Long-Term Care & Skilled Nursing Facilities: Key Insights for Attorneys Navigating Elder Care Cases

Cases involving nursing home care often raise concerns about high resident volumes and understaffing. In part two of this series, we explore the key differences between long-term care (LTC) and skilled nursing facilities (SNF).

This article provides critical insights into the staffing challenges faced by LTCs and SNFs, offering valuable information to help you navigate claims of elder abuse, neglect, and mismanagement in nursing homes.

If you missed it, click here to read part one, where we discuss the unique challenges posed by assisted living facilities (ALFs) for elderly clients and their families.

Nursing Homes

A nursing home is a private facility offering residential accommodations and medical care.

Long-term care (LTC) facilities and skilled nursing facilities (SNF) are both categorized as nursing homes. They both provide around-the-clock care for individuals who do not require hospital-level care but cannot live independently due to their medical conditions.

Both types of facilities are subject to strict regulations, licensing, and inspections by state and federal agencies.

Long-Term Care Facilities

Long-term care (LTC) facilities provide long-term medical care and support to people who need assistance with personal and medical care due to chronic conditions, disabilities, cognitive impairments, or age-related concerns. Various establishments, including continuing care retirement communities (CCRCs) and memory care centers, fall under the LTC category.

LTC is designed for individuals who require assistance with activities of daily living, such as bathing, dressing, or eating, and round-the-clock supervision or medical care from trained medical staff. Licensed medical staff, such as registered nurses (RNs), licensed practical nurses (LPNs), certified nursing assistants (CNAs), and therapists are available to deliver necessary medical care.

Unlicensed assistive personnel (UAPs) are available to provide non-medical assistance with tasks including grooming, meal preparation, cleaning, and other activities of daily living (ADLs).

Skilled Nursing Facilities

Skilled nursing facilities (SNFs) provide short-term nursing care for people who no longer need the care provided in a hospital but still require medical assistance before returning home. Patients may need SNF placement if they have decreased mobility or cannot adequately care for themselves, such as after a stroke or hip repair surgery.

SNFs offer medical, nursing, and rehabilitative services delivered by licensed professionals. Doctors and nurses provide medical care, such as medication administration, intravenous drug administration, and wound care. Physical, occupational, and speech therapists provide rehabilitation services. Nursing assistants help with mobility and ADLs, and ancillary staff prepare meals and provide janitorial services.

Nursing Home Staffing Requirements

Nursing homes must meet the federal minimum staffing standards. According to federal law, Medicare and Medicaid-certified nursing homes must have an RN on duty for at least 8 hours a day, 7 days a week. This RN role may include a Director of Nursing (DON) who may not provide direct care to residents. An RN or LPN must always be available, but no federal minimum staffing levels are established for nursing aides, who deliver most of the daily care.

In June 2024, the Biden-Harris Administration’s nursing home reform initiative enhanced minimum staffing standards in long-term care facilities.

According to the new regulations:

An RN must always be on-site, with some specific exemptions.
Nursing homes must ensure a minimum of 0.55 hours of RN staffing and 2.45 hours of nursing assistant staffing per resident per day.

Each staffing requirement independently supports nursing home residents’ safety and health. This means having an RN on-site 24/7 does not automatically fulfill the minimum hours per resident per day standard.

In addition to these federal regulations, individual states can establish their own requirements.

In Oregon, according to OAR 411-054-0070, nursing home facilities must employ enough awake direct care staff to meet each resident’s scheduled and unscheduled needs 24 hours a day.

Direct care staff are responsible for medication administration, resident-focus activities, resident supervision, and assistance with activities of daily living.

At least two direct care staff members must be available when a resident requires assistance from two staff members for scheduled or unscheduled needs.
In facilities with two or more detached buildings, if residents reside in both buildings or the building contains segregated or distinct areas, a designated awake caregiver must be available at all times in each building and segregated area.
Facilities must establish a defined, written system, whether manual or electronic, to determine the appropriate number of staff needed based on resident acuity and service needs.

Legal Concerns for Nursing Homes

Nursing homes provide housing for older adults with ongoing medical needs due to advanced age, chronic medical conditions, severe pain, permanent disabilities, or serious injuries. They are regulated and inspected by both state and federal agencies.

Short staffing concerns for nursing homes

Nursing homes often operate with the minimum required staff to fulfill regulations, and high patient-to-staff ratios can limit the ability to address the needs of diverse, complex residents.

These staffing shortages can lead to improper medication administration. Examples may include:

Blood pressure medication is given without first checking the resident’s blood pressure.
Insulin is administered without first checking the resident’s blood glucose.
The staff pre-document medication administration, making it difficult to verify whether a medication was given.

Additionally, due to short-staffing, nursing assessments are frequently missed or poorly documented in the Minimum Data Set (MDS). The MDS is a set of screening, functional, and clinical assessments that form the basis for the comprehensive assessments mandated for Medicare and Medicaid-certified long-term care facilities.

The MDS is an essential component of the federally mandated assessment process in nursing homes. It provides valuable support to staff in several critical areas, including:

Identifying health concerns.
Assessing residents’ functional capabilities.
Creating individualized care plans.
Guiding resource allocation.
Facilitating communication between facilities and external agencies.

Licensed healthcare professionals are required to complete MDS assessments within 14 days of a resident’s admission and repeat them quarterly, annually, and when there is a significant change in health status or at discharge.

However, high resident volumes and short staffing often lead to missed or incomplete documentation, which can delay care, obscure status changes, and hinder the creation of a clear medical timeline for identifying causes of decline.

Filing abuse and neglect claims against nursing homes

Filing abuse or neglect claims against a nursing home can be challenging. In many cases, high resident volumes and chronic understaffing contribute to neglect and abuse, which is frequently hidden from families. It will often take a major incident for families or other advocates to recognize a problem and act. Missing or substandard documentation further complicates matters. Medical expertise is required to link current issues to past events and reconstruct a clear history of provided care.

Conclusion

Different types of care facilities—assisted living, which we discussed in part one, and long-term care and skilled nursing care, which we discussed above—are tailored to meet the specific needs of older adults. The choice of care depends on individual circumstances, preferences, and requirements.

It’s essential to identify which care facilities align with the needs of the older adult population while ensuring they operate ethically, safely, and per established standards and regulations.

Negligence due to high resident populations and lack of qualified staff in these facilities can manifest through issues like medication errors, falls, skin breakdowns, delays in care, failure to provide prescribed treatments, and elopement.

How Integrity Legal Nurse Consulting PDX can help

An experienced legal nurse consultant can help you understand the complexities of geriatric care. They can evaluate if the resident has received appropriate care within the most suitable setting for their medical needs and conduct chart reviews and analyses to assess whether the facility adhered to medical orders and provided safe, best-practice care.

The nurse experts and consultants at Integrity Legal Nurse Consulting PDX have experience reviewing cases involving nursing homes and assisted living facilities.

Our nurses are available to answer your questions and provide valuable insights into the different care options and their implications for your cases. Click here to contact us and learn how we can best support you with your caseload.

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More From This Series:

Assisted Living Facilities: Key Insights for Attorneys Navigating Elder Care Cases