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How Inadequate Staffing in Nursing Homes Poses Risks of Injuries

Legally Reviewed and Edited by: Terry Cochran

It’s never an easy decision to place a loved one in a nursing home. Usually, it’s the result of a lengthy illness or complications from an injury or perhaps care at home has just become unsustainable. When we choose a nursing home, we want to be assured that our loved ones will receive the best care possible and will be treated with dignity and respect. When a nursing home is understaffed, the risk of injuries to our loved ones increases, and you may need a medical malpractice attorney to navigate your case.

Inadequate staffing is usually a budgetary decision, leaving the nurse to patient ratio at 18:1 on days that are well-staffed according to this report. On poorly staffed weekdays and weekends, the ratio can be 30:1, or 38:1. There are no federal staffing standards for patient ratios, although a registered nurse (RN) must be present for a minimum of 8 hours per day, and a licensed practical nurse (LPN) must be available 24 hours a day. One in eight nursing homes has too few nurses on duty.

With so many patients and so few skilled nursing staff, accidents happen. You should know the risks understaffing in nursing homes can pose to the safety of your loved ones, and what to do if your loved ones experience an injury due to staffing issues.

Why nursing homes are so understaffed

Many factors contribute to why nursing homes are understaffed, including a small pool of qualified candidates to choose from. Many nursing homes will not or cannot offer the pay and benefits that a larger hospital can offer, which reduces the number of potentially qualified candidates for nursing home staff.

While both a hospital and a nursing home may be high-stress environments with too many patients-to-nurse ratios, nurses, and certified nursing assistants (CNAs) are more likely to choose higher pay to deal with such conditions.

Another significant factor is labor costs. Smaller nursing homes cannot afford a large staff, and so they stretch their existing nursing staff, which is still not enough to adequately address the patient-to-nurse ratio. In larger facilities, the reluctance by management to put profits into properly staffing the nursing home remains a bone of contention for many nurses.

In large cities where the pool of potential candidates is larger, the stretching of nursing staff results in a high turnover rate, which compromises the continuity of care for patients. Not only does it jeopardize patient care, but a high turnover rate is a huge cost to the nursing facility. Not only must they recruit and train new employees, but they must also absorb the costs associated with mistakes made by new trainees and beds that cannot be used during new staff orientation periods.

Nursing homes are also not one of the more attractive areas of nursing, although they could be with adequate staffing and more guidance and support from management. Taking care of people at the end of their lives can be very emotionally and physically draining. Elderly people with dementia, incontinence, or the inability to perform simple daily tasks take extra time and patience to deliver the best care, and this can become a strain on even the most well-trained nurses. In a nursing home where one nurse is responsible for 18-38 of these patients, the idea of delivering quality care to everyone each shift is daunting. Nurses in nursing homes experience a higher percentage of burnout, which contributes to a decrease in the quality of patient care.

Boomerang hospital visits

One significant problem for nursing home patients is being shipped off to a hospital for treatment for infections, of which some are avoidable and due to understaffing issues such as pressure ulcers. Because hospitals make more from Medicare on a short-term admission than a long-term admission of an elderly patient, they are motivated to ship that patient back to the nursing home, often before they are ready.

On the other side of the coin, nursing homes are incentivized to ship out elderly patients to hospitals because Medicaid, which covers most nursing home residents, will pay a “bed-hold” fee. When patients return, Medicare covers their stay in the nursing home for the next 100 days, and Medicare pays more than Medicaid.

When patients are returned to these facilities, the understaffing of nurses and CNAs can lead to more infections and rehospitalizations, as important directives are ignored or unable to be completed by staff that are already at minimal levels, or who are experiencing a high rate of turnovers.


With high patient-to-nurse ratios and turnover rates, patients are often neglected simply because there are too many of them and not enough nursing staff or hours in the day. This can lead to patients suffering from pressure ulcers, lack of hygiene, missed or misinterpreted medical conditions, slips and falls, missed medications, infections, and a loss of social interactions.

