Maximum patient load

VickyRN, MSN, DNP, RN · Jul 17, 2004

You can report unsafe patient situations and staffing violations to the West Virginia Department of Health and Human Resources: http://www.wvdhhr.org/bcf/children_adult/aps/report.asp

The staff in nursing homes are (most of the time) caring individuals who are doing the best that they can under IMPOSSIBLE circumstances (such as what you described). The facility will only do what is MINIMALLY required and unfortunately, these "minimal" values were legislated back in the 90's at a time when nursing homes housed residents who were not as sick and feeble as the typical population is today. In some nursing homes, having dysphagia is a death sentence, because there is not enough staff to feed and hydrate properly--so the patient will die of dehydration or aspiration pneumonia from either not being fed or watered at all or being fed too rapidly.

Many nursing facilities are understaffed to the point of endangering the health of patients. When I worked ICU, I saw some pitiful cases come in from nursing homes--severe dehydration, bed sores, etc. Let me reiterate what I said earlier: the problem is not with the staff who work in these nursing homes, it is with the staffing ratios which are set by each state legislature ("minimum staffing" ratios).

A good link for legally mandated MINIMUM nursing home ratios in all 50 states: http://www.nccnhr.org/uploads/NHStateStaffingTables.pdf

Go to page 31 for West Virginia.

SUFFICIENT STAFF: No requirement.
LICENSED STAFF: (RN, LPN/LVN)
1 DON RN Full Time Day 8hrs/5days/wk and
1 RN/LPN Charge Nurse each unit each shift
NURSE ASSISTANT STAFF (NA/CNA)
No minimum requirement
DIRECT CARE STAFF
2.0 hprd [hours per resident day] including 0.4 hour licensed nurse time and
1.6 hour aide time
For 60+ beds: exclude DON
MORE LNs/STAFF
(LNs .46 hprd)
(Total 2.06 hprd)
Current Regulation: 64 CSR 13 sets forth a "Minimum
Ratio" chart for ascending levels of resident census in 10-
resident increments. At 100 residents (excluding the
DON), the ratio of total resident care personnel is 1:8 for a
24 hr period.

Another link: http://www.state.wv.us/sos/adlaw/

WV Code of State Rules, 64 CSR 13-9.1.b Nursing Services Eff: 2-27-97

To put all this in perspective: The MINIMUM level for SAFE CARE should be AT LEAST a total of 4.1 hours of direct care per resident per day... see this important link: http://www.nccnhr.org/govpolicy/246_1275_7800.cfm

West Virginia's levels are HALF of that.

Another link with some disturbing information about American nursing homes:

http://www.nccnhr.org/pdf/burger_mal_386.pdf

"Studies using a variety of measurements and performed over the last five to 10 years on different nursing home subgroups have shown that from 35 percent to 85 percent of U.S. nursing home residents are malnourished. Thirty to 50 percent are substandard in body weight. Specific components of The Nursing Home Reform Act of 1987 (NHRA) address the prevention of both malnutrition and dehydration--these include provisions for resident assessment, individualized care planning, physician oversight, standards for sufficient nurse staffing, and the provision of quality of life, care, and service. This law mandates that facilities meet residents' nutrition and hydration needs. Yet the level of malnutrition and dehydration in some American nursing homes is similar to that found in many poverty-stricken developing countries where inadequate food intake is compounded by repeated infections.

The consequences of these conditions for elderly nursing home residents are

potentially serious. Under-nutrition is associated with infections (including urinary tract infections and pneumonia), pressure ulcers, anemia, hypotension, confusion and impaired cognition, decreased wound healing, and hip fractures. Undernourished residents become weak, fatigued, bedridden, apathetic, and depressed. When hospitalized for an acute illness, malnourished or dehydrated residents suffer increased morbidity, and require

longer lengths of stay. Compared with well-nourished hospitalized nursing home

residents, they have a five-fold increase in mortality in the hospital.

Several risk factors contribute to the occurrence of malnutrition and dehydration. They include effects of multiple underlying chronic conditions, the side effects of the treatment of these conditions, and structural factors within the nursing home setting. Examples of these chronic conditions and their treatment include depression, cognitive impairment, poor oral health, dysphagia, and the side effects of medications. Often untreated, depression occurs in a significant percentage of residents, and depressed residents are more likely to suffer weight loss. Also, nationally, 60 to 70 percent of nursing

home residents are cognitively impaired. Many can no longer feed themselves. Nearly all residents of dementia units need assistance with eating. Poor oral health contributes to inadequate intake of nutrition: one study found that as many as 70 percent have untreated dental decay. Many nursing home residents have few or no teeth, and either poorly fitting or no dentures. Swallowing disorders (dysphagia) due to dementia, stroke, Parkinson's and

other neurological diseases affect 40 to 60 percent of nursing home residents. Finally, medications such as digitalis, psychotropic drugs, aspirin, and some antibiotics decrease appetite or irritate the stomach. Structural factors within the nursing home setting that contribute to malnutrition and dehydration include lack of individualized care, inadequate staffing, high nurse aide

turnover, and lack of professional supervision of aides. While eating habits are highly individualized, residents in most homes do not have a choice of foods; cultural and ethnic food preferences are ignored. In one study, when nutritional supplements were ordered in response to weight loss, only 2 percent of the residents consumed the supplements in accordance with the physician's order. Nursing homes are often poorly staffed. Certified nursing assistants (CNAs) typically assist seven to nine residents to eat and drink during the daytime, and as many as 12 to 15 residents during the evening meal. This contrasts with the ideal of one CNA for every two to three residents who require eating assistance. Residents are fed quickly or forcefully and sometimes not fed at all. Compounding the inadequate numbers of CNAs is a 93 percent per year staff turnover rate. A newly hired CNA may not know how to care for a resident already at risk for malnutrition and dehydration. The lack of supervisory licensed nurses, as well as their lack of nutritional

knowledge, leaves CNAs to do the best they can without appropriate help from

professionals.

Four issues are key to the prevention and treatment of malnutrition and

dehydration: inadequate staffing, poor environment, insufficient data collection, and lack of enforcement....

Usually, malnutrition is synonymous with PEU [protein/energy under-nutrition], the most serious, inadequately studied, and difficult-to-treat condition. Both calorie and protein intakes are often low among nursing home residents--30 to 50 percent are substandard in body weight, midarm muscle circumference, and serum-albumin level, which indicates widespread PEU.

Low serum-albumin levels cause edema when fluid flows from the blood vessels into the surrounding tissue. Also, blood pressure falls as serum-albumin levels fall. Reports on PEU's prevalence range from 50 to 85 percent. Rudman and Feller state that the incidence of PEU in American nursing homes is similar to that of many poverty-stricken developing countries, where the effects of inadequate food intake are compounded by the catabolic effects of repeated infections caused by poor hygiene."