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"At most homes, staffing below federal guidelines"

Marin Independent Journal

Richard Halstead
Article Launched: 06/22/2008 01:00:00 AM PDT

Inadequate staffing is the Achilles heel of most nursing homes, said Steve Garcia, a Long Beach–based lawyer who has sued nursing homes for providing substandard care.

"These people on the floor, they’re not doing it to get rich," Garcia said. "They could work at McDonald’s and make the same amount of money. They do it because they care. But when you ask one person to do the job of three people, there is going to be problems."

Carolyn Rosenblatt, a registered nurse and lawyer who helps Marin families figure out how to care for their aging elders, said, "It’s protocol everywhere that you’re supposed to turn a person or change their position every two hours." But it’s difficult to meet such requirements, Rosenblatt said, "if you’re short–staffed or have two aides call in sick that day."

Under state law, staffing of registered nurses, less trained licensed vocational nurses and nursing assistants combined must total a minimum of 3.2 hours per resident per day at nursing homes. Only one Marin nursing home – Aldersly Skilled – falls below that standard, at 2 hours and 55 minutes, according to the Centers for Medicare and Medicaid Services. Ten homes, however, fail to meet all staffing levels recommended by consultants to Medicare.

According to Medicare’s Web site, five homes – Rafael Convalescent, Pine Ridge, Smith Ranch, Northgate and Fifth Avenue – don’t currently staff a registered nurse for at least 45 minutes per resident per day, as recommended by consultants to Medicare. The Web site lists eight homes – Country Villa Novato, Fifth Avenue, Hillside, Nazareth, Pine Ridge, Rafael, The Redwoods and The Tamalpais – as not providing at least 33 minutes of licensed vocational nurse time per resident per day, as recommended by Medicare consultants.

Managers for The Tamalpais and Nazareth House point out that their facilities compensate for their lower use of licensed vocational nurses by staffing more registered nurses than recommended.

Aldersly’s executive director, JoAnne Maxwell, said the Medicare Web site is wrong. She said Aldersly is staffed at 3.39 hours per resident day.

Betsy Hite, a spokeswoman for the California Association of Health Facilities, an industry group representing nursing homes throughout the state, said nursing homes can’t be expected to meet federal staffing recommendations because Medi–Cal doesn’t reimburse for this level of care.

In 2004, California legislators passed a law that effectively raised Medi–Cal rates for most nursing homes from $124 per day in 2004 to $152 per day in 2006. At the time, Hite said, 17 percent of the state’s nursing homes were operating in bankruptcy.

Five Marin homes – Fifth Avenue, Hillside, Northgate, Pine Ridge and Pleasant Care – depend on Medi–Cal for the majority of their revenue. Hillside gets more than 82 percent of its revenue from Medi–Cal; Northgate gets more than 75 percent.

As a result of the rate hike, "There has definitely been an improvement in nursing home care," Hite said.

Not so, said Carlene Harrington, lead author of a University of California at San Francisco study that was released last month. The study found that the number of complaints about poor quality of care increased, as did documented deficiencies and citations.

"The quality of nursing home care has been a serious problem in California and nationwide for many years," Harrington said. "The legislation was designed to address that but, so far, it has not met the challenge."

Patricia McGinnis, executive director of California Advocates for Nursing Home Reform, sees a connection between staffing levels and the use of antipsychotic medications in California nursing homes. Issues having to do with the use of such medications were noted during recent inspections at three Marin nursing homes: Villa Marin, Rafael Convalescent and Pine Ridge.

The use of antipsychotics by nursing homes in California is much higher than the national average, McGinnis said. "You give somebody a drug and it shuts them up. We’re creeping back into using drugs as a substitute for staffing."

Hite said, "Part of this gets back to liability. There is a tremendous move to get away from restraining people, so you try to go restraint–free."