Care for Life? The Failing System of Nursing Home Care in the United States


Maura Fisher is from St. Louis, Missouri and is a junior at the University of Missouri.  She is majoring in Health Sciences with a Minor in Nutrition in hopes of becoming a Physical Therapist. She has been a Certified Nursing Assistant since 2013, which was her inspiration for writing this research paper. She loved being with her elderly residents, and she wrote this paper in hopes that changes would occur in order that they would receive the treatment that is necessary and so much deserved to them.

The phrase “respect your elders” is ingrained in most minds at a young age. This phrase, however, has been lost somewhere. A lack of respect for the elderly is especially present in the quality of health care they receive. Not only are the elderly discriminated against in the US health care system, many of their health problems are cast off as “getting old.” As the generation of baby boomers is approaching retirement age, the question of how to care for them grows more pressing. The first solution for most people may be to place their elderly family member in a nursing home; nursing home care, however, may not be the best option for everyone. The United States’ system of long term care (LTC) for the elderly is flawed for many reasons, most notably due to the lack of insurance dedicated to LTC as well as the chronic shortage of LTC nurses and nurse assistants.

The issue of elderly care is particularly urgent because nursing homes may not be able to provide care to the vast amount of elderly that will soon be in need of it. Many nursing homes already suffer from the understaffing  of nurses, and this will cause an even greater problem when more people need care. This understaffing leaves a heavier workload for the nurses thereby leading to poor quality care for the residents which can result in illnesses such as pressure ulcers, malnutrition, and depression. Nursing home care should be better regulated by state and federal government to prevent the various shortcomings associated with long term care. Therefore, both employees and residents would have a better place to work and live.

Long term care for the elderly is a relatively new issue, and this may be why the system has so many flaws. In the past, people died at an earlier age and most elderly remained in their homes or the homes of their family until they passed away. Now, people are living to be much older than in the past and require care for longer periods of time. Additionally, since many women, who once had the role of caretaker, now work, the idea that a family member should be cared for in their own home has changed. Therefore, the need for a system of elderly care has greatly increased. The approximately 500,000 nursing home beds in 1963 have skyrocketed to over 1.7 million today (Cooper, 1998, p. 154), and this number will grow exponentially in the next decade. By 2050, when the last of the baby boomer generation reaches 85, there will be an estimated 18.2 million potential LTC consumers (Cooper, 1998, p. 160). If beneficial reform does not happen soon, the United States may be in for the LTC crisis.  Although reform has occurred periodically throughout the years, nursing home care is still lacking in many aspects.

One of the main causes of the poor quality of care given to the elderly is the shortage of nurses in many nursing homes. The field of Geriatrics has one of the largest patient bases, however it has the fewest amount of caregivers. This is obviously a worrisome problem. Despite this issue, the current law mandating the amount of necessary workers in nursing homes does little to improve the situation. It states, “The facility must have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident as determined by resident assessments and individual plans of care” (Miranda, 2005). This statement is very ambiguous and leaves much to the interpretation of the administration of each nursing home, resulting in many situations of insufficient staffing.

A severe problem with this task falling in the hands of the administration lies in the fact that “among administrators, very few are certified, and without qualified leadership quality initiatives are harder to sustain” (Clemmit, 2006, p. 849). Also, many nursing homes do not want to pay and insure additional employees. Instead, they choose to run their staff on the bare minimum. It is clear that some sort of policy change is extremely necessary.

When a nursing home is understaffed, nurses are assigned a greater number of patients, resulting in less time to give sufficient care to all residents. Lack of enough nurses in nursing homes is the cause of many avoidable illnesses that are common throughout elderly care facilities. These illnesses, such as pressure ulcers and urinary tract infections, usually stem from neglect and improper sanitation practices.  In an eye-opening statewide investigation of nursing homes in California, researchers found that more than 7% of nursing home deaths were from preventable conditions such as starvation, dehydration, and infections related to bedsores (Cooper, 1998, p. 151).

This fact is not only heartbreaking, but also completely unacceptable because these sicknesses are so easily prevented with proper care. These infections and illnesses arise because nurses must work more quickly to get everything finished, which can lead to hasty decision making and improper technique (Miranda, 2005). The problem, though, may grow even worse in the near future. In order to provide care for the large number of people who will enter nursing homes, many more workers are necessary. The need for paid caregivers is increasing at a rate far greater than the rate of women ages 18-55, who make up most of the LTC workforce. However, to train and retain a sufficient workforce would require more funding, and the government is unwilling to allocate these funds to LTC. Therefore many nursing homes remain open despite improper treatment techniques and lack of sufficient workers.

