Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?

Abstract

Objectives: During the Coronavirus Disease 2019 (COVID-19) pandemic, US nursing homes (NHs) have been under pressure to maintain staff levels with limited access to personal protection equipment (PPE). This study examines the prevalence and factors associated with shortages of NH staff during the COVID-19 pandemic.

Design: We obtained self-reported information on staff shortages, resident and staff exposure to COVID-19, and PPE availability from a survey conducted by the Centers for Medicare and Medicaid Services in May 2020. Multivariate logistic regressions of staff shortages with state fixed-effects were conducted to examine the effect of COVID-19 factors in NHs.

Setting and participants: 11,920 free-standing NHs.

Measures: The dependent variables were self-reported shortages of licensed nurse staff, nurse aides, clinical staff, and other ancillary staff. We controlled for NH characteristics from the most recent Nursing Home Compare and Certification and Survey Provider Enhanced Reporting, market characteristics from Area Health Resources File, and state Medicaid reimbursement calculated from Truven data.

Results: Of the 11,920 NHs, 15.9%, 18.4%, 2.5%, and 9.8% reported shortages of licensed nurse staff, nurse aides, clinical staff, and other staff, respectively. Georgia and Minnesota reported the highest rates of shortages in licensed nurse and nurse aides (both >25%). Multivariate regressions suggest that shortages in licensed nurses and nurse aides were more likely in NHs having any resident with COVID-19 (adjusted odds ratio [AOR] = 1.44, 1.60, respectively) and any staff with COVID-19 (AOR = 1.37, 1.34, respectively). Having 1-week supply of PPE was associated with lower probability of staff shortages. NHs with a higher proportion of Medicare residents were less likely to experience shortages.

Conclusions/implications: Abundant staff shortages were reported by NHs and were mainly driven by COVID-19 factors. In the absence of appropriate staff, NHs may be unable to fulfill the requirement of infection control even under the risk of increased monetary penalties.

Keywords: COVID-19; Staff shortages; nursing homes; personal protection equipment.

Fig. 1

Percentage of nursing homes reporting staff shortages by state. (A) Reported shortage of licensed nurse staff (including the RN, LPN, and vocational nurse as reported by the provider). (B) Reported shortage of nurse aides (including the CNA, nurse aide, medication aide, and medication technician as reported by the provider).

Fig. 2

Prevalence of nursing home residents and staff with COVID-19. (A) Total number of residents with COVID-19 per 100 beds. (B) Total number of staff with COVID-19 per 100 beds. Number of cases were scaled to 100 beds to account for differences in nursing home size.