A research team says it has found a link between high nursing turnover and deficiency notices from federal regulators, but a veteran Baltimore medical director is challenging the team’s premise as fundamentally flawed.

A team made up of five professors from the University of Maryland and one professor from South Korea’s Chung-Ang University compared nursing turnover rates in 846 nursing homes, with quality deficiency notices from the Centers for Medicare & Medicaid Services (CMS) in those same centers.

Homes with high levels of certified nurse assistant (CNA) turnover also had high levels of deficiencies, especially in quality of care and resident behavior, the team reported in the latest issue of the Journal of the American Medical Directors Association (JAMDA).

In fact, those centers with the highest turnover of CNAs saw the odds that they would be cited increase by 54 percent. High turnover of licensed nurses was “significantly related” to quality-of-care deficiencies, the researchers found.

“I expected to see an impact, but not the strength of the impact,” study author and University of Maryland Nursing School Professor Nancy Lerner tells Provider. “I truly was surprised, because when you’re looking at turnover, it’s not like you’re saying, ‘They’re not replacing these people.’

They’re replacing people; they’re just replacing them with individuals who are less familiar with the residents.”

The correlation between turnover and deficiency remained strong even when researchers adjusted for other variables, including number of beds in the center and ownership of the centers, Lerner says.

For Lerner, a former director of nursing who spent more than 10 years in nursing homes, the team’s findings should concentrate providers’ attention on turnover.

“If, indeed, this is an issue, what can we do about turnover to make this issue better?” she says. “Or, are we destined to keep looking at this? Because turnover has been a problem as long as I’ve been around, and it seemingly continues to be a problem.“

Lerner and her colleagues are in the midst of extended research on the topic, but she says that the answer may not lie in mere dollars and cents.

“My gut is, somehow nurses and [CNAs], it’s not the work that’s an issue—it’s how they feel they’re treated or valued in general,” Lerner says. “Whenever we talk about turnover, the first thing we talk about is, well if we paid them more, this wouldn’t happen. I’m not sure that’s the case. Certainly, pay is important. But we need to value nurses and [nurse] assistants and give them some voice in what’s going on.”

But Lerner’s conclusions aren’t universally shared. In the same issue of JAMDA in which Lerner and her colleagues published their findings, Baltimore geriatrician and multifacility medical director Steven Levenson, MD, says the central premise of the study—that regulatory deficiencies are an indicator of care quality—is “unwarranted and should be reconsidered.”

“In the aggregate, the number of survey deficiencies you get doesn’t necessarily indicate how good or bad the facility is, because it doesn’t take into account who’s looking for what,” Levenson tells Provider.

Levenson says that turnover probably has a relationship to quality, but he’s worried that the focus on

survey results is too reductionist. For instance, just as a matter of calendar-math, 75 percent of time that residents spend in nursing homes is on evenings and weekends. Yet, most staffing surveys seem to focus primarily on care during the day shifts, Levenson says.

“It’s an article of faith that there’s allegedly a correlation between the amount of staff and the quality and I’m not sure that’s been tested sufficiently,” he says. 

The federal deficiency surveys are hopelessly inexact, Levenson claims, and aren’t uniformly applied to care. In his editorial, he cites data from the American Health Care Association that shows that the average 100-bed nursing home will serve 189 short-stay, post-acute residents for every 86 long term care residents. Yet the current regulatory regime is almost exclusively focused on those long term care residents, Levenson says.

“Although the focus of nursing home care is increasingly on short-stay patients,” he writes, “and also on managing health issues for long-term residents, the 1987 Omnibus Budget Reconciliation Act [OBRA ’87] regulatory requirements lean primarily toward psychosocial, functional, behavioral, and quality-of-life issues for long term care residents.”

Furthermore, regulators can often miss bigger questions by focusing on merely checking survey boxes, Levenson asserts. “Because the survey process focuses surveyors on compliance with regulations,” he writes, “surveyors may not even ask all the questions they need to.”

Levenson cites, as an example, cases of delirium. Delirium is “common in both the hospital and the nursing home, and it increases the risk of short- and longer-term complications such as dementia, pressure ulcers, pneumonia, hospitalization, slower post-hospitalization recover, and death.”

Dealing with delirium “requires a high index of suspicion and a coordinated effort” among caregivers, Levenson says. And while CMS clearly recognizes the threat, its surveys generally exclude delirium recognition, screening, and treatment in its analyses, Levenson says.

“However, surveyors only sometimes correctly determine deficiencies, especially in more complex cases, and appropriately link facility practices to resident outcomes,” Levenson says. “Although facilities may complain with some justification that surveyors sometimes incorrectly make such connections, surveyors often fail to recognize situations where cause identification, such as recognition of delirium, is incorrect and subsequent interventions are inappropriate or problematic.”

Overall, Levenson tells us that he’s worried that survey data create a dialectic of dumbing-down: Big, systemic problems in a home can get missed, and relatively minor problems can get over-emphasized.

“When they use the survey as barometer, they may not get any citations in a certain category, but they may still not be doing the right thing, or the right thing in the right way. And so the residents suffer,” he says. “For instance, quite often if there’s a deficiency in weight loss, nursing home administrators will go after the dietitian—and that just doesn’t address the problem. So, as with the care of patients, there are often multiple causes of a single finding and single causes of multiple findings. And until you do your careful analysis you have no way of knowing how to fix the problems.”

Lerner, the study’s author, says she understands why professionals may balk at using a deficiency as a measure of quality. But she says that, whether there’s a one-for-one comparison between deficiencies and quality, those who are on the frontlines of care have to take those deficiency standards seriously.

“The fact that survey information has to be in the lobby of every nursing home in America means that somebody is taking this seriously,” she says. “You give the best care you can, but when those surveyors come in the door, you’re concerned about what you’re doing and what they can find.”

And Lerner says that some deficiencies—especially the quality-of-care deficiencies—are important no matter how they’re measured.

“Those are the ones that hurt people,” she tells Provider. “That means you did something that had the potential to cause harm to a resident.”

Lerner and her team are already at work on a follow-up study, this one on the relationship between turnover among directors of nursing or administrators and deficiencies. The results appear to be even starker, she says.

“What we’re finding is that the longer the tenure of either a director of nursing or an administrator in a nursing home, the lower the number of deficiencies in a nursing home, and the lower the severity of deficiencies,” she says. “That’s even scarier, in some ways, than the turnover of CNAs.”