Patients who are immobile or have limited mobility are at particular risk of falling victim to neglect due to understaffing issues. Infections, falls, misdiagnoses, or missed diagnoses can all lead to serious illness, immobility, or even death.

Ninety-five percent of nursing home patients report either being neglected or witnessing another patient being neglected. Neglect can be particularly harmful in terms of isolation. Socialization is just as important to improved physical health as medications. A person’s emotional and mental well-being contributes to their physical healing. Patients who feel lonely often have a significantly higher mortality rate and immobility rate.


The high stress demands of a nursing home, coupled with understaffing, high turnover rates, and sometimes minimal supervision on nights and weekends, can foster an environment where patients are not only neglected but also abused.

To control patients with dementia or other medical conditions that may need extra attention from nursing staff, some nurses have resorted to overmedicating their patients. This is elder abuse. Not only could there be potential side effects from too much medication, but it is a form of control and confinement to which the patient and family have not given their consent.

Other indicators of nursing staff overworked and overstressed can be seen in physical abuse, where the nursing staff becomes so frustrated, they lash out. If you notice strange or unexplained bruising on your loved one or restraint marks around their ankles and wrists, ask questions. Seek out the advice of a medical malpractice attorney to review medical records, nursing home conditions, and nursing staff practices.


An overworked staff will eventually become run-down, sick, and exhausted. While many nursing homes offer overtime, and employees see this as a benefit, employees are trading crucial downtime with their family and friends for more time in an already-stressful environment. This compromises many nurses’ mental and emotional well-being and leads to a higher rate of burnout and turnover.

One of the risks to patient care from exhaustion is when a nurse makes a preventable error, either in direct care or data entry. Medical negligence and errors already account for over $19 billion in health care costs each year. A mistake made in medication, identification of a patient, reading of results, and other factors can lead to serious injury or even death.

Higher rates of illness among nursing staff who are overtired and overworked also puts patient safety at risk. Nurses and CNAs who have to call in sick are reducing an already understaffed crew. Nurses and CNAs who choose to come to work with an illness risk passing that illness onto their patients, many of whom have compromised immune systems.

Exhaustion can also cause a nurse to miss changes in a patient’s condition, which may be subtle or may be significant. Early warning signs of a more severe medical condition that go unnoticed can lead to complications and worsening of that condition. In fact,46% of nurses report they have missed a change in a patient’s condition because of understaffing and an excessive workload.


Infections are the primary cause of death in nursing homes across America. Not only does understaffing lead to a lack of sanitary conditions that can cause and spread infections, but neglect and abuse of patients can also cause infections.

Urinary tract infections, or UTIs, are both preventable and the most common type of infection found in nursing home patients. UTIs can cause more than just pain while urinating; they can lead to cognitive impairment, behavioral changes, and even episodes of disorientation or psychosis.

Nursing homes without adequate staffing often miss the signs of UTIs, and undiagnosed urinary infections can move into the kidneys and bladder, becoming more difficult to resolve or even septic. UTIs are often a symptom of diapers not being changed often enough, lack of assistance with maintaining proper hygiene, or lack of assistance with using the toilet more frequently, which can be a challenge for patients who lack mobility. Nursing homes who are understaffed have difficulties in getting to all of their patients in time, which can lead to these kinds of complications.

Another preventable and common infection is pneumonia, which the cause of 40,000 deaths each year. Immobile patients are more likely to develop pneumonia because they are unable to move around and fluid can build in the lungs, leading to infection. Patients with other health conditions or illnesses are also at risk for developing pneumonia.

Understaffing can lead to a delay in treatment because symptoms are not always discovered or observed immediately. A delay in treatment can mean severe health complications, including death, for any patient suffering from pneumonia.

Bedrail injuries

While bedrails are used to help keep elderly patients from injuring themselves or to help support them as they move around in bed, they can cause serious risks to patients. Patients are at risk of slipping between the bedrail and the mattress. If a patient does not have the strength to lift themselves out of this position, they are at risk of asphyxiation or heart attacks. Four thousand elderly patients are treated for bedrail injuries each year.

