Inadequate Staffing in Nursing Homes

Staff shortages are a major crisis in nursing homes across the United States, and include a shortage of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs). Adequate nursing home staffing is critical to providing quality resident care and can be defined as the appropriate number of well trained, properly supervised individuals who meet the personal care needs of nursing home residents.

Studies show that residents and their families directly relate the interaction between the CNA and the resident to their level of satisfaction with the nursing home. They also positively relate RN participation in direct care giving in improved quality of resident care.

Federal law requires nursing homes to have an adequate number of licensed and qualified staff to provide care and services sufficient for each resident to attain or maintain his or her highest practicable physical, mental and psychosocial well being. State staffing mandates vary as to how many staff members are required. In some states, the staff-to-resident ratio is solely based on the number of residents in a nursing home. In other states, the ratio depends upon the case-mix of a nursing home’s residents. It is important to understand that even though the nursing home may be fully staffed, many of these staff are doing “paperwork” duties and not providing direct care to residents. The bottom line is that if a nursing home is not able to provide quality care without multiple deficiencies, it does not have enough appropriately trained, qualified staff.

Who are direct care staff in the nursing home?

Currently, approximately 90% of direct patient care, including assistance with feeding, walking, bathing, toileting, and dressing is performed by CNAs. Even though nurses also ideally provide direct care, they are in short supply so are utilized to perform nursing assessments, pass medications, perform treatments, and fulfill paperwork requirements, instead of completing direct care.

How are CNAs trained to care for my loved one?

Minimum training standards for nursing assistants are federally mandated. Seventy-five hours of hands-on training in specifically designated areas are mandated for CNAs who work in nursing homes receiving Medicare or Medicaid funding. Thirty additional hours are spent in the classroom setting to total 105 hours. In addition, 12 hours per year of continuing education must be provided by the nursing home, with required topics that include infection control, abuse prevention, and resident rights.

There is high CNA staff turnover in nursing homes, and it is difficult to attract, train, and retain an adequate workforce. Turnover among CNAs, who provide most of the hands-on care, means that residents are constantly receiving care from new staff who often lack experience and knowledge of individual residents.
What are the proposed suggestions to increase the supply of direct caregivers in nursing homes?

Many solutions have been proposed to increase adequate staffing in nursing facilities. Some include:

  • Hiring single task workers (ex. those who are only trained to feed residents and who are not CNAs)
  • Mandating rigid federal staffing levels
  • Recruiting and hiring foreign workers to fill needs for staff


OIG, Audit Report A-12-12-97-0003, “Safeguarding Long-Term Care Residents,” September 1998.