Nursing Home Staffing Shortages Remain a Major Problem After COVID-19 Pandemic, DHHS Reports

Long-standing nursing home staffing and infection control issues significantly impacted the quality of care during the COVID-19 pandemic, and the findings of a new report suggests that it remains a major problem nationwide.

The U.S. Department of Health and Human Service (DHHS) Office of Inspector General (OIG) released a report on U.S. nursing home problems during the COVID-19 pandemic on February 26. The report highlights how long-term care facilities struggled  with a number of factors that resulted in high infection and mortality rates.

This is the final report in a three-part series by the OIG, which has analyzed how nursing homes were impacted by the COVID-19 pandemic, to determine what steps can be taken in the future to protect residents and staff during future outbreaks, or other health care system emergencies.

Previous OIG reports found that more than 1,300 nursing homes had COVID infection rates of 75% or higher during surge periods, and two in five residents had the virus in 2020 alone.

This final report found that, during the pandemic, nursing homes were hit with increased facility costs, high turnover rates, difficulty hiring staff, obtaining supplies, and failures to implement effective infection control practices. The report particularly focuses on nursing home staffing shortages, which are still ongoing today.

Nursing Home Staffing Shortage Concerns

Prior research has shown that insufficient staffing and frequent turnover reduces nursing home care quality, and increases the risk of nursing home neglect.

In 2021, a report released by New York Attorney General Letitia James indicated nursing home staffing shortages during COVID-19 contributed to a high number of deaths among some facilities in the state. An investigation led by a panel of U.S. lawmakers in 2022 also found that staffing shortages were a major contributing factor of COVID-19 deaths and poor resident health outcomes.

However, the problem did not abate after the pandemic receded, according to experts. A study conducted in 2023 revealed that less than 5% of U.S. nursing home meet staffing level requirements designed to ensure resident quality of care. Last month, a study found that most U.S. nursing homes are now relying on temporary nursing home agency staff, linking the practice to increased labor costs and decreased quality of care.

Less than a quarter of facilities used temporary staff prior to the pandemic, but nearly half used them in 2022, according to the recent study findings.

Nursing Home Staffing Challenges During COVID-19

In this latest report, the OIG interviewed nursing home administrators from 25 U.S. facilities, asking them to describe challenges staff and residents faced during the COVID-19 public health emergency. Administrators in each evaluation reported significant staffing problems, supply shortages, and increased facility costs at the start of the pandemic, which many facilities continue to struggle with.

Nursing home administrators reported significant staff shortages from the beginning of the pandemic, with many experienced workers retiring early or finding other jobs that lessened their chance of contracting COVID-19. Finding and keeping entry-level certified nurse aides (CNAs), dietary services, and housekeeping staff was challenging, they reported, as those positions offered lower compensation along with more physical and emotional demands, compared to those in the fast food, retail, or delivery industries.

Administrators indicated many candidates failed to attend interviews, new-hire orientation, or even their first scheduled workday. Training staff also proved challenging because many new employees lacked hands-on training due to the pandemic, and COVID-19 protocols changed so frequently that facilities did not have time to conduct routine training.

Nursing homes turned to temporary staffing agencies to meet minimum staffing requirements during the pandemic, but that decision drove up costs by 40% in some facilities and many went out of business, according to administrators. The report indicated nurse-staffing agencies pay higher wages than nursing homes, which upset the permanent staff receiving lower wages for the same position. Facilities also found agency staff were unreliable and failed to show up for work, arrived late, or did not perform their work duties, but administrators felt they could not complain to agencies out of fear that they would stop sending workers and leave the facility short-staffed.

Some facilities addressed staffing shortages by assigning nonclinical staff, including administrators, to distribute meals. However, this resulted in burnout among staff and contributed to high turnover rates. Many nursing homes took advantage of a temporary nurse aide waiver that allowed on-the-job training without certification, but expressed concern about their quality of work and ability to pass the certification exam after the waiver period ended.

In addition to the staffing problems, administrators reported long COVID-19 testing result turnarounds for staff and residents, as well as shortages of supplies and personal protective equipment (PPE) early in the pandemic because hospitals received priority ahead of nursing homes. These shortages drove up supply costs, along with increased facility costs that remain an ongoing issue among nursing homes, administrators indicated.

During the course of the pandemic, staff became frustrated over the constant use of PPE and many facilities reported difficulty in enforcing compliance to maintain staffing requirements. Administrators also reported residents struggled with wearing masks, and while health officials issued COVID-19 guidance, it was often unclear, leaving the majority of facilities unable to implement effective infection control procedures. This contributed to high infection and mortality rates, the report indicated.

Public Health Emergency Recommendations

The OIG indicates the ongoing staffing and infection control issues highlight the need for health care systems to improve resident health and safety.  It recommends the U.S. Centers for Medicare and Medicaid Services (CMS) implement effective procedures for future emergencies, and reassess existing CNA training and certification requirements.

Infection control requirements should also be assessed and revised, according to the OIG. The CMS should collaborate with health experts and take the report findings into account while it develops new strategies.

Once the CMS creates new infection control procedures, the OIG recommends it provides effective guidance to nursing homes, and assist them in complying with the new requirements. They also noted the CMS should develop a way for nursing homes to communicate with one another to share information.