Residents begged for a shower at a Columbus nursing home, sometimes going weeks or months without one. At least two residents at a Decatur nursing home died of COVID-19 after pandemic protocols broke down. A woman at a South Georgia home was left to change her own colostomy bag when it filled up.
In each case, Georgia Department of Community Health (DCH) inspectors investigated the allegations. And in each case, they found a common culprit: The facility’s caregivers were overworked and overwhelmed because they didn’t have enough nursing staff.
Already an issue before the pandemic, short staffing at Georgia’s nursing homes hit a crisis point after COVID-19 upended these facilities two years ago. But even as vaccines have eased stress on homes and allowed families to visit again, staffing problems persist in many locations, leaving residents vulnerable to neglect and suffering.
Nearly a third of Georgia’s nursing homes report being short of nursing staff, according to June data from the Centers for Medicare and Medicaid Services (CMS). Although numbers have improved since the Omicron outbreak early this year, the figures are self-reported and the actual number is probably higher, Georgia’s Long-Term Care Ombudsman Melanie McNeil said.
Low staffing is one of the most consistent complaints sent to her office, McNeil said — and statistics back up the criticism. Georgia’s nursing home patients receive some of the nation’s lowest hours of daily nursing care, according to recent timesheet data compiled by the Long Term Care Community Coalition. The state ranks 46th out of the 50 states and the District of Columbia.
“If you don’t have enough nurses and people aren’t getting turned, people end up with bed sores the size of dinner plates,” McNeil said. “That’s pretty terrible. But that’s what happens.”
“It was bad”: The painful symptoms of short staffing
Kisha Stanley remembers when her now 79-year-old mother, Yvonne Medley, was admitted to Atlanta nursing home Signature HealthCARE of Buckhead after a multiple sclerosis relapse hastened her decline.
The federal government has given the facility its lowest rating — a one-star out of five based on government inspections, staffing levels and quality measures, according to Medicare.gov.
Stanley’s mother was among the patients who suffered. The problems began almost immediately after she was admitted in 2014, Stanley said. Medley developed bed sores and urinary tract infections. Showers were scant, and Stanley had to throw away pants soaked in urine. When Stanley confronted staff about the problems, she was met with excuses, she said.
“They didn’t like me knowing or asking the questions,” she said. “It was bad.”
Credit: Natrice Miller / Natrice.Miller@ajc.com
Credit: Natrice Miller / Natrice.Miller@ajc.com
Stanley started logging every phone call, every email, every visit in a journal. The records fill up three composition notebooks now.
She tried to transfer her mother out of Signature HealthCARE of Buckhead in 2016, but no nearby nursing homes would take her, she said. Every facility said they were short on beds.
Once the pandemic began, the home transformed from a disappointment into “hell,” Stanley said.
Families could no longer visit. Medley almost never left her bed, and she again developed bed sores. Stanley saw her deteriorate through the pixels of limited Zoom calls.
Then last August, Medley called her daughter from the home, wailing in pain. Stanley called 911.
“I just kind of lost it,” she said.
An outside dentist diagnosed her mother with mouth ulcers and determined the nursing home had failed to provide proper oral care, Stanley said.
When visitation opened again in December, Stanley said she noticed the nursing staff seemed overwhelmed and more short staffed than before the pandemic. And the state found problems, too. In October 2021, DCH inspectors cited the facility for a shortage of “sufficient nursing staff” that contributed to a host of care issues.
The home had failed to give at least six residents scheduled showers and consistent incontinence brief care, records show. Staff was layering two adult diapers on residents at night to reduce the amount of times they had to be changed, leaving residents to sit in waste, the investigation said.
“Don’t bother me, we’re too busy,” staff would respond when she asked for help, one resident told investigators.
The nursing home defends its record, noting that investigators indicated the deficiencies caused no harm, said Signature HealthCARE spokeswoman Ann Bowdan Wilder.
“Signature HealthCARE of Buckhead has been recognized for its excellent heroism, hard work and dedication in the community,” she wrote in an email statement.
“Deal with it”: Nursing home inspections since the pandemic
Low staff isn’t a problem limited to Signature HealthCARE of Buckhead. It’s part of a nationwide labor shortage affecting businesses, restaurants, schools and more — and it’s persistently harming patients across Georgia’s nursing homes, DCH inspectors found.
Lawyer Michael Prieto echoes these findings. Over the years, he has helped dozens of plaintiffs sue nursing homes for wrongful death or negligence. Nursing homes cut down on staff again and again to save money, he said — a move that ultimately harms residents.
“Corporate emails [say]: ‘You gotta cut staff, you gotta cut staffing, how to cut staffing.’ And it’s all just to maximize profit,” he said. “Every nursing home case is about staffing.”
