffingvariable. For instance, insufficient toileting could be related to low staffing levels and/orinadequate supervision. At this phase, data from staff interviews were incorporated in thetables, which added to and sometimes clarified the relationship between quality of care andstaffing manicapital.com three study nurses were consulted and each reviewed the completed tables with respectto the postulated relationship between quality and staffing for the nursing facilities theyvisited. Their comments and insights were incorporated into the existing tables. The tableswere then reviewed for emerging patterns, which are reflected in the following section Findings Staffing LevelsThe staffing ratios for direct care nursing staff allocated to specific units during specificshifts were compiled by the study nurses during the site visit. The ratios represent actualratios at the times of observation and thus reflect situations of both 'normal' staffing, when aunit is staffed with the usual number of nursing staff and 'short staffing', when a unit isstaffed with fewer than the routinely assigned nursing staff. Nursing staff ratios varied, asexpected, per shift and per unit and with acuity level. The variation in staffing ratios forlicensed nursing staff was far greater than that for nursing assistants. While the ratios fornursing assistants fluctuated from to , the variation in ratios for RNs, LPNs andCertified Medication Assistants (CMAs) was to residents. The extremes on thehigher end of the spectrum, for nursing assistants and for nurses , reflected staffingsituations on the Medicare/ sub-acute units. The lower end of the spectrum, especially fornursing assistants, reflected situations when units were staffed below their routine levels.Staffing levels for licensed nursing staff under routine or 'normal' circumstances appeared attimes insufficient. Floor nurses frequently had multiple responsibilities, such as clinicalassignment that included medication passes and treatments in addition to administrative andsupervisory tasks. Managerial staff assigned to the units at times expressed beingoverburdened and unable to take care of all their responsibilities. This was confirmed bymany observations in different nursing facilities. Nurses frequently seemed more focused ongetting their paperwork done or getting the medication administered than on responding toresidents’ needs as they arose. In some instances, resident care suffered directly as the nursechose or could not respond to clear indications of resident or staff needs. More often though,supervisory responsibilities suffered, at times indirectly affecting resident manicapital.com following two examples illustrate how the quality of resident care was negativelyaffected when the licensed nursing staff was or felt unable to provide supervision in additionto their clinical or administrative assignments. By making the choice to ignore theirsupervisory responsibilities, the quality of care was indirectly manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Observation on the long-term care unit with designated sub-acute care beds revealsthat repositioning of the residents is insufficient on the evening shift. The nursingassistants on the evening shift have tenure between one day to eighteen months andare in need of supervision but the nurse is preoccupied with other duties. The nurse toresident ratio is The nurse has a heavy medication pass in addition to sixresidents on tube feeding; consequently, there is little time to supervise and/or assistthe nursing assistants. There is a nursing supervisor in the building in the eveningsbut her responsibility involves clinical care instead of nursing assistant supervision.Facility 40; pages 68, , , , Resident Med 01 has a history of pneumonia and several previous hospitalizationsfrom this nursing facility where she resides on the sub-acute unit. At the time of thesite visit the resident has a G-tube and receives tube feeding. Family has requestedthat staff gets the resident out of bed for a certain period each day. Observationsreveal that the resident is clean and groomed, but not out of bed during the weekdayshifts. The nursing staff ratio during these shifts is equal for nurses, LVNs, andnursing assistants. This sub-acute unit is a heavy care unit with twenty-sevenresidents, 25 of whom require extensive assistance with activities of daily living. Inaddition, fourteen residents have tube feeding and seventeen require wound- or stomacare. The floor nurses each care for twenty-seven residents but for a different task;one LVN administers medication, while the other does all the tube feedings. Theadministrative nurse, ratio , who supervises the unit during the week, expressesfeeling overwhelmed with paper work and indicates there is no time to "help staff".This is corroborated by the study nurse’s observations. Facility 10; pages 32, 38, 58,69, 72, The following example demonstrates a special care unit that was adequately staffed and thenursing staff was able to complete all their manicapital.com residents on the Alzheimer/dementia unit are appropriately dressed, clean andgroomed at all times. The unit is clean and free of odors. Residents are toileted. Oneparticular observation involves a nursing assistant assisting a resident with handwashing following toileting, testing the temparature of the water before placing theresident’s hands under the faucet, cueing the resident to dry her own hands, allowingthe resident to maintain her skill. Similar occurences are observed with otherresidents. There is sufficient staff available on this Alzheimer/dementia unit. Nurse toresident ratio and nursing assistant to resident ratio The unit census istwenty-four residents: one requires stoma care, four have nebulizer treatments andall residents require some assistance with activities of daily living. Staff to residentratio is the same on day and evening shift, during the week and weekends. The staffis well trained, and has tenure between three and five years. Facility 17; pages Numbers of nursing staff did make a difference. When insufficient staff were available, theprovided care was more likely to be inadequate. This was revealed by inadequate responsesto residents’ immediate needs, for example, lack of or delayed response to call lights, foodbeing served cold, inadequate or no assistance with eating, and inadequate monitoring of theresidents in general. This inadequate monitoring could and did at times lead to more seriousAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

