Effects of Nursing Shortage

The most important measure of the quality of care is the amount of nursing staff available to provide care.  Nursing homes are labor-intensive and require nursing staff that are well-educated, experienced, and compassionate. The effects of nursing shortage directly impact the quality of care received by patients.

The process of care includes:

  • Assistance with activities of daily living (bathing and dressing) and
  • Special nursing services such as wound care, nutrition and incontinence management, medication and behavioral management, and chronic disease management.

The positive relationship between nurse staffing and quality of care in nursing homes has been demonstrated by a number of studies reported by the Institute of Medicine. Higher staffing hours per resident, particularly Registered Nursing (RN) hours, have been consistently and convincingly associated with the overall quality of care including:

  • Improved resident survival rates, functional status, and incontinence care;
  • Fewer pressure sores and infections;
  • Less physical restraint, catheter, and antibiotic use;
  • Less weight loss and dehydration;
  • Improved nutritional status;
  • Lower hospitalization rates; and,
  • Higher rates of discharge to home.

Unfortunately for many nursing home patients, nursing homes routinely and intentionally fail to satisfy staffing regulations. As with most businesses, labor is the most expensive component in operating a nursing home. Hence, the owners and operators of these facilities have a strong financial incentive to staff at inadequate levels at the expense of patient health and safety, which leads to elder neglect.

The profound impact of staffing on the quality of care provided to nursing home patients has been codified at both the State and Federal levels. Among other requirements, a facility must employ sufficient nursing staff to provide a minimum daily average of 3.5 nursing hours per patient day. That means, each patient, on average, must receive at least 3.5 nursing hours per day. The math is simple. The patient census appears in the numerator and the total hours worked by direct caregivers appear in the denominator. Only direct caregivers shall be counted toward NHPPD. Only activities representing “nursing services” may be counted towards the hours worked by direct caregivers. Activities that do not constitute “nursing services” include:

  • Paid or unpaid time spent on meal periods;
  • Staff time spent in non-nursing services functions such as laundry, maintenance, administrative and financial recordkeeping, and administrative maintenance of health records;
  • Staff vacation, holiday, or sick leave time;
  • Nursing services are provided in the same shift as non-nursing services by employees who are primarily engaged in non-nursing services unless the facility provides documentation of the actual time spent on nursing services.

The California Legislature has mandated that a skilled nursing facility maintain a bare minimum numeric ratio of 3.5 nursing hours per day (NHPPD). (Health & Saf. Code §1276.5, subd. (a).) The plain purpose of mandatory minimum nursing staff levels is to protect the health and safety of residents. The California Legislature and DPH have made it abundantly clear that 3.5 NHPPD is a bare minimum, and additional staff may be necessary to provide adequate care to residents to ensure resident safety. For example,

  • Health & Saf. Code §1276.65 states: (d) The staffing ratios to be developed pursuant to this section shall be minimum standards only. Skilled nursing facilities shall employ and schedule additional staff as needed to ensure quality resident care based on the needs of individual residents and to ensure compliance with all relevant state and federal staffing requirements.
  • 42 CFR §483.30 Nursing Services defines sufficient staff as (1) “The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans.”

In addition, the nursing facility must post the nurse staffing information on a daily basis pursuant to 42 CFR §483.30(e), which includes:

(i) Facility name.

(ii) The current date.

(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:

(A) Registered nurses.

(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).

(C) Certified nurse aides.

(iv) Resident census.

The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard. 42 CFR §483.30(e)(3).


When making the difficult decision about where to place your loved one for skilled nursing care, whether it be for short-term care or long-term care, ask the nursing facility to view the daily NHPPD numbers. Shop around and compare the NHPPD numbers. Generally, a higher level of staffing equates to better care.

If you suspect a loved one has been injured, neglected, or abused while in the care of a Southern California nursing home, assisted living facility, or caretaker, or if you are the victim, it is important to contact Moran Law immediately to discuss your case.