This lack of quality care not only affects the physical health of the resident, but it also affects their emotional well-being. The quality of life for many elderly residents in nursing homes is poor. While “the percentage of residents spending most of their time in bed dropped by more than a third between 1999 and 2005,” (Clemmit, 2006, p. 843).

This does little to affect their quality of life. The residents who once spent most of their time in bed now spend their days in chairs. Residents that are bed-ridden or chair ridden are required to be repositioned once every two hours, but many times when a resident is in a chair, this repositioning is overlooked, and the residents may sit without interaction with nurse for hours at a time. Sitting in a chair doing nothing for hours at a time provides no cognitive stimulation for residents. The emotional degeneration resulting from this poor care is evident in residents. Depression affects one in six elderly patients in general medical practice, but this figure is even higher in nursing homes. Older people also have the highest rate of suicide,  and many medical problems common among the elderly may be intensified by depression (Leaver, 2003, p. 450). The lack of emotional support proves even more detrimental to the numerous residents that have Dementia and Alzheimer’s . While neither of these diseases can be cured, the phrase “if you don’t use it you lose it” applies. Without mental stimulation these residents can decline more rapidly. Along with this cognitive decline, residents with mental diseases such as Dementia and Alzheimer’s are especially at risk for abuse, neglect, and injury. These resident’s often times need constant oversight because they are at high risk of falls and other forms of accidental self-endangerment. Unfortunately, they do not always receive this much-needed protective oversight. It is very important for all residents in a nursing home to receive cognitive therapy and emotional support, but because of the amount of work nurses have, they are unable to provide this simple task that can make a world of difference both emotionally and physically.

Nursing homes have difficultly properly staffing nurses, but a more stable working environment may make nurses more willing to work in this setting permanently. Along with the issue of a heavier workload, understaffing creates an atmosphere where nurses face high liability, which often causes nurses to leave their job, further enhancing the issue of understaffing. Currently, turnover rates  for LTC jobs range from 50% to 100% yearly, which means that in a year the field of LTC could lose half or all of its employees (Clemmit, 2006, p. 849).With a rate like this, it is no surprise that nursing homes are severely understaffed. So what is the reason for such a lack of desire to work in this field? As mentioned before it could be the high risk of liability placed on nurses. Nurses are held accountable for their actions despite the circumstances that lead to them. This stress takes a large toll on nurses, whose main priority is their residents.

Many nurses become discouraged because “not only are these nurses faced with the dissatisfaction of not being able to properly care for the residents, they also must bear the heavy burden of knowing that they may be held personally liable when they walk into work and realize that they are one of too few employees working their shift” (Miranda, 2005). In a working environment like this one, sufficient workers are a must, but the facilities are unable to provide for their employees, which ultimately harms the residents.

Another factor that may result in the low amount of nurses in geriatric care could be the lack of benefits. For example, nursing assistants provide more than 80% of direct care to residents, yet the average annual income for a nurse assistant totals at $13,224 with no health insurance or pension benefits in many cases. Many people thrive in their jobs knowing that there is the possibility of upward mobility, but for nurses in the nursing home setting there is little career path beyond a certain point. Nursing home care, therefore, has become a temporary position for many nurses, who eventually move on to fields that have more room for upward mobility and better benefits and pay, leaving their residents to suffer.

The government provides little to no monetary aid to nursing home resident’s which leaves many elderly helpless and unable to pay for their care. Nursing home care averages around $40,000 a year, and majority of residents live in a nursing home for more than 2 years. However, LTC for the elderly is not covered by private insurance because of the high cost of coverage, so the majority of the payment comes out of pocket. This poses an issue because the majority of nursing home residents are women who rely on social security and their husband’s pension to pay their bills.

Because these people are retired, there is no way to get more money once they run out, and most of them do run out fairly quickly. Although there are systems of insurance for long term care in place, they do little to subsidize the cost for the majority of elderly residents. For example, “Medicare,  the federal health insurance program for the elderly and disabled, only covers short stays in skilled-nursing homes following a hospital discharge. And Medicaid , the federal-state health insurance program for the poor, cannot be used for nursing home care unless virtually all the resident’s assets have been used up” (Cooper, 1998, p. 149).