incidents such as a fall. However, inadequate care did not always relate to an observednegative outcome for the particular quality areas investigated for this study; e.g., inadequateassistance with feeding would not always be evident in weight loss. Frequently, this occurredbecause low staffing and inadequate care was not a problem continuously, for instance, theresident would eat well when fed in the morning while adequate staff was available butwould consume less or nothing at all in the evening when adequate staffing was manicapital.com a certain minimum staffing threshold, resident care was compromised. Above thisminimum threshold, quality varied based on other staffing issues. When staffing levels wereadequate, the relationship between staffing level and quality of care was not always manicapital.comr, other staffing related variables also contributed very substantially to quality ofcare Allocation of Staff among Shifts and UnitsOne of the staffing variables contributing to differences in resident care was the allocation ofnursing staff and non-nursing staff. Actual nursing staff ratios collected on the different unitsduring the various shifts do not reflect the more complex staffing reality in the visitednursing facilities. Support staff, such as activity staff and social workers, management,clerical staff and housekeeping were not available at all times in similar numbers. Supportstaff were less likely to be available during the evening and weekend shifts; some of thesupport staff was not available at all during these shifts. Another factor that was not reflectedin the nursing staff ratios on particular units was the availability of nursing and non-nursingsupport staff during peak hours (e.g., mealtimes). Finally, care was influenced by theallocation of nursing staff to particular units and/or re-allocation of assigned nursing staff todifferent units when short staffing manicapital.comt StaffAdditional nursing staff, such as single task workers and management staff, were generallyavailable during the week on dayshifts, but not always during the evenings or manicapital.com task workers were found in many facilities and they performed a variety of manicapital.com facilities had bath aides who were almost exclusively assigned to the dayshift, althoughthe evening shift also completed a fair number of baths. While many single task workersprovided personal hygiene care, other single task workers performed such duties as transferof residents to and from the dining area, cleaning and refilling water pitchers, and lighthousekeeping manicapital.comment staff were often available in greater numbers during the weekday shiftsproviding support to the direct care nursing staff by handling staffing situations, unexpectedemergencies, dealing with families and, by providing additional supervision. Other nonnursingsupport staff were present during the day and sometimes into the evening manicapital.com included ward clerks or unit secretaries, activity staff, dietary assistants, maintenance,and housekeeping. The presence of support staff often positively affected resident care byrelieving the nursing staff from responsibilities that they might otherwise have to manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

In the following case that took place on an Alzheimer/dementia unit, one staff memberrevealed how welcome the assistance from activity support staff was in monitoring theresidents on this manicapital.comnt I06 is observed with one leg caught under the footrest of a reclining manicapital.com resident who is seated in the lounge in a recliner chair has attempted to risewhile the nursing assistant is toileting other residents. The study nurse intervenes byextricating the resident’s foot. This unit, with a resident census of 19 is routinelystaffed by one nursing assistant only. It is at times difficult for the nursing assistant tomonitor all the residents especially when routine nursing tasks require her to be in aresident room. On various occasions, activity staff and housekeeping were observedin a supporting capacity by ambulating the residents. One nursing assistant informsthe study nurse that the activity staff will be moving off the unit and she expresses herconcern for the residents’ safety, "They (activity staff) do help considerably." Facility43; pages 12, 57, 63, , The following example illustrates the negative affects when support staff was unable toprovide their manicapital.com study nurse observes many residents on this secured Alzheimer/dementia unitsleeping in chairs/wheelchairs. This occurred frequently during the week that thestudy nurse conducts her observations. Activities posted on the activity calendar arenot conducted and few residents are involved in activities. Activity staff is notpermanently assigned to this unit and the nursing assistants are expected to conductresident activities. However, the nursing staff on this unit consists of two nursingassistants who are fully occupied with nursing responsibilities. They conduct onlyoccasional activities. The activity coordinator indicates, "Help is needed on theassisted living wing this week," and therefore, she is not able to provide all activities.Facility 15; pages 13, 74, 87, 88, 90, The next example illustrates the difference between the day and the evening shift. While theday shift already has a better nursing assistant to resident ratio, the day shift has theadditional benefit of the presence of restorative support staff to assist in the dining manicapital.comnt S12, residing on the long-term care unit, was admitted over two years agowith a diagnosis of depression among others. She had a one-level eating decline onthe most recent MDS assessment. The dietary assessment is excellent and theresident’s weight is stable. The resident has been placed in the restorative feedingprogram since she requires increased assistance with eating. During the day shift,when restorative staff assists in the dining room, resident S12 receives proper cueingand assistance and eats well. However, this is not the case on the evening manicapital.comnt S12 does not receive any assistance during the evening meal and does notconsume any food. On the day shift the nursing assistant to resident ratio is withan additional restorative nursing assistant available for fifteen residents. Thenursing assistant to resident ratio on the evening shift is The two nursingassistants assigned to the restorative dining room during the evening shift are alsoresponsible for the residents who remain in their own rooms during mealtime. TheAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

