WASHINGTON—“This is nationwide,” says Julie Martinez, a licensed practical nurse in a Buffalo-area nursing home. “There is short-staffing everywhere. They could never pay us as health-care workers what we deserve, and they need to start. We need more workers, and we need better pay.”

Martinez, an 1199SEIU member, was speaking at an online discussion Apr. 6 between four nursing-home workers and federal Centers for Medicare and Medicaid Services (CMS) administrator Chiquita Brooks-LaSure. It was organized by the Service Employees International Union, which represents about 160,000 nursing-home workers.

The COVID-19 pandemic, Martinez said, “ripped the Band-Aid off what all of us health-care workers have already known”: chronic problems with staffing and low pay. More than 200,000 nursing-home residents and staff have died of COVID, almost a quarter of the total U.S. death toll of 980,000. In the Greenville, R.I. facility where certified nursing assistant Adelina Ramos works with Alzheimer’s patients, more than 20 died within a month when the pandemic first hit. Staffing has gotten worse since then, she said.

“Some of us have to work two or three jobs,” Ramos, an 1199NE member, said. “I’ve been working doubles almost every day, because we don’t have anyone else to fill the shifts.”

Asked later what her vision of an ideal nursing home would be, she said a staff-to-patients ratio adequate to give personal care, especially on weekends; workers having a voice in the process; and management held accountable.

CEOs “save money on short-staffing,” Ramos said.

The Biden administration’s priorities, Brooks-LaSure said, are setting national minimum-staffing standards, transparency about conditions and ownership, and more effective enforcement against nursing homes that are not meeting standards for care. Those were the central points of a package of plans the White House announced Feb. 28, on the eve of the President’s State of the Union address.

“As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up,” Biden said in the speech. “That ends on my watch. Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect.”

Most of those measures will be done by administrative action rather than by legislation. They include proposing national staffing standards within a year; increasing scrutiny of “the poorest-performing nursing homes”; improving job training; rolling back Trump-era relaxation of infection-prevention regulations; and developing a template to help states to tie Medicaid payments to clinical staff wages and benefits, including additional pay for experience and specialization.

Ensuring that increases in Medicare and Medicaid payments go toward better pay for staff is crucial, said SEIU executive vice president Leslie Frane.

The administration also plans to ask Congress to appropriate more than $400 million for inspections, increase fines for violations, and set minimum standards for corporations that own nursing homes to receive payment from Medicare or Medicaid.

Reps. Jan Schakowsky (D-Ill.) and Mark Takano (D-Calif.) introduced a bill in January 2021 that would set minimum staffing standards for nursing homes and at least two weeks of paid sick leave for all employees. Neither it nor its Senate counterpart, sponsored by Cory Booker (D-N.J.) have received a committee hearing. 

The Biden administration also plans to look into the “growing role” of private-equity investment. Private equity firms, the White House says, now own about 5% of all nursing homes, and their investment in them has multiplied from $5 billion in 2000 to more than $100 billion in 2018. It cited studies showing that nursing homes taken over by private equity average 3% fewer hours of frontline nursing staffing, an excess mortality rate for residents about 10% higher, and COVID-19 infection rates 30% above statewide averages.

Nursing-home workers say the worst thing about understaffing is that it makes them unable to give residents personal care. 

“People do not realize how demanding this job is and how much skill it takes,” said SEIU Healthcare Michigan member Tamara Blue. In the Detroit nursing home where she works as a certified nursing assistant (CNA) on the midnight shift, she’ll have 16 patients on a good night and as many as 32 on a bad one. That makes it hard to give physical care — “when residents are not properly turned, their skin deteriorates,” she said, and next to impossible to give emotional support, when they “need someone to sit and hold their hand.”

How can nursing homes retain staff, she asked, when McDonald’s is paying more “than what we get for taking care of humans”?

Residents “shouldn’t have to lose their dignity,” said SEIU Healthcare Pennsylvania member Barbara Coleman, a CNA at a nursing home in Scranton. Even at a minimum standard of 2.7 hours of care per patient per day, she said, at 16 patients per CNA, “the math doesn’t add up.”

She remembers when high-school students — “candy-stripers” — would come in to do activities with residents, and would like to see residents allowed to go out. If they don’t have a connection to the outside community, she said, it feels like a prison — “but they’re not getting the funding a prison does.”

Ramos and Blue both said they’ve seen owners hire temporary staff, paid twice as much as permanent workers, to look good when state inspectors come.

“The revenue is there” for improvements, said Blue.

Nursing-home workers take care of “people in their last days,” said Martinez, and they should be happy and comfortable — not left lying in feces and urine because workers are overloaded. It’s hard to keep your composure on the job sometimes, but you have to, she added. 

“I love my residents. You’re taught in nursing school ‘Don’t get too attached.’ How can you not?” she said. “It breaks your heart. They deserve better.”


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