There are, however, no forms of insurance for home based care; so many elderly people are forced prematurely into the nursing home system, where their assets are used up much more rapidly. A worse problem lies in the lack of insurance for elderly living in assisted living facilities. While these facilities, on average, are cheaper than skilled-nursing homes,  they are completely private-pay and create a financial burden on the residents. Many times residents who run out of money are forced to live in a type of facility called a board-and-care facility which accepts social security checks for payment.

The operator is paid however much the social security check is for, and is often times underfunded. Because the price varies from resident to resident, the care given there is extremely poor, if given at all. Another option for these elderly residents is to enter into a skilled-nursing home on Medicaid. In many cases these residents are not in need of this type of care, but just being in that setting causes them to be more susceptible to illnesses and can cause them to decline in health more rapidly. Some workers in LTC believe that Medicaid should be extended to cover some of the assisted living fees many elderly face. This would, however, require a huge increase of funds, which would result in a heavier toll on the taxpayers. If nursing home care insurance is not improved, these government insurance funds may face bankruptcy and a difficulty paying the insurance for the millions of elderly residents who will be on Medicaid.

From all the issues presented, there is proof that nursing home care is flawed. Because of the way inspections are conducted, it is easy for these many insufficiencies to go unnoticed or to continue with just a small penalty. These problems continue to exist because state inspection boards fail to conduct a thorough and sufficient examination of nursing homes. The inspection team, consisting of at least one registered nurse, looks at many different aspects of care including nursing techniques, staff/resident interaction, and environment. On average, the state inspects each nursing home once a year, or more if the nursing home has had poor results in the past. Usually these inspections tend to be unannounced and can last around three days. This may cause one to ask though, “if nursing homes are only inspected once a year for three days, what is happening the other 362 days of the year?” This is exactly where the problem lies. From working in a nursing home, I can name at least 10 violations I noticed in my first shift.

I, however, was on the inside: viewing from a perspective many inspectors do not get to see. When nursing homes are surprised with an inspection, somehow understaffing is no longer an issue. On these occasions, the administration calls in all PRN nurses and many off duty nurses in order to possess a full staff. For these few short days, the issues associated with understaffing are resolved, but the rest of the year these issues continue just as strongly as ever. Even if these issues are discovered, state inspectors usually just warrant a fine to the nursing home. While this may be an inconvenience to the home, it does nothing to prevent the issues from happening again. The main problem present here is how all of this affects the residents that live in these homes. These nursing homes are, just as the name states, the homes of these residents, and they deserve to be treated as if a state inspector were always watching.

Because of the lack of purposeful government intervention in Long Term Care many harmful things, such as understaffing and insufficient insurance coverage are allowed to continue, despite the damaging impact they have on the employees, but more importantly the residents. The elderly are some of the most vulnerable in our society, and they are being taken advantage of. Nursing homes should be a place to happily and healthily live the rest of their life, but they instead have been allowed to become a depressing and infectious place to shorten their life. With the vast number of adults who will soon need care, this injustice needs to be resolved. The United States healthcare system is presently going through many drastic and necessary changes and Long Term Care should be included in these beneficial changes.

Not only in means of better quality care for residents, but also in better benefits and security for the nurses. The current system of Long Term Care in the United States not only shows a complete lack of respect for people, but it also is leading to economic disaster. The United States must better regulate Long Term Care laws to provide more beneficial coverage to elderly and to provide better benefits and more security to nurses in order to solve the issue of understaffing. If the United States were to fix the many deplorable faults of the Long Term Care system, we may once again restore respect to our deserving elderly population.

Reference List

Clemmit, M. (2006). Caring for the elderly. CQ Researcher 16(36), 842-861

Cooper, M. H. (1998). Is adequate Long Term Care available? CQ Researcher 8)7), 145-168.

Leaver, J. (2003). Geriatric depression scale. The Gale Encyclopedia of Mental Disorders. Ed.       Madeline Harris and Ellen Thackerey. Vol. 1. Detroit: Gale, 2003. 449-451. Gale Virtual       Reference Library.

Miranda, R. (2005). Protecting nurses from liability for negligence when their nursing home is             understaffed. Internet Journal of Law, Healthcare & Ethics 3(2).