Minnesota’s long-term care industry has long struggled with staff shortages. But after two years of COVID-19, the industry is reeling and a hard reality is beginning to take a toll on the residents of these facilities and their families.
The pandemic has crippled the industry’s ability to recruit and retain workers. The state’s long-term care workforce has plummeted by around 20 percent during the last two years. Since 2019, 18 nursing homes have closed, including six so far this year.
Complaints alleging violations of state and federal policy tied to the immediate health of residents have doubled over the last two and a half years. It’s metastasized into a situation observers say may be compromising care quality and can’t easily be remedied.
“The staffing shortage is strong and alive in so many of our long-term care settings,” said Cheryl Hennen, the state’s ombudsperson for long-term care. “It's evidenced by the fact that our resident complaints are going up about the staffing.”
Hennen said the concerns are often centered around basic daily care.
“What has been consistent, what continues to come up is receiving basic care — receiving a bath, for example, assistance with dressing, if they needed assistance with transfers. That is common, that is consistent. So basic care is something that we hear about.”
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She said her office is also hearing about moving residents internally so they can all be in one area, so “staff do not have to go from the floor to answer the calls of help.”
‘They forgot her’
Two sisters shared a story with MPR News highlighting the concerns families face — and their uncertainty about how to navigate those concerns.
They said their 96-year-old mother, who’s in a care facility in southern Minnesota, told them recently how she was masked and left alone for more than 40 minutes for what was supposed to be a 10-minute nebulizer treatment.
While the staff member eventually came back to remove the nebulizer mask, their mother was left shaken.
“She called us immediately,” one of the sisters said. “She couldn't let that thought go, that … they forgot her,” one of the sisters said. “It was like 40 minutes, 45 minutes and my mom was claustrophobic — tried to take this mask off herself and was struggling and struggling.”
The sisters blame a staff shortage at the facility. Like many families, though, they said they were reluctant to complain, fearing retribution. The sisters asked MPR News not to identify them, their mother or the facility for the same reason.
While the Minnesota Department of Health reports that the overall number of complaints and reports received for nursing homes each year fell from nearly 13,000 in 2019 to 8,289 last year, the number of serious complaints, classified as “immediate jeopardy” situations, quadrupled in that time. Substantiated complaints more than doubled from 323 in 2019 to 734 in 2021, though the percentage of substantiated complaints went down over that time.
An immediate jeopardy complaint requires immediate response. It’s viewed as “a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death or harm,” according to the federal Centers for Medicare and Medicaid Services.
“The concerning thing is really the number of complaints that are coming in that are being triaged as a more serious issue, which requires a more timely on site investigation,” said Maria King, director for the health regulation division at the Minnesota Department of Health.
“We do know that this particular trend is not unique to Minnesota, but that there are other states across the nation that are seeing this same trend. And the number of immediate jeopardy citations that we're citing whether or not they're related to the immediate jeopardy,” King said.
“Complaints that come in that get triaged as an immediate jeopardy are also concerning because that number has also increased.”
Kari Thurlow, the president and CEO of LeadingAge Minnesota, the state’s largest association of senior care providers, said the industry is working to address the problems that lead to complaints.
“We can't help but wonder if our workforce situation in senior care doesn't play a contributing factor,” she said.
King said during the pandemic, site checks did not happen as often because COVID protocols slowed them down.
“People weren't having their routine evaluations conducted in the same frequency that they would normally have had outside of the pandemic. And so, you know, it could be that those factors do play into this,” she said.
King also said that families who weren’t able to see loved ones during the beginning of the pandemic also might have been more concerned when they saw the resident months later — as their health could have changed during that time.
“Some of the more frequently cited findings at the immediate jeopardy level would be things related to accidents and supervision,” she said. “Sometimes that involves persons that didn't get the appropriate care as, for example, it could be someone that didn't get transferred with an appropriate lift device.”
King said it’s hard to say from her office’s standpoint that this is all due to staffing, although it could be a major factor. She said training and other factors like fewer evaluations could be at play too.
Pay, politics perpetuate problems
Relatively low pay has long been a sore spot in long-term care.
Recent job post listings show resident assistants make between $12 and $20 an hour. Nursing assistants make between $15 and $24 an hour, according to data from the Minnesota Department of Employment and Economic Development.
“We have been plagued throughout the pandemic, with high levels of vacancies in our senior care settings, more than 20,000 jobs are open. That's about 20 percent of our workforce,” Thurlow said. “We can't help but wonder that the turnover that occurs when we have that number of openings, the dependency and increased use of temporary staff likely plays some sort of contributing factor that we can't help but but urge action to address as one of those issues that is key to ensuring that seniors have safe quality care.”
Thurlow says when staff leave, it has a compounding effect, not only on care, but on the viability of facilities.
“You may have open beds, you may have open assisted living units. But you can't admit people because you don't have the staff,” she said. “And that means that you're not necessarily bringing in the revenue to support that organization. And it creates a spiral, a downward financial spiral that is difficult to recover from.”
Thurlow and other industry leaders urged state lawmakers to take action that they say would allow the care facilities to pay more and make jobs more attractive.
The industry says the Legislature sets both Medicaid and private pay rates for nursing homes. They say in order to raise wages and attract more people to the field, they need higher reimbursement rates.
“Long term care providers really can't just raise wages until state lawmakers act to increase reimbursement rates. They have the power to do so. And they went home last legislative session without taking action really on raising reimbursement rates,” she said.
Thurlow hopes it will be addressed quickly in the next session.
“We hope that this isn't treated like a regular budget issue where everything was left until May to be addressed, because every week that goes on makes us worry that much more about our staffing crisis,” she said.