At the Muscogee Manor & Rehabilitation Center in Columbus, most of the facility’s regular staff had left, leaving dispatched nurses from an external agency to pick up the slack, according to a May 2021 DCH inspection. Residents reported that they begged for showers, some going without for weeks or months.
At East Lake Arbor in Decatur, the director of nursing — who was taking on triple duties as infection control prevention nurse, staffing coordinator and COVID-19 testing tracker — said she couldn’t keep up because she was too busy filling in for missing nurses, according to an inspector’s April 2021 DCH report. Regulators later discovered that weekly coronavirus testing for staff and residents broke down. Two residents died of COVID-19 after the same nurses treated both COVID-19 positive and COVID-19 negative residents.
“If you don't have enough nurses and people aren't getting turned, people end up with bed sores the size of dinner plates."
- Melanie McNeil, Georgia’s Long-Term Care Ombudsman
At Glenvue Health and Rehab, overworked nurses left a resident to change her own colostomy bag, a July 2021 DCH report said. A colostomy bag redirects waste from the intestines straight into the bag. When staff complained about the shortage of help, management told them they “just have to deal with it,” one nurse told investigators.
Officials at East Lake Arbor and Glenvue Health and Rehab did not respond to multiple requests for comment via email and voicemail. Other administrators say they’ve tried to increase wages and bonuses and recruitment, but those efforts have fallen short.
“We have a nursing industry that is not capable of producing enough nurses to meet the needs of area Health Care providers,” Britt Hayes, president and CEO of the Hospital Authority of Columbus, which owns Muscogee Manor & Rehabilitation Center, wrote in an email statement.
Over the past year and a half, the DCH cited six homes in total for short staffing that was linked to neglect, abuse and even death. But that’s likely just the tip of the iceberg on a larger problem, experts say.
Investigators typically only cite short staffing if the consequences are extreme — even though it’s one of the biggest problems facing nursing homes today, said Toby Edelman, senior policy attorney with the Washington-based Center for Medicare Advocacy. That’s because federal regulations have few rules for what counts as “sufficient nursing staff.” So though only six nursing homes were cited, even more are probably at fault, Edelman believes.
“They might cite the outcome that they’re seeing,” Edelman said, “but they won’t cite staffing.”
‘We know what needs to be done:’ Federal regulation and funding
Staffing doesn’t just challenge Georgia’s nursing homes. The problem is widespread enough that it caught the eye of the White House.
In February, President Joe Biden’s administration outlined a series of proposals and guidance to address the problem and improve care, including better funding for quality facilities, higher fines for poor-performing facilities and minimum nursing home staff requirements.
“Establishing a minimum staffing level ensures that all nursing home residents are provided safe, quality care, and that workers have the support they need to provide high-quality care,” the White House statement said.
What you can do
If you’re worried about conditions in a loved one’s nursing home, there are ways to learn more about a facility and its quality of care. Medicare.gov rates nursing homes from one to five stars based on health inspections, staffing levels and quality levels. You can also check Georgia’s Department of Community Health inspection reports portal to see how a nursing home fared during its state check-ups.
Neil Pruitt, CEO of PruittHealth, which operates more than 50 homes in Georgia, said that about 20% of the company’s homes have closed due to low staffing since the pandemic began. More than 2,000 positions are currently open across the Norcross-based company.
That’s why Pruitt worries about Biden’s proposals — especially minimum nursing staff regulations.
“It’s pretty absurd. We can’t find staff as it is,” he said. “We need help from the government.”
Help has been delivered throughout the pandemic, but that hasn’t been enough, according to Tony Marshall, president and CEO of Georgia Health Care Association (GHCA), a trade-group that represents most of the state’s nursing homes.
In 2020, Georgia’s state government gave skilled nursing centers $113 million in CARES Act emergency relief funding to boost staff hires and staff testing. This year, it increased Medicaid payments $10 per patient per day. Still, Medicaid reimburses facilities far less than the facilities pay to take care of residents, he said. Last year, GHCA requested an extra $347 million in American Rescue Plan Act funds.
“It is just difficult to be able to pay the wages and benefits to allow you to be competitive in the marketplace,” Marshall said.
But the nursing home industry’s cry of poverty doesn’t match with the data, said Edelman with the Center for Medicare Advocacy. She said nursing homes get plenty of money.
Investors have noted the profitability in nursing homes and recently showed extra interest in them, according to an analysis by the Medicare Payment Advisory Commission. At the height of COVID-19 in 2020, facilities even made a 3% profit due to extra pandemic funding benefits, it noted. But that money is not trickling down to staff, Edelman said.
Nurses face low wages and benefits coupled with high hours and danger, so it’s only natural that they quit, she said. But with better working conditions, some might return.
“We know what needs to be done,” Edelman said. “I think the question is whether there’s the will to do it.”