Charlene Harrington, Associate Editor

The minimum number of direct care staff must be distributed as follows:

Minimum Level of Direct Care Staff ( RN, LVN/LPN, or CNA)

Direct care staff standards will take into account specific needs of residents at mealtimes. At all mealtimes, there will be:

1 nursing FTE for each 2-3 residents who are entirely dependent on assistance

1 nursing FTE for each 2-4 residents who are partially

Despite federal and state regulations designed to ensure adequate nutrition, nutritional deficiencies are common among nursing home residents. Studies have shown that 30%-85% of nursing home residents are malnourished.

In a 5-year study that investigated the social, cultural, clinical, and environmental factors that influenced nutritional care in nursing homes, the authors found that an inadequate number of staff and lack of supervision of CNAs by professional staff were the major factors that contributed to malnutrition, weight loss, and death.

Nursing home residents are physically and cognitively impaired; many have swallowing disorders. Residents are therefore dependent upon staff for skillful assistance, and they must be fed slowly and carefully. Typically, it takes 30 minutes to one hour to assist or feed a resident. In our study on the day shift, each CNA had 7-9 residents to care for. In the evening, each CNA was responsible for the care of 12-15 residents. About one hour was allotted for mealtime; the CNAs therefore had about 5-10 minutes to assist or feed each resident. Consequently, residents were fed hurriedly and forcefully; some were not fed at all. We calculated the body mass index (BMI) of the residents in our study. For people over the age of 65, the BMI should range from 24 to 29. Values below 24 indicate that a person may be ill and malnourished. The BMI of the residents in our study ranged from 12 to 30. Their mean BMI was 20; 82% of the residents had a BMI below 24. To improve the nutritional care of residents, it is imperative that the staff/resident ratio at mealtime be increased. CNAs should have no more than 2-3 residents to feed or assist with meals, and professional nurses must supervise them. We have delegated nutritional care, a complex undertaking, to untrained, unsupervised, and often-overburdened CNAs.

Source: Kayser-Jones, J. (1997). Inadequate staffing at mealtimes. Journal of Gerontological Nursing 23(8), 14-21. and Kayser-Jones, J., and Schell, E. (1997) The effect of staffing on the quality of care at mealtime. Nursing Outlook 45(2), 64-72.

Anderson, Hsieh and Su found that increased RN staffing was associated with improvements in resident outcomes; achieving improvements in resident outcomes requires greater spending. The purpose of this study was to identify resource allocation patterns that relate to resident outcomes in nursing homes. Data were obtained from the Texas Department of Human Services for all nursing homes in the state. Data on staffing levels and financial resource allocation were obtained from the Texas Medicaid Nursing Facility 1990 Cost Reports, and data on case mix and resident outcomes were obtained from the 1990 Client Assessment, Review, and Evaluation Form 3652-A. Study limitations included the lack of psychosocial indicators of resident outcomes, the use of data from one state, limiting generalizability and the limitation of using secondary data where there is a substantial lag time between the actual data collection and when data become available for secondary use. Strengths of the study design include the careful control of case mix influence on outcomes. Other strengths that improved the quality of the study included the use of the configurational approach and the fact that the researchers regrouped the sample in different ways to confirm the veracity of the initial findings.

Anderson, R.A., Hsieh, P.C., & Su, H.F. (1998) Resource allocation and resident outcomes in nursing homes: comparisons between the best and worst. Research in Nursing Health 21, 297-313.

RN and LPN nursing hours were significantly related to improved functional ability, increased probability of discharge home and decreased probability of death. The authors of this study advocated a greater use of licensed nurses in the nursing home setting. The study examined the effects of selected nursing home attributes in Minnesota on specific outcomes for residents 65 and older admitted in each of 3 years, 1988 to 1990. The study controlled for residents' age and previous functional ability and illustrated the effect of licensed nursing is as powerful 3 years after admission as it is in the year after admission. Nursing home attributes included size, ownership, noncompliance with a state correction order, and licensed and nonlicensed nursing hours. Information on facility attributes was obtained from the Minnesota Department of Human Services Long-term Care Division. Outcomes included functional ability, discharge home and death. Calculating the resident's Total Dependence Score and the total score on the assessment of eight activities of daily living operationalized the functional outcome. The authors highlighted that if real improvements in nursing home care in the future are to be achieved, a vital first step will be the adoption of a new paradigm for quality, one that emphasizes and expects a reasonable level of benefit.