Sick elderly person

Increased regulation of certified nursing assistants in assisted living and memory care communities is associated with fewer hospital admissions for residents, but more specific regulations for licensed practical nurses has the opposite effect, according to a study published Wednesday in Health Affairs.

The study, the authors said, is among the first to examine the influence of changing staffing regulations on assisted living residents’ outcomes. The results, they said, have “striking implications” for practice, policy and research in assisted living, including recommendations for staffing requirements.

Specifically, the investigators found that “increased regulatory specificity” for CNAs, such as a change from requiring “sufficient” direct care worker staffing to requiring a specific staffing ratio or level, was associated with a 4% reduction in the monthly risk for hospitalization among residents in their sample and a 6% reduction among the subgroup of residents living with dementia. An increase in regulatory specificity for LPNs, however, was associated with a 2.5% increase in the monthly risk for hospitalization and a 5% increase among the subgroup with dementia.

“Given the time necessary to provide adequate care for activities of daily living to assisted living residents, particularly those living with dementia, more specific regulations as they relate to minimum staff — and therefore potential increase in direct care worker stuffing in assisted living — could prevent resident falls, functional decline and exacerbation of other conditions that lead to hospitalization,” the researchers wrote.

The increased hospitalization rates tied to tighter LPN requirements, they said, could be attributed to several factors, including staffing reductions made in other areas to accommodate more expensive LPN workers or “unfunded mandates” for higher paid staff members that resulted in cost-cutting measures in other areas that could have adversely affected quality of care.

The majority of care provided in assisted living is not state-subsidized, despite the increase in Medicaid waivers and state plans that cover services in assisted living, the authors noted. 

“Thus, there are few mechanisms to increase financial support to help assisted living communities meet increased staffing requirements, potentially leaving providers to cut costs at the margins or pass the additional costs on to residents,” they said.

The authors also said that their findings may reflect a “dampening effect.” Regulations that increased staffing levels at communities with the lowest staffing levels may have caused other providers to “staff down” if they viewed minimum staffing requirements as the maximum staff needed. The authors warned that careful consideration be given to the unintended consequences of assisted living staffing regulations, particularly for higher paid staff members.

Alternatively, the researchers said, having an increased LPN presence in a community could have heightened the recognition of signs and symptoms of declining health among residents, which could have resulted in hospitalization.

“LPNs might not have the training or scope of practice needed to care for sick residents safely in the assisted living environment, requiring sufficient backup by RNs to prevent hospitalization,” they said. 

The research was supported by a grant from the National Institute on Aging.