SMITHFIELD, R.I. — After working in the dementia unit of her nursing home for the last seven years, certified nursing assistant Adelina Ramos said she finally started to see positive staffing changes.
Ramos, who works at Greenville Skilled Nursing and Rehabilitation in Smithfield, said she went from juggling 30 needy patients at a time with one other CNA to handling just seven to eight patients on her own thanks to a new minimum staffing law that went into effect this year. It was the first time, she said Wednesday, that she was able to provide the kind of care that her patients deserved in years.
“And then it was ripped away from us,” said Ramos.
On Jan. 21, just three weeks after the Nursing Home Staffing and Quality Care Act went into effect, Governor Dan McKee signed an executive order that allowed nursing homes to bypass the state’s staffing requirements without being penalized.
Greenville, a 131-bed for-profit facility that lost nearly 30 residents to COVID-19 since March 2020, complied with the law by hiring workers from staffing agencies to help their staffers. The temporary workers get paid more than Ramos, she says, but without the mandate, she fears that facilities like hers will stop paying for additional workers and patient safety could be put at risk.
Without minimum staffing requirements, “We’re going to go back to a dark time for nursing homes,” she said.
Long-term care facilities were hit particularly hard throughout the pandemic. Nearly 1,780 residents in Rhode Island’s nursing homes died after contracting COVID-19. The facilities that serve the state’s most frail aren’t well funded, and rely heavily on reimbursements rates through Medicaid and Medicare that are less than the actual cost of care. And nursing home workers -- who are largely people of color, immigrants, or from low-income backgrounds -- are paid significantly less than people with the same credentials who work in hospitals and other health care settings.
In his executive order, McKee wrote that the only way for nursing facilities to maintain the staff-to-resident ratio required by the law would be to reduce the number of residents residing in each facility. Industry experts say that’s only part of the problem.
“We aren’t looking to change the staffing ratio. But we’re being realistic about the economics and know it’s not going to work. Not in Rhode Island or elsewhere,” said Jim Nyberg, the president of LeadingAge RI, an organization that represents non-profit nursing homes. “A ratio isn’t going to magically make workers appear. And we don’t have enough to compete with the hospitals that are giving away $25,000 sign-on bonuses.”
Hospitals in Rhode Island, which are mostly owned by large corporations, were assigned military medical workers earlier this month to help highly paid nurses and doctors get through the latest COVID-19 surge caused by the highly infectious Omicron variant.
Dr. Saul N. Weingart, the president of Lifespan-owned Rhode Island Hospital, told the Globe recently that the added personnel is helpful, but the military workers will only be there for 30 days. Weingart said he plans on asking for an extension, but it’s up to the U.S. Department of Defense, not Lifespan or the state, to grant that extension.
Rhode Island Hospital’s chief medical officer Dr. G. Dean Roye said during a Wednesday morning press conference that the hospital is running between a “25 to 35 percent” staffing shortage without the added help.
“Things are improving slightly,” he said as members of the military medical personnel team stood behind him. “But it’s going to take a pipeline fix to get to the bottom of the problem. My greatest fear is that this isn’t the end…. I’m really scared we’ll end up in a similar situation all over again with a new variant.”
Nursing homes, which were hit hardest at the beginning of the pandemic and are still reeling with human and financial losses, did not receive help from military medical personnel. According to Nyberg, struggling nursing home administrators are wondering: “Why not help us?”
Richard Gamache, the CEO of Aldersbridge Communities, which owns several not-for-profit long-term care facilities in Rhode Island, said he’s attempted to close the gaps in the staffing shortage by offering bonuses and paying overtime. But nursing homes do not have the financial resources to compete with hospitals, he says. Some of his organization’s younger nurses were recruited to local hospitals, and were able to use their multi-thousand dollar bonuses to pay down their student loans.
“Poaching from one another only speeds up this race to the bottom, as we fight over a pool of candidates that is too small to fill the open positions,” he said. “We are in the midst of a public health emergency, but long term elder care is at a decided disadvantage because we are reliant on Medicaid, which pays 15 to 20 percent less than what it costs for us to provide care.”
Gamache said that on average, Aldersbridge receives about $240 per day to care for their residents.
“That’s $10 an hour. It’s the same amount I used to pay a teenager to babysit my children when they were small,” he quipped. “I blame it on ageism, but it’s even more than that. Our workforce is predominantly female, with a large number of immigrants, so I see some racism and sexism involved, too.”
John Gage, the president and CEO of the Rhode Island Health Care Association, said he’s asked the state to deploy the National Guard to nursing homes, but was told it wouldn’t be possible.
“What the state had told us was that there was no healthcare component to the RI National Guard. It was outside their scope to provide clinical staffing assistance,” he said. But last week, National Guard troops were deployed by the governor to Butler Hospital, and President Joe Biden sent medical military personnel to help ease the crisis at Rhode Island Hospital.
And yet, Gage said, “There’s been no discussion of their providing staffing assistance in nursing home that we are aware of at this time.”
On Wednesday, he sent a letter to McKee, informing him that there are 1,920 open positions across all nursing home facilities in the state. Without a reprieve from the minimum staffing standards, he said, nursing homes would have to dole out $8 million in non-compliance fines within the first quarter, and $32 million within the first year.
The state health department said it would cost $21 million for nursing homes to hire the staff needed to be compliant with state law. The staffing mandate provided a 0.5 percent increase in funding to help hire those workers, but that would only cover $2 million of the $21 million cost.
“This is a $19 million unfunded mandate,” Gage said.
McKee’s office did not immediately respond to inquiries from the Globe on Wednesday.
Aldersbridge Communities’ Gamache said that while he appreciates the one-month reprieve from the minimum staffing mandate, it’s going to take longer than until mid-February, when the executive order expires, to ease the staffing crisis in health care.
“COVID has shone the light on all that is broken in this system. Direct care workers need better pay and benefits, and they also deserve the respect and admiration of our society as a whole,” he said.
Raise the Bar on Resident Care, a coalition of organizations including Service Employees International Union 1199NE (the union that represents many frontline workers in nursing homes and hospitals), sent a letter to the governor’s office this week, urging him to immediately rescind his executive order.
“Delaying implementation of this law in the middle of our generation’s worst public health crisis is exactly the wrong direction for our state’s most vulnerable citizens,” read the letter.
Nicole Jean-Gilles, a registered nurse at Bannister Center for Rehabilitation and Nursing in Providence, said during a brief interview during her shift break Wednesday that she’s caring for over 25 patients on her own.
“That’s a lot of people to take care of. They are so sick, so demanding, and they need us for everything— from showering to eating,” said Jean-Gilles, who said that coworkers have opted to quit and start working at McDonalds, where they pay is better. “Being a nurse or CNA in this state is not easy. You have to really love what you do.”
“We’re dealing with human beings. They cannot care for themselves and are here for a reason,” she said. “They need the care they deserve, and they rely on us to do it. This is basic human decency.”