A newly published study of COVID-19 in nursing homes links larger numbers of employees to higher rates of infection and death for residents – raising fresh doubts about New York’s recently enacted “safe staffing” law.

The nationwide study from Health Affairs, drawing data from more than 7,000 nursing homes from June through September 2020, compared the rates of COVID-19 infection and death to the numbers of employees entering each facility on a daily basis.

Residents in the quarter of homes with the largest number of employees had 92 percent higher infection rates and 133 percent higher mortality rates than homes in the bottom quartile.

The authors said this finding “conforms to expectations from basic principles of epidemiology.”

“In the absence of a robust and rapid testing system to prevent asymptomatic COVID-19-infected staff from coming to work, increases in the number of unique individuals entering a nursing home increase the probability of [skilled nursing facility] residents being exposed to the virus and subsequent outbreaks.”

These findings are being published two months after the state Legislature passed a minimum staffing law that will force most nursing homes to add more employees.

Supporters of the measure pointed to a January report from the office of Attorney General Letitia James, which found a correlation between low staffing and high death rates during the coronavirus pandemic of the previous year.

However, that analysis relied on flawed data. As the report itself showed, the Cuomo administration’s method of counting nursing home deaths – which omitted residents who died after being transferred to hospitals for treatment – left out approximately one-third of the victims. The report also limited its examination to the period before mid-November 2020, and therefore missed thousands more deaths that occurred during a winter wave.

In March, an Empire Center analysis – drawing on more complete data obtained through its successful Freedom of Information lawsuit against the Health Department – cast doubt on the attorney general’s findings.

It found no clear correlation between staff and death rates: homes with a one-star federal rating for staffing had lower death rates than homes with two or three stars, but higher rates than those with four or five stars.

The Empire Center’s report said there was “no basis to believe that regulating staffing levels … would have protected residents from the coronavirus pandemic.”

The Health Affairs study – using more granular data from a larger pool of nursing homes in multiple states – did find a correlation, but in the opposite direction of the one postulated by the attorney general’s office. Its findings suggest that increased staffing might actually be counterproductive, by putting residents in contact with larger numbers of potentially infected individuals.

The authors, recognizing that higher staffing can be beneficial in other ways, argue for a nuanced approach that, for example, limits the use of part-time personnel.

“Our findings do not imply that nursing homes should have lower staffing ratios per resident,” the authors write. “Rather, our findings suggest that when facilities with the same staffing ratios are being compared, nursing homes that can provide those staff hours with fewer unique staff members will be better able to protect their residents from COVID-19.”

Under the new state law, facilities must provide an average of at least 3.5 hours of caregiver time per day resident, including at least 1.1 hours of attention from licensed nurses and 2.2 hours from certified nursing aides.

Industry officials have predicted this policy will increase the use of part-time and temporary personnel – as facilities scramble to backfill for permanent employees who call in sick or go on leave.

This isn’t the only potential unintended consequence. The law could also put pressure on homes to replace higher-trained nurses with lower-trained and less expensive nursing aides.

This is an example of why transparency matters: The Cuomo administration refused to share accurate data on nursing home deaths, which caused the attorney general to produce a flawed analysis, which led the Legislature to pass a problematic statute – and New York’s nursing home residents will face the consequences.


About the Author

Bill Hammond

As the Empire Center’s senior fellow for health policy, Bill Hammond tracks fast-moving developments in New York’s massive health care industry, with a focus on how decisions made in Albany and Washington affect the well-being of patients, providers, taxpayers and the state’s economy.

Read more by Bill Hammond

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