nursing assistants divide their time between the dining area and the residents whorequire assistance in their rooms. Facility 40; pages 88, The presence or absence of support staff affected resident care on all different shifts;however, since their presence is less likely on evening and weekend shifts, resident care wasmore often negatively affected on these manicapital.com TimesAnother factor that is not reflected in the nursing staff ratios for particular units duringparticular shifts is the distribution of staff during peak times. This was most notable duringmealtimes. The distribution of staff and the assignment of responsibilities during these timesaffected the resident care in two ways: 1) residents in the dining area received inadequateassistance or supervision with eating; and/or 2) residents who remained on the unit for anyreason received little or no attention to their immediate manicapital.com the following two examples, most or all available nursing staff were active with residenttransport to or from their mealtime locations. In those instances, residents who remained intheir rooms on the units either by choice or because of higher dependency needs receivedinadequate manicapital.com observation involves a resident call light not answered for six minutes. Oneresident asks the study nurse present in the hall to find an aide to help her roommatewho needs to be toileted. All nursing assistants are involved in assisting residentsback to their rooms after breakfast. There is no aide present on the unit at this time.Facility 53; pages A call light on the long-term care unit is ringing for at least five minutes. In additionto the unanswered call light, a visitor informs the study nurse who is present forobservations that an IV unit is beeping. No nursing staff is available for manicapital.com LPN in charge of the unit, the unit manager, and the DON are all in a residentroom where a resident is being transferred to the hospital. All nursing assistantsassigned to the unit are transferring residents to the dining areas. Facility 14; pageThe following example demonstrates a facility that has found ways to proportionatelydistribute nursing staff during the mealtime peak manicapital.com facility has two mealtime sittings. Some residents remain in their rooms; someeat in the dining room. All residents receive individual attention. Response to calllights is immediate during meals and at other times. One nursing assistant remainson the floor during mealtimes to answer call lights and telephones. This allows theother aides to assist the residents with their meals without being distracted and/orinterrupted. Nurses also assist with meals and do not distribute medication duringthese times.Facility 43; pages , Appropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Allocation to Special Care UnitsAlzheimer/dementia units in some facilities were at times exclusively staffed with one ormore nursing assistants and no licensed nursing staff. This was not unusual for the nightshift, but in at least three of the six facilities with an Alzheimer/dementia unit, this was thecase for all shifts. In addition, some of these units were monitored by a Social ServiceDirector instead of nursing manicapital.com such instances, an LPN from a nearby unit would administer medication to the residentson the Alzheimer/dementia unit. In addition, the nurse was responsible for the residents’medical and/or behavioral needs on this unit. However, the nurses assigned to supervisethese units did not observe the special care unit residents on an ongoing basis. The nursingassistants were responsible for observations of any new symptoms and/or changingconditions and communicating these to the nurse in charge. Even though the nursingassistants may be astute in their observations, medical and/or behavioral needs may not berecognized timely and/or timely interventions may be omitted as demonstrated in thefollowing manicapital.comnt 6 located on the Alzheimer/dementia unit experiences increased edema tothe lower extremities. Resident wears Ted hose, but the nursing assistant is unable toput the Ted hose on. The nursing assistant reports this information timely to thenurse who monitors the residents on this special care unit. No apparent assessmentof the resident is completed. The lower extremities of this resident are still veryedematous two days later. No elevation of legs is observed. This unit is staffedexclusively with nursing assistants. A nurse on the adjacent unit monitors theresidents and administers medication on this special care unit. No follow-up andmonitoring by licensed staff of symptoms. Facility 52; pages 6,7, 34, 35, 91, Many nursing facilities redistributed their available nursing staff when demands on otherunits necessitated this. Staff from the Alzheimer/dementia units were more likely to bepulled from their location in order to increase staffing levels on other units, most notably theMedicare/sub-acute units. At times, this resulted in the Alzheimer/dementia unit becomingunderstaffed. Although the risks of compromised resident care when short staffing occurs onthe Medicare/sub-acute units were potentially more immediate, care to the residents on theAlzheimer/dementia unit was at times manicapital.com following case illustrates two negative effects from the redistribution of nursing manicapital.com Alzheimer unit was left short staffed and in addition, the direct care workers wereunfamiliar with the unit, which can be particularly devastating on an Alzheimer manicapital.com is a pervasive odor of urine on the Alzheimer/dementia unit throughout oneparticular Saturday day shift. In addition, many residents look rather unkempt. Thestudy nurse did not observe the unit during breakfast time. However, in the words ofthe scheduled LPN, "Breakfast time was a mess." The nursing assistants, three ofthem, were all new to the unit and did not know the residents well. As a result, someresidents did not receive the correct diet. Residents were leaving the dining roomAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

