The Serious Consequences of Senior Care Understaffing

A senior living in an assisted living community stumbles and falls on the way to use the bathroom in the middle of the night. She is startled, but reassured since she can push her call light and wait for a caregiver to arrive. She assumes that since she lives in an assisted living community, where caregivers are only steps away, that she will not be waiting on the floor of her bathroom for too long. While the senior is waiting on the floor for assistance, the caregivers at the assisted living community are furiously working to attend to the complex needs of other residents. The caregivers are working without proper teamwork support and the fallen senior’s call light goes unnoticed for hours. When a caregiver finally notices the call light, she runs to the senior’s apartment to find her exhausted, scared, and in pain.

This scenario, unfortunately, is not too uncommon in the world of senior care. Many times, there are too few caregivers to attend to the complex needs of residents living in assisted living, skilled nursing, or hospice communities. In fact, a report from the U.S. Department of Health and Human Services estimates that 54% of skilled nursing facilities currently fall short of the recommended staffing levels. Fortunately, the more you know about understaffing and the consequences, the better you can adapt your care choices accordingly.

What is understaffing?
Understaffing is the practice of not scheduling enough caregivers to meet the needs of residents. Caregivers can include CNAs or uncertified care support, as well as nurses. Understaffing happens intentionally and unintentionally, and throughout different levels of senior care including skilled nursing facilities (also known as nursing homes), assisted living communities, and hospice support.

How does understaffing happen?
At first glance, it can seem that understaffing can be prevented. However, the understaffing problems facing senior care communities go beyond the simple solution of putting more caregivers on the schedule to work. There are multiple factors that can lead to an understaffing culture and crisis within a care community. First, understaffing can happen due to staff illness or requests for time off. Missing staff members cause the remaining caregivers to pick up the slack caring for residents. This is frustrating for caregivers and residents, but is typically solved within the day or week as caregivers return to normal scheduled duties.

Next, and most commonly, understaffing is caused by a caregiver-resident ratio that is determined by the senior care community. Setting a caregiver-resident ratio is meant to save the senior care community money in caregiver wages, but the ratio is often exceedingly unrealistic and does not take into account specific, complex needs of individual residents. These ratios are often set by administration based on a formula that factors in the number of residents in the community that week.

What are resident consequences of understaffing?
Residents suffer when senior care communities consistently practice understaffing. Most senior care communities have a ratio of 1 caregiver per 8 residents. While this ratio may seem realistic to those who are not familiar with senior care, it is actually decreases the amount of personalized care and attention offered to residents.

Most residents living in assisted living or skilled nursing communities have complex needs related to chronic medical conditions. Seniors living in communities can struggle with ambulation, requiring one or more caregivers to assist them with moving from the bed to a wheelchair, or with walking to the dining room. Seniors also often require assistance getting dressed and ready for the day, performing hygiene tasks, using the restroom, and eating. These tasks require the help of attentive caregivers, using personalized approaches based on the resident’s unique needs and preferences. Best practice in senior care states that residents should be given assistance in a way that promotes overall wellness, independence, and health. Further, a decade long push for person-first care dictates an approach that is based on the senior’s previous life history, preferences, and personality. Person-centered care is the industry expectation for all residents of senior living care, but especially those with some memory impairment and who are receiving hospice care while in a skilled nursing or assisted living environment.

Seniors receiving hospice care in assisted living or skilled nursing facilities typically have even more complex medical needs, including pain management and limited mobility. Fortunately, hospice programs typically provide additional support for the senior through visiting caregivers and nurses. This extra manpower provides additional personalized care opportunities for the senior, but is still often not enough to give the senior quality care in a timely manner around the clock.

For caregivers who have a hospice patient on their resident roster, things can become more complicated. Caregivers want to do a good job, and give the hospice patient especially calm and purposeful days. Hospice patients often have specialized interventions that rely on the caregiver for execution, such as having favorite music playing in the room, moistening the mouth or lips, body turning to prevent skin breakdown, or pain prevention measures. However, with seven other residents to care for at the same time, those good intentions are often simply not realistic.

Hospice patients, especially those who are nonverbal or unable to request help as they need it, are vulnerable to neglect and harm due to understaffing. Regular safety checks can be pushed back if other residents need attention, and even turning (to prevent pressure ulcers for residents that are not mobile) can be postponed due to the caregiver working with other residents. This neglect can lead to serious safety and dignity issues for the hospice patient, and could go unnoticed for hours or even days.

