Recently, a group of leading geranio logical nurses sent the following letter to Senator Charles Grassley, Chair of the Senate Special Committee on Aging, expressing their concerns about HCFAs recent Phase 1 report nn ieir concerns about HLFAs recent "Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homt "Appropriateness ot Minimum Nurse Staffing Ratios i Journal readers who support the actions recommended in the letter are urged to contact their respective Congresspersons, as well as Senator Grassley at 202-224-3744 or the Senate Special Committe on Aging at 202-224-5364 to exoress their concerns.
October 12, 2000
The Honorable Charles Grassley
Chairman, Senate Special Committee on Aging
825 Senate Hart Office building
Washington, DC 20510
Dear Senator Grassley,
We want ot Acknowledge with appreciation and gratitude your commitment and leadership in initiating and sponsoring legislation and policies pertaining to the ederly and long ter-care. We would like to solicit your support and action again, now.
The Health Care Financing Administration's (HCFA) August 1, 2000 report "Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase I' has interesting findings but it has not addressed the supervisor to caregiver ratio and has inadequately addressed to resident ratio mandated by the Omnibus Reconciliation Act (OBRA) '90 authorization. Specific problems with the study and asqpects of nursing care that must be taken into account are detailed in the Appendix to this letter.
In order for Congress to get a realistic assessment of the minimum staffing needed for good nursing home care, we urge you to take the following actions:
1. Request, for Phase II of the HCFA address the role of Registered Nurses (RNs) and Licensed Practical/Vocational Nurses (LPNs) as caregivers, as well as Certified Nurse Aides or Nursing Assistants (CNAs) as caregivers.
2. Request that HCFA address the supervisory roles of RNs and PNs/LVNs in the coordination and delivery fo good care in nursing homes. (HCFA could seek consultation with the U.S. Army nurse staffing experts.)
3. Request that the General Accounting Office (GAO) conduct an independent study of the needed minimum staffing of direct caregivers to residents and supervisory nurses to direct to caregivers needed for delivering good care in nursing homes and/or request such a study by the U.S. Army experts in the Workload Management System for Nursing.
As you are aware, the average elderly person in long-term care has three to six clinical diagnoses (comorbidities), and polypharmacy is common, as elderly people may average 3 to 18 drugs per day. There are many important aspects of caregiving of the disabled elderly which Nurse Aides can not perform bacause of their limited training and scope of practice. Individualized care ina nursing home requires professional observation and judgement and skillfull coordination of services. HCFA has, thus far, failed to respond to provisions of the mandate of the OBRA 1990 mandate, to:
...study and report to Congress ... on the appropriateness of stablishing minimum caregiver to resident ratios and minimium supervisor to caregiver ratios for skilled nursing facilities serving as providers of services under Title XVIII of thye Social Security Act and nursing facilities receiving payment under a state plan under Title XIX of the Social Security Act, and shall include in such study recomendations regarding appropriate minimum ratios (Congressional Record, October 26, 1990).
As nursing home resident advocates and health care proffessionals, we ask that you request that Phase II of the study proceed to thoroughly address these issues so Congress can be advise of staffing needed to assure adequate staffing in nursing homes to deliver good care in conformance with law, regulation, and nursing standards of care. With better proffessional supervision in long-term care facilities, we may be able to prevent many of the widely reported medication errors, infections, pressure sores, malnutrition, dehydration, and other avoidable and harmful complications.
Kathleen Buckwalter, PHD, RN, FAAN
University of Iowa
Meridean L. Maas, PhD, RN, FAAN
Cedar Rapids, IA
Sarah Greene Burger, RN, BSN, MPH
Diane Carter RN, MSN
Barbara K. Haight RNC, DrPH, FAAN
Mary S. Harper, PhD, RN, FAAN
Charlene Harrington PhD, RN, FAAN
San Francisco, CA
Carole P. Jennings, PhD, RN
Nancy Jonhson, RN-C, BSN
Little Rock, AR
Deborah Karas, RN - BC, MS
Jeanie Kayser-Jones, PhD, RN, FAAN
San Francisco, CA
Mathy Mezey, EdD, RN, FAAN
New York, NY
Martha MotherRN, MN, MHSA
Joan C. Warden-Saunders RN-C, BSN, FADONA
Caregivers to Residents
Phase I of the HCFA study appears to consider only nurse aides as caregivers, when actually, RNs, LPNs/LVNs and Certified Nurse Aides or Nursing Assistants (CNAs) and nurse aides in training all are involved as caregivers in certified nursing homes. Nurse Aides reportedly administer as much as 80% to 90% of personal care to nursing home residents currently, but there is a vitally important 10% to 20% of care provided by licensed nurses. An inadequate percentage of care given by RNs makes it difficult to properly address the observation and care needs of nursing home residents who have multiple chronic illnesses and disabilities and changing health status.