area before eating and wandered back into the halls or into their rooms, notreceiving adequate assistance. The study nurse who observed this unit during othermeals notes this confusion does not occur when regular staff is on. Residents areassisted in a more organized manner with regular staff present. Three familiescomplain regarding the resident care provided during this particular weekend. Callinson various units in the facility had necessitated staffing changes. This largefacility with several long-term care units and one Medicare/sub-acute unit does notuse agency staff. Instead, the facility re-allocates available staff, especially from thevarious long-term care units to the Medicare units. Facility 14; pages , , , , 16, , The cases highlighted in this section on staff allocation demonstrate the complex relationshipbetween staffing and the quality of resident care. Inappropriate staff allocation, whichnegatively affected resident care on particular units and during particular shifts, was but onevariable. In addition, short staffing, particularly resulting from staff absences, appeared insome of the examples as an additional contributing factor Staff AbsencesMany of the visited nursing facilities had hiring needs at the time of the site visit. The fewnursing facilities that had no, or very few hiring needs, were either located in rural areas oroffered benefits that were attractive for their staff. The benefits ranged from offering daycare and free parking space to generous shift differentials for shifts difficult to manicapital.comgh nursing facilities attempted to fully staff all units, 'short staffing' frequentlyoccurred. Short staffing refers to a unit being staffed with fewer than the routinely or 'ideally'assigned nursing staff: a condition that occurred in many nursing facilities on a regular manicapital.com staffing disproportionally affected the evening and the weekend manicapital.com staffing was often related to 'call-ins': a staff member calling in to cancel for ascheduled shift. Call-ins occurred just a short time before the beginning of a scheduled manicapital.com direct care nursing staff on the units where short staffing occurred were faced with thesame number of residents, who required the same amount of assistance and supervision. Toperform the same tasks/responsibilities during the same allotted time, the direct care workerin many instances worked harder, longer hours and/or skipped their breaks. Still, not all thetasks could be done as expected. Observations showed that personal hygiene, grooming,assistance with mealtime, distribution of snacks, toileting, repositioning, and the response tocall lights were the most likely care areas to be compromised. Incidents such as falls andresident altercations also appeared to manicapital.com following three examples illustrate the negative effects on resident care when shortstaffing occurred. Note that all situations occurred during weekend shifts, not unusual, sincethese shifts were disproportionately represented by call-ins. The first two examples involvethe same nursing facility and show the safety issues that result when staffing is below acertain minimum threshold. Staff could simply not cope with the overwhelmingresponsibilities. It is noteworthy that more serious incidents, such as a fall and a residentaltercation, occurred under these manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Resident SAC1 with a history of repeated falls is recently admitted to the skilled unitfrom the facility’s residential wing. The merri walker for which the resident has aMD order is no longer being used, since the resident takes it apart. The resident fellwhile residing on the skilled unit. The resident, who requires assistance withdressing, is wearing no shoes at the time of the fall from a non-reclining, non-slantchair. The incident occurs on a Sunday morning. Several staff have called in and, onthis particular unit, only one nursing assistant reports timely to work. Two nursingassistants are not in at the appointed time, one has called off for the day and the otherwill come in later. This leaves one nursing assistant to deal with twenty-sevenresidents during the early morning hours. The nursing assistant is simply unable toprovide all residents with the necessary assistance and/or monitor the residentsadequately. Facility 55; pages 19, , 95, The following observations were made in the same facility during breakfast in the restorativedining room. This happened on the same Sunday morning shift and at this time no additionalstaff members had appeared for work manicapital.com resident is pushing her wheelchair into the table and a male resident is yelling ather to get away. Another resident says,"He's liable to haul off and hit her." Thismale resident begins to shove the resident in the wheelchair. The unit nursingassistant is occupied ambulating another resident in the hall and is unable to come tothe dining room. Two other residents are moving and setting tables in the diningroom, as the unit is short staffed. One alert resident comments, "You can sure tell it'sSunday: the tables aren't set, the coffee is not here, there's no one in the dining roomin case someone falls. It is a law you know." There is one nursing assistant on theunit out of the scheduled three. Facility 55; pages , 96, The following case illustrates similarly a short staffing situation due to call-ins. However,even though resident care was negatively affected, the consequences were less seriousbecause the staffing ratio was not as drastically curtailed as in the previous manicapital.com residents remain undressed/ ungroomed until the noon mealtime on one Sundaymorning. The Saturday night shift had one nursing assistant call in and cancel hershift. There