They’re called “nursing homes,” so most of us assume that they have nurses — registered nurses — on the premises.
But not all the time. In some facilities, not even most of the time.
The 1987 federal law intended to reform the country’s nursing homes required a registered nurse on-site only eight hours a day, regardless of the size of the facility. Supporters at the time understood that in a building full of sick and disabled elders, health crises could occur at any hour. But getting the legislation passed required substantial compromises, including in regulations allowing reduced nurse staffing.
“It’s something advocates have wanted to return to ever since,” said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care. “I think most people will be both shocked and appalled that there’s not an R.N. on duty around the clock.”
One person who was indeed “completely shocked” to learn this was Representative Jan Schakowsky, Democrat of Illinois. “This applied to nursing homes whatever the number of beds,” she told me in an interview. “One hundred. Four hundred.”
She responded by introducing on July 31 the bluntly titled Put A Registered Nurse in the Nursing Home Act, or House Vote 5373. It would require that a direct-care registered nurse (not an administrator) be present 24 hours a day, seven days a week, in all the nearly 16,000 nursing homes that receive Medicare or Medicaid reimbursement.
“It’s been close to 30 years,” she said. “It’s high time to provide better care.”
It’s hard to calculate how many nursing homes would be affected. Thirteen states already require 24-hour registered nurse coverage in some cases, but their statutes vary. In Tennessee, Rhode Island, Hawaii and Connecticut, for instance, nursing homes must have a registered nurse on duty 24/7, period. California makes that requirement only for nursing homes with more than 100 beds, and New Jersey only for those with more than 150.
Elsewhere? There’s little published research, but the American Association of Nurse Assessment Coordination — one of several nursing organizations backing the bill — rooted through the ratings data on Medicare’s Nursing Home Compare site for 2012. Its researchers counted how many facilities had at least four staff registered nurses (one was probably the director of nursing) and theoretically could cover every shift.
In the end, 1,777 nursing homes did not, which means that at least 11.4 percent have no registered nurse available around the clock. But that’s a fuzzy percentage, because a home could have two on the day shift and none at night, or have some registered nurses doing administration instead of patient care. Besides, all staffing data is self-reported. The actual proportion of nursing homes without a direct-care registered nurse much of each day could well be higher.
Ms. Schakowsky’s bill specifies registered nurses because they play a specific role. Licensed practical nurses are vital to good care, and of course the lowest-paid certified nursing assistants — the aides — provide most hands-on help. But only registered nurses are trained and licensed to evaluate a patient’s care and conduct assessments when his or her condition changes, which can happen rapidly — and at 3 a.m.
“Without someone to make an assessment right then and there, that resident could be at risk,” Ms. Grant said. Maybe he won’t be hospitalized when it’s necessary. Just as dangerously, maybe someone will call 911 when he could be treated in the nursing home and avoid being hospitalized.
Studies have repeatedly pointed to the importance of registered nurses. With higher registered-nurse staffing, patients have fewer pressure ulcers (aka bedsores) and urinary tract infections and catheterizations. They stay out of hospitals longer. Their homes get fewer serious deficiencies from state inspectors. Their care improves, but it costs less.
Adding registered nurses doesn’t constitute a big-ticket expense, either. The average annual salary for registered nurses, the Bureau of Labor Statistics says, was $68,910 last year. But operators are worried about finding enough, especially in rural areas, said Ms. Grant, who has met with industry leaders. Nurses often prefer higher-paying jobs in hospitals.
Ms. Schakowsky has enlisted five co-sponsors — all Democrats — but suspects that “we’ll have bipartisan support on legislation like this,” she said “I’m hopeful.”
Adding registered nurses will hardly solve all the quality problems at nursing homes, which need more staff of other varieties, too. But it’s important unfinished business.
Otherwise, we probably should refer to these facilities as something besides nursing homes: “pre-hospitalization holding facilities,” perhaps, or “well-intended residences for the incurably underattended to.” You can probably come up with a few even-less-flattering names yourselves.