The HCFA study observed that 2.0 hours per resident day of nurse aide care, is a threshold level of staffing between greater and lesser incidence of harmful avoidable outcomes. Certainly this is not an appropriate level of required staffing. Minimum staffing should be based on the time required to provide at least good if not excellent care for prevention of harm and to achieve comfort and highest practicable well-being for each resident.
Caregiving includes not only the five nursing services addressed in a contract study by UCLA (i.e., feeding or assistance with eating; bathing and assistance with personal hygiene, dressing, toileting; assisting with change of position; mobility; exercise), but also many important services not addressed in the study, such as:
* Assessment and monitoring of resident care needs.
* Coordination of interdisciplinary care planning and adjustment of care plans.
* Quick response to resident requests for assistance.
* Administration of medications and treatments.
* Tube feedings and intravenous nutrition and hydration,
* Catheter and ostomy care.
* Assuring adequate fluid intake and output, and proper bowel function.
* Monitoring nutritional intake.
* Tracheotomy and ventilator care.
* Monitoring weight gain and loss, and vital signs.
* Prevention of pressure ulcers and contractures.
* Teaching and other communication with residents and families.
* Evaluation and reporting responses to care, and adjustment of care plans.
* Documentation of care given and changes in resident health status.
* Providing physical, psychological, and spiritual care for residents who are dying, and supportive assistance to families.
* Admission, transfer, and discharge care.
Supervisors to Caregivers
Phase I of the HCFA study does not address the nurse supervisory role and time needed for supervising caregivers at the nursing unit level, the facility level and at the nursing administration level. Nursing supervision must realistically reflect accountability of RNs for the quality of care delegated to LPNs or LVNs and CNAs.
At the nursing unit level, supervisory functions include:
* Assignment of resident care duties.
* Evaluation of the delivery of care and observation of safety and infection control precautions.
* Contacting physicians and families about resident changes in health status.
* Instruction and assistance to caregivers.
* Responding to observations of direct caregivers.
* Assurance of adequacy of supplies for each shift and functioning of equipment.
* Requesting and reporting laboratory work and other diagnostic procedures.
* Assuring accurate and valid documentation of care.
* Coordinating communication between nursing services and physicians, families, therapists, and other providers of services on the nursing unit.
* Transfer of information from one shift to another on resident status.
At the facility level supervisory functions include:
* Replacing staff who do not report to duty.
* Coordinating assignment of personnel to meet the needs of the residents on a facility-wide level.
* Coordinating care of residents (e.g. nursing with dietary, physical therapy, activities).
* Assistance to nursing units with action, documentation, communication required for admissions, discharges, transfers, change in health status, and deaths.
* Dealing with concerns of families, physicians, and staff.
At the nursing administration RN supervisory level, responsibilities include:
* Establishing and maintaining nursing services policy and procedure for the facility.
* Staffing nursing services: recruitment, screening, hiring, and supervision of personnel.
* Delegation of responsibility to house and unît supervisory and charge nurses.
* Scheduling nursing personnel to cover all hours every day for provision of nursing services.
* Evaluation of staff performance.
* Staff development and continuing education.
* Coordination of nursing services with all other service providers and facility departments.
* Submission of timely required reports to local, state, and federal authorities.
* Quality assurance for nursing services, regarding conf ormance with all relevant law, regulation, and delivery of care to meet nursing standards.
* Policy and procedure.
* Coordination with facility administrator regarding budget, facility, and corporate policy.