was no replacement staff member to substitute for this manicapital.come the night shift was working short and not able to complete the sameworkload, fewer residents are out of bed, groomed and dressed when the day shiftarrives. The day shift is able to provide appropriate assistance and has caught up ontheir work by noon. Facility 2; page Interviews with staff in many different facilities confirmed that call-ins mainly occurred onthe evening and weekend shifts. Even though the study nurses observed several of theseinstances for themselves, as the above examples indicate, staff members, from floor staff toadministrative staff were often more informative as to the extent of these practices. Thenumber of call-ins was reportedly high (occurring almost daily on at least one of the shifts) inat least nine of the visited facilities. Working short staffed because of call-ins did not seeman uncommon occurrence in these manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

In at least two facilities, both rated highly by the study nurses, call-ins were only anoccasional occurrence. Both nursing facilities employed a combination of management andenforcement practices to achieve this result. One facility offered generous shift differentialsfor targeted shifts in combination with flexible scheduling. Strict policies regarding call-inswere in place and the facility had very few problems as a result. The DON was not afraid toterminate nursing employees if their performance required this. This facility was located inan urban area where nursing jobs were at a premium. However, this nursing facility had noproblems recruiting nursing staff; in fact, it had a waiting list with prospective candmanicapital.com shifts in this facility were fully covered despite the nursing shortage and the facility didnot rely on agency staff. The other facility offered tuition reimbursement for nurses, RNsand LPNs, following completion of a certain amount of time on the job. In addition, therewas free parking for staff at this urban facility and in-house day care at very reasonable manicapital.com facility did have infrequent call-ins, and the facility made use of agency and/or supportstaff (e.g., bath aides) as manicapital.com facilities where short staffing occurred various strategies were employed to replaceworkers: use of agency staff, redistribution of available scheduled workers, andrequesting/mandating staff to work additional hours or double shifts AgencySeven of the investigated nursing facilities worked with agency staff, four did so on a regularbasis. The facilities using agencies ranged in quality of nursing care from above average tobelow average.Facility staff's perception of the quality of care provided by agency staff is often rathernegative. Facility staff at times indicated that the job performance of agency staff wasinadequate or insufficient, at a minimum worse than the job performance of regular facilitystaff. However, this assumption was not borne out in the observations made by the studynurses. In their report, the study nurses rarely connected quality of care specifically toagency staff, negatively or positively. Rather, it appeared that agency staff 'blended in' withfacility staff, especially when nursing assistants were concerned. When the facility staffprovided excellent resident care, so did agency staff; if the facility staff was slacking orprovided inadequate care, so did agency staff.Facility staff raised concerns regarding familiarity of agency staff with the residents forwhich they cared. For this reason, some nursing facilities opted to forego use of any agencystaff, instead working short staffed or having staff work extended hours or double manicapital.com nursing facilities made use of agency staff on a limited basis. Most facilities usingagency staff attempted to counteract this concern by requesting the same agency staff on arepeat basis and some were successful in doing so. However, this strategy did not alwaysavoid the need to reorient agency staff due to long lapses between service, changes inresidents’ status, and information overload for agency workers who worked in differentfacilities. Some responsibility of orienting the agency workers to the facility and informingthem about the residents’ status rests with the facility. In most facilities, the agency workerswere expected to follow the same routine as the regular facility staff and no arrangementsAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

were made to accommodate their special status. Report to agency workers was ofteninsufficient to encourage the provision of adequate care. In addition, when agency staff didnot receive adequate orientation to the facility and/or sufficient resident information, thedirect care nursing staff working with the agency staff experienced an increased workloadand additional stress as a manicapital.com more than one facility, management expressed that the use of agency staff posed a heavystrain on the budget. Although confirmation of these perceptions was beyond the scope ofthis study, these concerns by management influenced management strategies in dealing withshort staffing situations. For example, some facilities attempted to reduce the numbers ofagency staff, one facility went as far as declaring their facility 'agency free'. However, thisgoal was accomplished by requesting or mandating that regular nursing staff increase theirworking hours. Direct care staff then worked additional hours, extra shifts and/or doubleshifts Extended Work HoursDouble and extra shifts were performed in many nursing facilities on a regular manicapital.coms refer to two consecutive shifts, usually eight hours each. Two double shifts workedon consecutive days on the weekend are often referred to as a Baylor shift or manicapital.coms doubles and Baylors, nursing staff often worked extra hours in addition to theirregular work schedule. The hours in addition to the regular schedule were added to therespective employees’ usual schedule or were worked in the form of extra shifts during theweek. Extra shifts refer to shifts worked on the employees’ scheduled days off. Staff did attimes receive additional reimbursement for the performance of Baylor shifts (often anadditional