Regular care tasks that residents need, like assistance with hygiene, toileting, and memory redirection, cannot be personalized when understaffing occurs. When caregivers are tasked with caring for 8 residents during the course of one shift, crucial care tasks are often rushed and hurried. As a result, understaffed senior care communities can see an increase in resident falls, a decrease in resident satisfaction, and an increased risk of abuse or neglect cases. The health risks for seniors that are associated with understaffing issues are significant. Without regular safety checks, residents who are at a higher risk to fall can fall more often or can suffer greater injury during those unsupervised times. Residents also suffer skin breakdown due to insufficient toileting opportunities or poor perinatal care. Increased health issues, along with the feeling of being rushed during tasks, can lead to residents and family members feeling frustrated and unsatisfied. This can lead to lower scores on resident satisfaction surveys, as well as an increased risk of a complaint to the local public health department or Ombudsman.

What are staff consequences of understaffing?
Residents are not the only ones who feel the negative consequences of understaffing; staff members acutely feel it too. Caregivers who work in a senior care community that is consistently understaffed are required to care for many residents during their shift, which can lead to rushed interactions, increased frustrations, decreased staff morale, and even increased staff turnover.
First and foremost, caregivers are genuinely interested in meeting the needs of their residents. Caregivers also choose senior care as their career because they want to spend time getting to know their residents and fostering a trusting relationship with them. Unfortunately, understaffing does not allow for the time to grow relationships between residents and caregivers.

Consider a regular shift for a caregiver who works the day time shift. In those 7 hours (not including required lunch and other breaks), the caregiver is responsible for the wellbeing and safety of 8 residents. While the U.S. Health and Human Services recommends a minimum of two hours of care per day per resident, that caregiver is unable to give even one hour of care per day per resident in this schedule. In the course of the 7 hour shift, the caregiver must first get the 8 residents ready for the day, which can include hands on or full assistance. Beyond showering, dressing, performing hygiene tasks and toileting the residents on the roster, the caregiver must also get the residents to and from breakfast, as well as lunch. In between these tasks, the caregiver must also assist with any other needs the residents have during the course of the day including trips to the bathroom, helping to transfer in and out of bed for rest, and any safety checks. Finally, the caregiver is also responsible for performing other interventions as listed on the resident care plan, which is a personalized document that gives staff direction on how to keep the resident healthy, happy, and engaged. What a day!

Caregivers, unfortunately, rarely have the opportunity to sit down and interact with a resident on a personal level. More commonly, tasks are rushed and hurried which can lead to unintentional harm to the resident. Caregivers are unable to take their time and give residents choice based on resident preferences, decreasing the chance to perform true person-centered care.

Next, caregivers working in an understaffed senior care community can become frustrated quickly. Hurried interactions with residents, and a never-ending to do list of tasks during the course of one shift can be overwhelming, to say the least. Caregivers who find themselves working with even less help due to an absent teammate can end up caring for their 8 residents along with more. Seniors with complex medical conditions can have needs that change on a regular basis, and safety is always a serious concern. Without the proper support, encouragement, and help, a caregiver can become overwhelmed and frustrated.

That caregiver frustration can lead to decreased staff morale and increased staff turnover. It does not take too many shifts working understaffed to understand how caregivers can begin to feel unsupported and underappreciated. While they put their residents first and try their hardest, without additional staffing assistance, caregivers can feel like they are giving fast and impersonal care to residents, and without building a relationship that matters. Unfortunately, increased staff turnover only leads to understaffing as new team members must be trained and oriented to the community before joining the care team on the floor.

What can you do now?
Understaffing in senior care communities negatively affects everyone. Residents feel uncared for and have an increased opportunity for falls or abuse. Caregivers become frustrated with their rushed and unsupported day, leading them to quit a job they love. However, you can make decisions that can positively influence the understaffing culture within senior care communities. If you are a family member or older adult seeking a senior care community, be sure to ask about staff to resident ratios. Don’t consider a community that will not give you a solid answer, or one that says the ratio exceeds one caregiver per five residents. The risks of moving into an understaffed community are real and should not be taken lightly.

If you are a caregiver, you have the opportunity to change the industry. If you are working in a perpetually understaffed community, talk to your supervisors about it and work to become a part of the solution. You can volunteer to review the schedule and offer your input on which hours of the day could use a few extra caregivers on hand to provide better resident care. Encourage supervisors to shadow a caregiver during especially busy times per day; sometimes that first hand experience can significantly sway the opinion of a supervisor and give you the extra help you need. Finally, consider networking with other caregivers in other senior care communities to see how they handle understaffing situations. Brainstorming with other care professionals can be a positive way to influence the care of the residents you serve.

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