Low Staffing and Poor Quality of Care at Nation's For-Profit Nursing Homes

By Elizabeth Fernandez on November 29, 2011

The nation’s largest for-profit nursing homes deliver significantly lower quality of care because they typically have fewer staff nurses than non-profit and government-owned nursing homes.

That’s the finding of a new UCSF-led analysis of quality of care at nursing homes around the country. It is the first-ever study focusing solely on staffing and quality at the 10 largest for-profit chains.

Charlene Harrington, RN, PhD, FAANCharlene Harrington, RN, PhD, FAAN

The article is published online in advance of print publication in Health Services Research.

“Poor quality of care is endemic in many nursing homes, but we found that the most serious problems occur in the largest for-profit chains,” said first author Charlene Harrington, RN, PhD, professor emeritus of sociology and nursing at the UCSF School of Nursing. Harrington also is director of the UCSF National Center for Personal Assistance Services.

“The top 10 chains have a strategy of keeping labor costs low to increase profits,” Harrington said. “They are not making quality a priority.”

Low nurse staffing levels are considered the strongest predictor of poor nursing home quality.

The 10 largest for-profit chains operate about 2,000 nursing homes in the United States, controlling approximately 13 percent of the country’s nursing home beds.

In recent decades, nursing home chains have undergone a considerable expansion. A number of chains were publicly-traded companies until the early 2000s, when five of the country’s largest chains went bankrupt. Following restructuring and ownership changes, as well as increases in Medicare payments, the largest chains became more financially stable. More recently, some of the largest publicly held chains were purchased by private equity investment firms, which invest funds received from investors, with whom they share profits and losses.  

The researchers compared staffing levels and facility deficiencies at the for-profit chains to those at homes run by five other ownership groups to measure quality of care. The 10 largest chains were selected because they are influential in the nursing home industry and are the most successful in terms of growth and market share.  

The study found that for-profit homes strive to keep their costs down by reducing staffing, particularly RN staffing.

Recent Medicare cuts in payment rates for nursing home residents – by 11 percent in October, 2011 – may further jeopardize the health and safety of residents if the chains respond by reducing staffing and wages, Harrington said.

The 10 largest for-profit chains in 2008 were HCR Manor Care, Golden Living, Life Care Centers of America, Kindred Healthcare, Genesis HealthCare Corporation, Sun Health Care Group, Inc., SavaSeniorCare LLC, Extendicare Health Services, Inc., National Health Care Corporation, and Skilled HealthCare, LLC.

From 2003 to 2008, these chains had fewer nurse “staffing hours” than non-profit and government nursing homes when controlling for other factors. Together, these companies had the sickest residents, but their total nursing hours were 30 percent lower than non-profit and government nursing homes. Moreover, the top chains were well below the national average for RN and total nurse staffing, and below the minimum nurse staffing recommended by experts.

The 10 largest for-profit chains were cited for 36 percent more deficiencies and 41  percent more serious deficiencies than the best facilities. Deficiencies include failure to prevent pressure sores, resident weight loss, falls, infections, resident mistreatment, poor sanitary conditions, and other problems that could seriously harm residents.

The study also found that the four largest for-profit nursing home chains purchased by private equity companies between 2003 and 2008 had more deficiencies after being acquired. The study is the first to make the connection between worse care following acquisition by private equity companies.

The authors said that more study is needed on the subject. They also said that greater accountability and quality oversight mechanisms would help improve nursing home care, along with effective funding incentives and sanctions for low staffing and poor quality.

UCSF is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care.