eight hours pay). This was less likely if doubles were performed in a similararrangement during the week. In some facilities, extra shifts/hours were compensated at ahigher hourly rate, although in most instances this was not the manicapital.com facilities do not have explicit policies regarding the maximum number of hours anemployee may work in a given pay period. Some facilities limit the practice of workingdoubles or Baylors because someone in management, often the DON, does not manicapital.comr, the lack of clear and explicit policies governing maximum number of workinghours for individual employees can conceivably result in employees working longuninterrupted stretches of sixteen hours or manicapital.com study did not obtain detailed information about the number of shifts/hours worked in aparticular period by facility nursing staff. However, staff were interviewed regarding thenumber of doubles they had worked in the previous seven days. The practice of performingdouble shifts appeared pervasive. In thirteen of the seventeen visited nursing facilities atleast one nursing staff member, but frequently more, had worked between one to threedoubles in the previous seven days. In five of these facilities, at least one staff member hadworked between four to seven doubles in the last seven days. Moreover, in one of these,more than a third of the interviewed nursing staff had worked between eight to eleven doubleshifts in the last fourteen days. What this does not reveal is the practice whereby direct carenursing staff who performed Baylor shifts during the weekend had already completed a fulltimework schedule in another facility or at another job in the previous five days. All directAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

care nursing staff, RNs, LPN/LVNs, CMAs and nursing assistants, were engaged in thesework practices, however nursing assistants performed most of the doubles.Nursing staff demonstrated varying attitudes regarding extended work hours. Many workerswho engaged in these practices were motivated by financial incentives. At other times, staffworked additional hours to help out because, "Someone needs to care for them (theresidents)." In other instances, staff felt pressured by management to work additionalhours/shifts. As an illustration, some nursing staff revealed to the study nurses that they, "donot pick up the phone" on their days off out of fear they will be summoned to work on theirfree time. Staffing practices encouraging or mandating additional work hours, especiallydoubles or extra shifts, often resulted in physical and/or emotional tiredness, at timesdecreased morale, increased numbers of call-ins and staff turnover.A direct relationship between poor outcomes and the employee’s condition as a result ofspending extensive and exhaustive hours on the job was difficult to ascertain. Observationdid not reveal whether decreased motivation, irritable behavior and/or obvious mistakes werethe result of extensive working hours or whether other factors were the cause. Interviewswith nursing staff intimated in several instances a direct relationship between poor jobperformance and tiredness due to having worked double manicapital.com the following example, as relayed by one of the staff nurses on this particularAlzheimer/dementia unit, poor resident care was directly related to the nursing staff workingextended manicapital.com RN, who works in a facility where many nursing staff work Baylor shifts, notes thefollowing, "Nursing assistants are short with the residents, especially the last shift of thefour-shift stretch." She states, "The residents get snapped at by nursing assistants whenthey work too many hours. Residents may be told to 'go away' or 'you've already askedthat question'." Facility 14; pages , In the following example the nurse who committed a medication error excused this mistakereferring to a previously worked double manicapital.com LPN, working on an Alzheimer/dementia unit, did not administer AM insulin to aresident who subsequently leaves the facility on pass for a visit with family. The familychecks the blood sugar level at home; BS level shows as The family places atelephone call to the facility at some time during the day to inquire why the resident'sblood sugar is so high. The LPN realizes that she failed to administer insulin. She statesthat she "feels terrible", but claims that she is "too tired" after working a double shift.Facility 23; page The incident happened in one of the larger facilities where the policy was to use no agencystaff. Staff instead were asked to work additional hours/extra shifts. The nursing staff, bothnurses and nursing assistants, worked a substantial number of hours, frequently in the form ofdouble manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

SupervisionSupervision was defined as leadership activities including the following:• providing/requesting relevant information including clear instructions regardingstandards of care in general and more specifically regarding a residents’ status;delegating/allocating work to appropriate unit staff; acknowledging/reprimanding jobperformance and enforcing professional standards of care; providing/supporting/assisting/motivating/encouraging staff when manicapital.com presence or lack of adequate nursing supervision was studied on two levels: 1) thefacility level where management develops management practices and directives for nursingstaff throughout the facility; and 2) the unit level where individual nurses direct the nursingactivities of the direct care workers on a day-to-day basis.Facility-Wide ManagementThe presence or lack of good leadership on the management level had far reachingconsequences. Consistent and adequate supervision on the unit level was accomplishedwhen there was strong involvement of management staff most notably from the Director ofNursing (DON). The DON was in the position to identify and address problems concerningthe factors influencing the quality of resident care, be they logistical, clinical or manicapital.com leadership at the facility management level was observed in the four nursing facilitieswhere staff provided good to above average nursing care. Good management consisted ofclear guidelines and