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Low pay, tough work leads to 'high rate of burn out' for nursing home nurses

Daily Gazette (Sterling, IL) - 12/20/2014

Dec. 20--On the morning of Nov. 7, 2012, an 87-year-old diabetic man was late waking up at the Good Samaritan Society in Mount Carroll.

At 7 a.m., he appeared to be snoring and in no apparent distress.

The man was usually awake by 8 a.m. and was always putting on his call light. He was somewhat demanding, his power of attorney representative later told surveyors.

At 9 a.m., while a nurse shaved him and gave him morning care, he made noises, but didn't wake up.

The certified nursing assistant made an emergency "stat" call on the radio.

There was no immediate response.

The nurse made her way to the hallway and found a licensed practical nurse "with an armful of pills [who] said she would come down as soon as she got rid of the pills."

When an emergency call is made, all nurses are expected to respond, according to the director of nursing, who added that all nurses are expected to keep their radio volume at a level that can be heard.

That wasn't the case with the registered nurse on call that morning, who told surveyors her radio was in her pocket with the volume turned down.

The RN didn't assess the man because she wasn't working the hallway where she was supposed to be. She was passing medications in another part of the nursing home after an LPN asked for assistance.

At least two other nurses who had radios didn't respond to the emergency call.

By 9:30 a.m., a CNA told the man's power of attorney the resident "did not look good."

The representative told a surveyor later that when she saw him, he looked gray and felt cold, as if he were dead. No staff member was with him at this time.

An ambulance was called. It arrived at 9:42 a.m. The man wasn't responsive to verbal or painful stimulation.

When an emergency medical technician asked a nurse whether the man's blood sugar had been checked, she said she "had not gotten around to it yet."

Based on interviews with staff in the days afterward, the nursing home was cited for a failure to respond to an emergency request, which contributed to a 2-hour delay in treatment and hospitalization. The nursing home was also cited for a failure to monitor the man's blood sugar level when he was unresponsive.

There was no fine from the federal government or the Illinois Department of Public Health.

An LPN later told surveyors that although the levels of care of the residents had increased, the teamwork and communication among the staff hadn't.

Luann Correll, the nursing home's administrator, didn't return a request for an interview and tour of the facility.

'Backbone of the industry'

In a nursing home, the CNAs have the most hands-on interaction with residents, yet they're often the lowest-paid medical staffers.

Depending on their level of experience, education and the shift they work, starting pay for a CNA in the Sauk Valley ranges from $8.75 to $10.50 an hour, according to interviews with nursing home administrators.

The pay for nursing home administrators in 2013 ranged from roughly $75,000 to $100,000 a year, according to publicly available cost reports for the nursing homes.

Despite their low pay, CNAs are vitally important to resident care and the quality of life, the administrators say.

"Being a CNA, it's the backbone of the industry," said Bonnie O'Connell, administrator at Heritage Square in Dixon. "They're highly regarded in this facility. And it's the hardest job here, being a CNA. ... It's a high rate of burn out. They always think the grass is greener on the other side, and it isn't always. And they always think that other guy, where they're going to go, is going to be easier, and it isn't.

"But a lot of that -- their jobs -- can be made easier by the support staff, by the activities, involvement. Support staff can really make their jobs a lot lighter."

Because people now live in their own homes longer, incoming nursing home residents require a higher level of care, so the nursing done by a CNA or LPN goes beyond simply giving medication at the right time, said Susan Swart, executive director of Illinois chapter of the American Nurses Association.

Having more registered nurses, who are better versed in the "global understanding" of residents' needs, leads to better care -- and not just physical care, but mental and emotional, she said.

"Current law, unfortunately, in Illinois is that an RN is only required to be in a long-term care facility for 8 hours a day," Swart said, adding that nursing homes can get waivers if they have difficulty hiring an RN.

Nursing homes in the Sauk Valley have RNs on staff, and some have RNs working more than 8 hours a day.

Some even have more RNs on staff than appear in their staffing levels, because many administrators or other staffers also have RN certification.

Swart favors higher staffing levels in nursing homes and having an RN on staff for every shift.

According to the Nursing Home Compare tool on www.medicare.gov, the state average for licensed nursing care for each resident each day is 1 hour and 32 minutes. This figure includes RNs, LPNs and licensed vocational nurses.

The national average is 1 hour and 40 minutes.

The state average for CNA hours for each resident is 2 hours and 14 minutes. The statewide average for RN time for each resident is 56 minutes.

Most of the nursing homes in the Sauk Valley are below those state averages, even though they still meet the legal requirement.

On Jan. 1, the minimum staffing required by the state was increased to 3 hours and 48 minutes of direct care each day for a skilled care resident, and 2 hours and 30 minutes of direct care each day for an intermediate care resident.

According to information from Centers for Medicare & Medicaid Services, the average nursing home resident in the Sauk Valley could be cared for by a licensed nurse (RN, LPN or LVN) for 1 hour and 14 minutes each day, and by a CNA for 2 hours and 17 minutes a day.

The staffing levels available on the Nursing Home Compare website don't differentiate between skilled care residents and intermediate care residents.

Both of those figures are below the national average. The area has a lower licensed nurse level than the state average, but a higher level for CNAs. The area's RN level -- 38.75 minutes for each resident each day -- is below both the state (56) and national (50) averages.

The average total direct care time, not including physical therapy, is 3 hours and 31 minutes a day.

Like much of the data or information in reports, the averages need context. Administrators interviewed said they had adequate staffing levels to provide quality care, but could use more.

Winning Wheels in Prophetstown, a facility that provides rehabilitative services for residents with brain or spinal cord injuries, has a 2-star rating for its staff on Nursing Home Compare.

Steve Territo is the senior vice president of operations for American Health Enterprises Inc., a management group that helps to manage Winning Wheels. He said the low rating has a lot to do with a mistake the facility made when it sent its staffing numbers to the state.

"We had done it straight off of payroll and did not put them in the right categories," he said. "So when you look on the Nursing Home Compare website, it looks like our nursing is below what the state average is, but in reality, our licensed staffing, it's outrageous how many people we have here at any given time. But we were putting them in an administrative category."

It will take a while for the website's methodology to reflect a more accurate picture, he said.

It's a common complaint nursing home administrators have about the Nursing Home Compare tool -- bad surveys stay up longer than good ones.

Swart said that although she supports an increase in staffing levels, she doesn't support a flat rate because every facility and resident is different and has different needs.

"Long-term care is about priorities," she said. "We think that resources need to be focused on the priority that provides the best and safest care. And we think that means having the resources for having a RN on duty."

The long-term financial cost of having more RNs would be offset by reduced costs of fines or other expenses, she said.

Advocates and administrators say that a higher level of care is provided when there's good communication between the resident and all the nurses. That's the very thing the LPN in Mount Carroll said wasn't happening.

Brian Lee, executive director at Families for Better Care, said it's not just the number of nurses you put on a wing -- it's their quality and engagement that make the difference.

"There needs to be a voice," he said. "And they have to be included in the care planning process. They need be be involved in that process.

"That's the difference. They can get the training, but if they're not engaged, then the staffing has just become a number on paper. It's about engagement, and engaging at all levels."

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