Understaffed nurses are not always able to check on each patient frequently throughout their shift, which can lead to an increased risk of bedrail injuries. The potential consequences of bedrail injuries are severe. Besides asphyxiation and cardiac arrest, patients are also at risk for hitting their heads on their bedrails, resulting in contusions and traumatic brain injuries.

Traumatic brain injuries

Traumatic brain injuries

Traumatic brain injuries, or TBIs, can be caused by a fall or a blow to the head. The average nursing home resident will fall a minimum of 2 times per year, and 50% of documented nursing home falls result in head trauma.

Residents often fall when their basic needs are not being met. If they are hungry, need socialization, need to use the restroom, or are trying to move around to prevent bed sores, they are more likely to try and stand and walk to take care of their own needs. Nursing staff is supposed to be in place to assist patients with these daily, even hourly tasks, but understaffing often prevents nurses and CNAs from reaching patients in time.

Some falls are inevitable and cannot be prevented, but the lack of proper staffing in nursing homes raises the number of reported falls. There probably are many more falls that are never reported. Patients who hit their heads and develop a TBI have a 40% chance of a full recovery.

Malpractice lawyers, along with doctors and other medical experts, will be able to review your loved one’s medical records and document the environment of the nursing home to help determine if your loved one’s fall is the result of neglect. In Michigan and other states, doctors must review a case before it can be brought forward as a medical malpractice lawsuit. A finding in favor of your suspicions will help you fight against the conditions that led to your loved one’s injuries.

Medication errors

Medication errors can happen in any hospital, pharmacy, or nursing home, but they are particularly more complicated and common in nursing homes. Elderly patients are more likely to be on several kinds of prescription drugs, which means they need to be monitored for adverse side effects when they first start taking a new drug.

Inadequate staffing leads to an inability to monitor so many patients with new prescriptions. Likewise, it can also lead to errors in the administration of those medications, especially for staff who are exhausted and have high patient loads.

Preventable medical errors, including medication errors, kill up to 95,000 people each year. An experienced medical malpractice attorney can help you seek justice for your loved one and force the nursing home to address their inadequate staffing issues more forcefully.

Final thoughts

We don’t always have many choices when it comes to finding a skilled nursing home to bring our loved ones to, but we try to make the best choice. We hope the staff will do their best to take care of our family members and friends, but sometimes, management has created unfair and understaffed working conditions beyond the nurses’ control.

Visit your loved one often and observe the patient-to-nurse ratio. Ask questions, advocate, and be involved in the care of your loved one. If you suspect that your loved one has sustained an injury or preventable illness because of neglect, abuse, or staffing conditions, seek out the help of lawyers specializing in medical malpractice such as Cochran, Kroll & Associates, P.C. to help seek justice for your loved one.

If you feel your elderly loved one has been a victim of an understaffed nursing home, call our law firm on 866-MICH-LAW for a no obligation case evaluation, on the phone, over the internet, in-person, at your home or even in the hospital.

Statutes of limitations limit the length of time you have to file a lawsuit, so it is important you act quickly. Proving a medical error was caused by negligence is a complicated matter, but our experienced medical malpractice legal team will work hard to fight for your loved one’s rights. Partner, Terry Cochran says, “It would be totally unfair if an injured person was unable to seek compensation because he or she couldn’t afford an attorney.” At Cochran, Kroll & Associate, P.C we never charge a fee unless a recovery is made.

Disclaimer : The information provided is general and not for legal advice. The blogs are not intended to provide legal counsel and no attorney-client relationship is created nor intended.

Ms. Barry is studying Communications at the University of Pennsylvania. She has won multiple awards both for her persuasive and creative writing and has written extensively on the topics of medical malpractice law, personal and birth injury law, product liability law. When she's not researching and writing about these topics, she edits a literary magazine and tutors students at Penn's writing center.



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