protocols, adequate training and instruction, evaluation of jobperformance, and consistent enforcement of policies. Inadequate management on this leveldid not necessarily result in inadequate provision of care, but it became a matter of individualskills and motivation of nursing staff on the different manicapital.com following two examples demonstrate how strong management enables the staff toperform good resident care. In this first case, strong leadership from management wasevident in their regular presence on the units, their willingness to assist staff when neededand the provision of clear instructions and guidelines. This resulted in a cohesive staffwilling to deliver good resident manicapital.com residents in this nursing facility are at risk for pressure ulcers but only tworesidents in the long-stay samples had developed pressure ulcers in the previous 90days. Repositioning is done frequently and timely. In addition, observation showedthat nursing assistants assisted ambulatory residents to the restroom for manicapital.com residents who have difficulty ambulating are changed every hours. Whenresidents wear attends they receive good peri care and regular changes of manicapital.com staff is truly motivated in this small rural nursing facility. The staff is dedicated toproviding excellent care and they succeed to a large degree. The nurses expect acertain level of care from the nursing assistants and the nursing assistants live up tothe standards. Management is very involved andoften present on the floors. Allnursing staff has clear work assignments; specific tasks, such as weighing, vitals etc.,are assigned to specific staff on specific days. Assignments are clear and manicapital.comriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Good team work, excellent supervision. Qualityof resident care rated as aboveaverage by study nurse. Facility 13; pages , 42, In this second case, strong supervision from management staff combined with excellent stafftraining resulted in good staff manicapital.com one nursing facility, with a sub-acute isolation unit, mainly for isolation ofresidents with MRSA, VRE, UTIs, and URIs, most of the residents are admitted withhospital-acquired infections. There is a very strong focus on isolation techniques andexcellent monitoring and enforcement. Prevention and screening for infection isadequate, hand washing is consistent, gloves are worn, and antiseptic dispensers arelocated throughout the facility. Administration/Infection Control provides educationalprograms to teach staff proper isolation techniques and the facility provides inservicesrelated to isolation precautions for families and friends. Strict policies arein place to enforce compliance with infection control. Anyone who is observed notwashing hands or not wearing gloves can be terminated on the spot. Facility hasimplemented a tracking and trending program for infections. Facility 11; pages , , 74, , , , , , Unit ManagementSupervision of direct care nursing staff influencing the quality of provided care were mosteffective when carried out on the units. It was on this level that an insufficient adherence toproper procedures, insufficient implementation of care plans, and inappropriate staff-residentinteraction could be noticed immediately and corrected. However, the nurses who wereassigned with the supervising tasks were often not in the position to provide the neededguidance. Floor nurses, and charge nurses who were mostly in the position of observingwhat was actually happening with resident care had their own assignments, which involvedadministering medication and/or providing treatments. Unit managers, who often did notprovide direct resident care, had multiple responsibilities from case management to nursingstaff management. Faced with their own task the nursing staff on the units often ignoredtheir supervising responsibilities. This was partly due to nursing staff levels as discussed inan earlier section. However, supervising nursing staff on the units differed considerably intheir ability to lead their manicapital.com following two cases, both recorded in the same nursing facility but on different units,highlights how differences in supervisory skills of the individual nurses in charge, directlyaffected the quality of care. Inadequate supervision in the first case resulted in poor qualityof care. The second case illustrates the positive effects of good nursing manicapital.com resident XX on the long-term care unit is calling out for help manicapital.com is initially no response from staff. In addition, many call lights are manicapital.com unit manager (in the facility on his day off to catch up on paperwork), the chargeLPN and three nursing assistants are all gathered at the nurses' station, visiting witheach other. It takes about ten minutes before the LPN directs a nursing assistant tofind out who is calling. The nursing assistant reports that resident XX is short ofbreath, sweaty and "looks kind of gray". The LPN instructs the nursing assistant to doa pulse O2. The nursing assistant completes this as instructed. Pulse O2 is low(82%). The LPN meanwhile has not left the nurses' station and gives no indicationAppropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

that she will act on this information. The nursing assistant becomes angry, confrontsthe LPN and tells her, "Do something." The nurse then calls the physician withoutperforming a resident assessment herself. The MD gives new orders for O2 to titrateto 90%, stat CBC and a chest X-ray. The nursing assistant in the meantime has takenappropriate action to relieve the resident’s discomfort (HOB elevated). Shecontinues to check on the resident and responds to call lights. Facility 23; pages 19,It was not clear what the reasons were for this inappropriate response to resident needs on thepart of the LPN and some nursing assistants. This was a weekend shift and several of theworkers had performed one or more double shifts in the previous seven days. However, thiswas similarly the case on the sub-acute care unit where an RN was present as a supervisor onthe same shift. Her performance as a nurse and as a supervisor was quite the opposite andthe resulting resident care was similarly manicapital.comse to call