Proposed federal regulations intended to boost staffing and care at nursing homes and other long-term care facilities across the country are prompting a mix of reactions in Oregon — with some saying more is needed, and others saying it could backfire.
The rule follows other efforts to improve weaknesses in the health care system exposed by the pandemic. Supporters say the new rules, which shrink staff-to-patient ratios, will make residents safer and better cared for. But opponents warn that amid workforce shortages, facilities will be forced to accept fewer people, shrinking already scarce resources for long-term care. These criticisms come despite the fact that 63% of Oregon facilities already meet the new guidelines.
Dozens of Oregonians have already weighed in on the rules, including Mary Anne Spradlin, a former registered nurse who lives in Salem. She wrote in a public comment that while working as manager at a nursing home in the past, she was told she would be eligible for a bonus if she ran her building short-staffed on a regular basis. Spradlin said she refused.
“Imagine needing to go to the bathroom and needing help to get to the toilet and get your pants down and there’s no one to help you,” she wrote. “It’s a horrible experience and it happens every day in nursing homes across America.”
But Allen James, an administrator at Avamere Rehabilitation Of Oregon City, said the regulations would worsen staffing challenges. “If you are to do this, we will need additional funding,” he wrote.
The Biden administration announced the proposal in September in response to what it called chronic understaffing and substandard care at nursing homes. More than 200,000 nursing home residents and workers died from COVID-19 during the pandemic. In Oregon, which didn’t track nursing home deaths specifically, nearly 3,000 people who lived or worked in “congregate settings,” such as nursing homes, died from COVID-19.
The new federal rules include base minimum staffing levels that Oregon is expected to easily meet.
But in a state with ongoing shortages of registered nurses, the requirement of hiring more RNs could be a stumbling block, industry officials say.
“The notion that we’re going to somehow be able to hire more of them, and for the night shifts, just seems impossible,” Philip Bentley, president and CEO of the Oregon Health Care Association, told The Lund Report.
Bentley said his group’s members — roughly 130 long-term care facilities in Oregon that would be affected by the regulations — already limit how many residents they accept because of the shortage of registered nurses. He said the regulations could make that worse.
Supporters, however, point to research showing that increased staffing improves care and reduces injuries in nursing homes.
“Time and again, studies show that increased staffing has better health outcomes for residents; having time to spend with residents attending to their needs is better for residents and reduces worker burnout,” Pati Urias — spokesperson for Service Employees International Union Local 503, which represents 3,800 Oregon nursing home workers — told The Lund Report in an email.
Where Oregon stands now
An analysis by health policy think tank KFF found that Oregon is among a handful of states where a majority of nursing homes would meet the new regulations' key requirements.
Nearly all of Oregon’s nursing homes would meet the requirement that nurse aides (or certified nursing assistants) provide two and a half hours of care each day to residents, the analysis found. The aides help residents with daily tasks such as eating, bathing and using the bathroom. Urias said the proposed regulation’s requirements around nurse aides is nearly identical to Oregon’s.
However, the analysis found only about two-thirds of Oregon’s nursing homes would meet the new requirement to have a registered nurse provide about half an hour of care each day to residents. Registered nurses can administer medications, perform tests and can implement resident treatment plans.
Urias said that while Oregon has some of the best nursing home staffing standards in the country, some facilities remain understaffed. The proposed regulations will require nursing homes to disclose their staffing levels.
The requirement for additional registered nurses concerns Bentley, who said nursing homes have a hard time competing with hospitals for registered nurses, often relying on expensive staffing companies instead.
Bentley pointed to national data compiled by the Long Term Care Community Coalition indicating that Oregon already has one of the highest nursing home staffing levels in the country.
He said the way the proposed regulations are structured would penalize Oregon nursing homes that often rely on licensed practical nurses. LPNs keep patients comfortable and administer basic care but have less training than registered nurses.
The regulations don’t count licensed practical nurses toward the hours of care that residents receive from nurse aides.
He said any minimum nurse staffing rule “should recognize all of the nursing categories that serve residents in nursing facilities.”
Already, more than 4,600 people have submitted public comment on the rules since they were posted one month ago.
One of them is Jennifer Cicero, an administrator of an assisted living facility in Hermiston. She wrote that her company is already struggling to meet the requirements of a recently enacted state rule that requires facilities to staff based on the needs of residents. She wrote that the law looks “great on paper but sometimes impossible to staff and financially crippling.”
She said that her company had previously committed to not moving residents, unless they need higher levels of care.
“They would be able to stay when they run out of money and during their transition to death,” she wrote. “Now with this rule we are looking to discharge at least 7 residents from the home they have gotten to know and love as well as the care team they trust … People have nowhere to go.”
Cathy Elizondo, a former nursing facility manager who became a nursing home inspector for the state of Oregon, echoed Cicero, writing that, “As much as I wish, mandating staffing would magically make the LTC staffing crisis go away, it WILL NOT … In Oregon, facilities are hard-pressed to recruit RNs, so making a 24/7 RN mandate is truly not feasible.”
Regina Ford, however, wrote that the rules don’t go far enough, though they represent progress. She worked in long-term care facilities for years as a certified nursing assistant and medication aide before volunteering with the state Long-term Care Ombudsman office, set up to investigate complaints.
“The vast majority of nursing homes and assisted living centers do not come close to giving the care needed, contracted for and required for residents,” she wrote, adding that the rules will “rein in the abuses that have benefitted big business over the needs of workers and elders for so long.”
Barb Crumpacker of Idaho wrote that her sister suffered a compound fracture of her arm while in an Oregon facility — bone visibly piercing the skin — but was not X-rayed until Crumpacker complained to the state after hearing about it.
“By then, the bones were healing incorrectly (overlapped instead of end to end),” she wrote, adding that her sister told her that “folks needed bed pans, for hours & no one came to answer their call button … If care facilities can’t find or keep staff, they should not be able to just warehouse folks.”
Public comment on the regulations closes on Nov. 6. Federal officials will consider changes to the regulations before implementing them.
Clarification: This article has been updated to reflect that the KFF's analysis concerns two requirements of the proposed federal regulations.