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Staff to Resident Ratios

Published August 17, 2011 3:16 PM by Brian Garavaglia

In the February 2011 edition of Caring for the Ages, attorney and nurse Janet Feldkamp writes about the potential issues faced by many facilities that do not provide enough attention to maintaining adequate staff to patient ratios.  This has been a perennial issue that has plagued many administrators. Administrators often understand the need to staff on the basis of patient acuity. 

Acuity levels can vary from one day to the next. However, administrators are also placed in the unfortunate position of attempting to administrate nursing care facilities and provide the best quality of care possible, while at the other extreme, dealing with company owners and company executives that often feel a blanket number of budgeted hours per patient is the correct way to manage and eliminate unnecessary labor hours and the expenses they incur.  As Ms. Feldkamp writes, facility administration must review the staff ratios regularly to make sure their facility can address the needs of all their residents. 

This type of request often makes owners and company executives quiver. At one extreme, nursing care facilities are organizational arrangements that are meant to care for the fail individual and provide the necessary care they need.  However, at the other extreme, this does not sit well with the traditional business philosophy of maximizing profits and minimizing costs, which businesses attempt to do to be successful and profit making organizations. 

Therefore, since one attempts to manage the margins in a business environment, the last thing that many corporate executives want to hear is that they need to do so with a sliding scale of labor hours that are determined based on day-to-day acuity levels. In fact, this often defies the traditional basis of how we establish a budget for businesses.  However, health care is a business that is not exactly similar to many other businesses, especially since our unwavering budget constants can have dramatic implications on the human beings that we care for in these health care environments. 

The article provides an incisive and insightful recommendation by a long-term care legal expert to all in the nursing home area. As Ms. Feldkamp explains, just because a facility may meet the minimum state requirements in staffing does not preclude the facility from being cited, and even facing astronomical lawsuits, for not having proper staff to appropriately address the needs of the facility's residents. 

Her argument for paying attention to the daily acuity level and staffing appropriately on the basis of this level is predominately based upon the interpretative understanding of what is deemed sufficient and necessary staffing.  First, many states have explicitly stated minimum nurse staff to patient hourly requirements. However, this does not necessarily mean that just because you fulfill the minimum requirements you are legally cleared of any further obligation. Furthermore, on the federal level, the law is even more nebulous, reading:

The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual care plans (F-353).

As one can see the word "sufficient," is highly interpretive. Therefore, sufficient staffing is a highly interpretive guideline with very little objective data to firmly guide your staffing requirements. Furthermore, even with the minimum staffing requirements that are usually addressed by state laws, these are often only minimum requirements, and they also leave much to interpretation, especially in regards to managing and staffing appropriately based on resident acuity. To compound this situation, often it is not until some level of harm has been experienced by a resident(s) that many after-the-fact determinations are made regarding inappropriate staffing that failed to accommodate the needs for all residents, and ultimately led to the harm that a resident experienced. 

As one can see, stating to a jury that one's staffing was appropriate, regardless of the resident being harmed, as well as stating they were adhering to budgetary guidelines set forth by the company that precluded their ability to staff toward acuity, will do very little to endear the facility toward a courtroom jury or even toward forestalling any type of major civil monetary penalty that the federal government and its agencies in this area may invoke. 

Therefore, although Ms. Feldkamp's admonition may be somewhat disquieting toward many upper level executives within long-term care that pride themselves on maintaining constancy in their budgetary requirements, the monumental expense to the company for not paying greater attention to acuity staffing requirements can be too great to overlook. However, I do suspect that many will continue to overlook the need to properly adjust daily staffing on the basis of acuity and rationalize that their chances of being one of the next nursing homes to be targeted on this level are infinitely small and insignificant in the long run.

So where does that leave us on this argument. Most administrators and directors of nursing will continue to recognize the need to staff on the basis of acuity. However, most will continue to face formidable opposition on this level by those business executives that are concerned about maintaining a constant and uniformly numerical budget for labor. Variable and sliding scale management of labor hours often drives higher level executives and accountants crazy, since the core foundation of any budget is to enhance constancy, predictability and aid in the overall management of one financial costs. 

Furthermore, since most higher level executives are somewhat alienated from the daily landscape of the nursing home environment, they will continue to advocate for following the budget quite closely as it relates to management costs, regardless of the highly variable level of acuity that most nursing homes face on a day-to-day basis. Sadly, the important information and legal advice that Ms. Feldkamp provides will probably not be addressed seriously and on a more widespread level until many more facilities are forced to pay the piper. 


Feldkamp, J.K. (2011/Feb).  Light staffing can mean heavy liability.  Caring for the Ages: A monthly newspaper for long-term care practitioners, 12(2), 26.   



posted by Brian Garavaglia


i think you are very right on this topic. do you have a recommendaion about the best way to figure out acuity? is there a software program that can aide in this? i am trying to do it based on the mds, but that is proving to be quite challenging.

debbie, nursing - don March 7, 2012 2:32 PM
dallas TX

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About this Blog

    Brian Garavaglia, PhD
    Occupation: Long-term care administrator
    Setting: Sterling Heights, Mich.
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