lights is timely on the Medicare unit during the weekend eveningshift. All nursing assistants are providing care as needed. The RN on duty isinformed by a family member that one resident has edema to the lower manicapital.com RN notifies the family member that she has already placed a call to the resident’sphysician and is awaiting a return call. The nurse informs the family that she willplace a repeat call to the MD if she does not receive a return call in the next thirtyminutes. The MD calls within the designated period and gives new orders for manicapital.com RN informs the family and instructs the nursing assistant as to the newinterventions. This RN is clearly in charge: communicative with nursing assistantsand family members, aware of the resident’s condition, performing timelyassessments and responding appropriately. As a result, the resident receives goodcare. Facility 23; page Inadequate supervision on the unit level often resulted in poor implementation of individualresident care plans, clinical guidelines and/or protocols, and unresponsiveness to residents'needs. When adequate supervision on the units was insufficient or lacking, the provision ofhigh quality care rested solely with the individual nursing assistants, who were sometimes upto the task and sometimes manicapital.comnt 13 who resides on the Alzheimer/dementia unit has been noted with a weightloss of 13 lbs. since admission. Care plan interventions specify: carnation with allmeals, ice cream with lunch and dinner, and high caloric snacks TID. The residentdoes not receive carnation with lunch as per care plan, ice cream is offered but theresident refuses. The nursing staff does not encourage the resident to increase hismeal intake. The resident consumes just 25 % of his lunch. During this meal, oneLPN is on the unit distributing medication. No supervision of nursing assistant staff isobserved nor does the nurse give any indication that she is aware of the care planinstructions for this particular resident. Facility 15; pages , 82, Appropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Management Tools, Protocols, and StandardsEven though nurses who functioned in a supervisory capacity differed in their skills to lead,enforcement of good care practices did not always require their active manicapital.comision on the unit level was most effective when a system was in place where staff wasreminded to accomplish a task and where the supervisor could easily verify its manicapital.com systems can be more or less sophisticated but they always involved a situation whereexpectations were clear, standards of care were explicit, and practice guidelines wereavailable. It is at this point that management staff can be important but this is not manicapital.com following example was recorded on a unit where the nursing supervisor did notparticularly engage in apparent supervision. The unit, however, ran smoothly and theresidents all received good nursing manicapital.com residents on the Alzheimer/dementia unit are appropriately dressed, clean andgroomed at all times. The unit is clean and free of odors. The nursing assistants areobserved assisting the residents with hand washing following toileting. A bathlist isposted on the unit and baths are signed off by the nursing assistantss whencompleted. If a resident refuses on a scheduled bath day, another nursing assistanttries at a later time, if the resident then still refuses the next shift tries. The unitcoordinator does not accept postponement of scheduled baths to the next day, the nextshift is okay. Nursing assistants are experienced in working with Alzheimerresidents; they are observed testing the water temperature before placing a resident’shands under the faucet, cueing a resident to dry her own hands, allowing the residentto maintain skill. There is sufficient staff available on this special care unit. Thenurse to resident ratio is and the nursing assistant to resident ratio Theratios are the same on the day and evening shift, during the week and weekends. Thestaff is well trained and has tenure between three to five years. Few occurrences ofsupervision are observed. However, expectations are made very clear, and tools arein place to facilitate easy implementation and enforcement. Facility 17; pages In the next example management found a strategy to increase the likelihood that staffdelivered resident care as expected. Observations revealed that this was an effective manicapital.com this large nursing facility with a sub-acute isolation unit expectations are madevery clear. Staff is well trained and family and friends are in-serviced on isolationprecautions. Implementation of good care practices is reinforced in several manicapital.com hand washing is performed consistently by nursing staff. Soap containersplaced throughout the facility are monitored to ensure they are used. Gel dispensersare located on all the halls. Every two hours TEA-time (turn, evaluate and assess) isannounced over the loudspeaker reminding the nursing staff of their task. As a result,residents are assessed and repositioned every two hours, even though, this mayrequire staff to don masks and gloves. In addition, a routine for feeding isestablished ensuring that all residents are fed. Staff performs well in general. Thefacility is highly rated by the study nurse. Facility 11; pages 25, 26, 59, , ,, Appropriateness of Minimum Nurse Staffing Ratios in Nursing HomesPhase II Final Report, December

Management TrainingDuring interviews, nurses in different professional capacities expressed thatthey did not feel prepared to supervise or that they felt uncomfortable in that role. In general,the nurses expressed that they did not feel adequately trained. Training on issues ofmanagement appeared to be lacking from their professional educational manicapital.com nursing facilities did not provide additional training in the form of in-services on thesubject. The topic might have been addressed in one-on-one training sessions that somefacilities did offer their staff. In only one facility, where supervision was in general verygood and resident care was equally above average, both the DON and a unit manager raisedthe subject of

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