Staffing Has Collapsed in Many Virginia Nursing Homes, Creating a Health Crisis for Our Most Vulnerable Citizens

by James C. Sherlock

I am seldom surprised by Virginia’s nursing home staffing problems, but new government data show no progress on staffing since October of last year.

Data from the Centers for Medicare & Medicaid Services show that the number of significantly understaffed facilities has not budged in seven months.

The numbers don’t lie.

And it undeniably represents a health crisis for our most vulnerable citizens.

The questions are: what are the facility operators and the Virginia Department of Health going to do about it?

CMS nursing home staffing data processed 11/1/22 can be found here. A total of 288 facilities at that time accepted Medicare or Medicaid or both. In summary from November 1 data, 140 of them were rated one star for staffing.

Data obtained from CMS processed 06/1/23: same source, 289 facilities total,  Still 140 one-star staffing.

Zero progress.

The figure of 48% — half — of Virginia’s nursing homes at one-star staffing level is one of the worst in the nation. By every measure of that staffing we are near the bottom.

Those shortfalls are proven to have dangerous implications for the health and safety of the 14,642 Virginians who were residents of those one-star staffed Virginia facilities on an average day in the past quarter.

Registered nurse (RN) staffing in particular, including direct care RN staffing in excess of supervisory positions, represents a crisis.

It needs to be treated like one.

Virginia Heath Care Association. I asked the Virginia Health Care Association (VHCA) for comment, including what their members are doing to turn it around. I will print it verbatim if they respond.

All of the talk by VHCA representatives at the infamous hearing of the House Health, Welfare and Institutions (HWI) Committee hearing in January was about training and increasing the numbers of Certified Nurse Assistants (CNA).

But some of our one-star facilities could max out their CNA workforce and not meet staffing requirements if they do not have enough registered nurses (RNs) specifically, and LPNs.

RNs not only supervise medical care in nursing homes, but also are the only ones in those buildings licensed to provide some of the required medical care directly, especially to patients in skilled nursing beds.

Annual turnover among the licensed nurses is between 50% and north of 80% in the understaffed facilities. RN turnover is generally higher.

Understaffing is, unfortunately, a self-reinforcing condition.

It takes a vocation, not just a job opening, for dedicated nurses to commit to working in nursing homes. There is a big nursing shortage in Virginia and nationally, and they have other options. It is difficult work, but can be very rewarding to those dedicated to the mission under the right conditions.

The nurses that the nursing homes want and need, those with vocations for the work, can look at an understaffed facility posting “Nurses needed, all shifts” ads, as well as the CMS Nursing Home Compare website that is available to all, and figure out where she or he will and will not be able to find a suitable working environment.

An environment that will enable that nurse to carry out her or his duties the right way.

That is before the fact that many nursing homes do not offer competitive wages to RNs.

So, I ask VHCA what their members plan to do.

The ethical thing to do for the nursing homes without sufficient staffing would be to reduce their patient loads by attrition, especially the predictable discharges of skilled nursing facility (SNF) patients who require the highest level of nursing staff and are generally in the same facilities as long-term care (NF) patients, until staffing reaches patient needs.

I hope they will do it on their own initiative. If they do, they should find recruiting easier. And they will earn the gratitude and trust of future patients.

The General Assembly. In this crisis they rolled over like puppies, lowering the staffing goalposts in Virginia far below what federal studies have shown to be safe.

Federal standard: 4.1 total nursing hours per patient per day. Virginia’s pending July 1 2025 standard, 3.08 total nursing hours per patient per day.

For what? They should be ashamed of themselves.

Virginia Health Commissioner. I also ask Virginia’s Health Commissioner for her plans to address the problem.

She has the tool at her disposal — the administrative sanction of “restricting or prohibiting new admissions to any nursing facility” until nursing staffs are sufficient for their current patients.

That will fix the problem in three months because SNF patients nearly all leave in that period of time.

From that same regulation:

A. Nothing in this part shall prohibit the department from exercising its responsibility and authority to enforce the regulation, including proceeding directly to imposition of administrative sanctions, when the quality of care or the quality of life has been severely compromised.

I hope she will in fact exercise it if the nursing homes do not do it voluntarily.

Updated July 25 at 3:37 PM to correct number of Virginia nursing homes with one star staffing on Nov. 1, 2022.