Covid-19 exposed the devastating consequences of staff shortages in nursing homes. But the problem isn't new

A licensed practical nurse walks down a hallway at an assisted living facility in Marlborough, Massachusetts, in August 2020.

(CNN)Julie Moore recalls harrowing experiences from the pandemic inside the Philadelphia nursing home where she works.

As the virus spread throughout the facility last year, emergency responders came and went regularly, taking yet another resident running low on oxygen to the hospital. Staff members were infected and some died, leaving a facility already running low on employees struggling to keep up with residents' needs.
"It was so few of us in the building that we were just literally running from floor to floor seeing who needed help," Moore, who works as a certified nursing assistant, said. "It was an absolute nightmare."
Covid-19 ravaged nursing homes across the United States -- killing more than 132,000 residents and more than 1,900 staff members as of June 13, according to the Centers for Medicare & Medicaid Services (CMS) -- and it also highlighted the dire consequences that staff shortages in those long-term care facilities can have.
Julie Moore
But experts say this has been a decades-old problem.
"Seventy-five percent of the nursing homes had inadequate staffing before the pandemic started," said Charlene Harrington, a professor emerita at the University of California, San Francisco. "It's not surprising that they weren't able to cope with it."
Recruiting new staff wasn't easy before: The pay is low and the work is demanding. In May 2020, the median annual wage for nursing assistants -- most of whom work full-time -- in nursing care facilities was $30,120, according to the US Bureau of Labor Statistics.
"It's a very hard job and no one wants to come to do that job specifically for the amount that we're paid now," said Chaunte Jones, a certified nursing assistant in Michigan.
And the pandemic didn't make things easier. A June 2021 survey from the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) found 94% of nursing home providers had a shortage of staff members in the last month -- and more than half lost key members of their staff during the pandemic due to workers quitting.
"What you're telling nursing home assistants, nursing home staff, is that they need to work for probably the same amount of pay -- or maybe a small raise, who knows -- and they need to put their lives and their family's lives at risk by going into a nursing home where Covid-19 could creep in at any time," said Michael Barnett, an assistant professor of health policy and management at Harvard T.H. Chan School of Public Health.
Now, nursing home staff across the country are demanding change and better pay and providers are calling on the government for more funding to tackle the staffing crisis.

Patients suffer from the shortages

The long-standing shortage in these positions and high turnover rates left staff members across long-term care facilities scrambling for years to tend to every resident, and they're often unable to finish their tasks each day, Harrington said.
Federal regulations require that facilities have "sufficient nursing staff" with the necessary skill sets to keep residents safe and maintain their well-being.
Facilities that receive Medicaid and Medicare payments are required to provide 24-hour licensed nursing services, have a registered nurse for at least eight consecutive hours every day and have a registered nurse designated to serve as director of nursing on a full-time basis.
"Nursing homes are perpetually understaffed and the reason for that is because there are no federal minimum staff-to-patient ratio standards," said Richard Mollot, executive director of the non-profit Long Term Care Community Coalition.
A 2001 study by CMS, responsible for regulating nursing homes, found staff should spend at least 4.1 hours per resident daily. But there are no federal requirements for daily nursing hours per resident.
And states' minimum standards are "generally well below the levels recommended by researchers and experts to consistently meet the needs of each resident," according to a 2020 report co-authored by Harrington.
The report found that missed care -- often a symptom of staff shortages -- was associated with patients' "adverse events including pressure ulcers, medication errors, new infections and IVs running dry or leaking." It also found facilities with higher nurse staffing levels tended to have reduced emergency room use and rehospitalizations.
"We've documented for over 20 years the terrible care in some of these nursing homes," Harrington said. "And staffing is the fundamental service."
A CMS spokesperson said the agency collects staffing data from nursing homes and uses a star rating system -- available to the public -- to help incentivize higher staffing. If a facility's data shows inadequate staffing, the facility will have a reduction in its rating and will also be subject to unannounced surveys from state officials, the spokesperson said. A nursing home found to have insufficient staff can also face money penalties and be cut off from Medicare payments, the spokesperson said.
But the problem isn't just getting more staff in the door -- it's keeping them. Moore says that even when her Philadelphia facility recruits new staff members, the low wages and heavy workload mean they often don't stick around too long.
"I walk around the facility now and I barely know the people that are working in there because it's like a revolving door now," she said.
Nationally, registered nurses in nursing homes had an average turnover rate of more than 140% in 2017 and 2018, according to a March 2021 report published in the journal Health Affairs. Certified nursing assistants had a rate of more than 129%, the report found. Some facilities had annual total nursing staff turnover rates of more than 300%.
"One thing is clear," Barnett, from Harvard, said. "Nursing homes were not helped by the extremely volatile and tenuous nature of nursing home staffing that we went into the pandemic with, and things got worse."

What's driving the shortages