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Nursing-home study finds reduced staffing in those in states giving them immunity from COVID lawsuits
Mary Van Beusekom, MS
Today at 5:13 p.m.
COVID-19 A study of more than 13,000 US nursing homes concludes that those in states that adopted laws granting them immunity from COVID-related lawsuits operated with 2.5% less daily staff than those in states without those protections, potentially compromising patient care.
Northwestern University researchers led the study, publishing their findings yesterday in JAMA Health Forum.
The team used a difference-in-differences model to assess staffing levels in all 13,205 US nursing homes that reported data from January 2018 through March 2023. Data were derived from the Centers for Medicare & Medicaid Services’ Nursing Home Compare and Payroll Based Journal Daily Staffing Averages websites, as well as weekly nursing home COVID-19 cases.
“A central goal of medical malpractice law is to ensure quality of care by deterring negligent treatment,” the authors wrote. But “during the COVID-19 pandemic, many states adopted immunity from tort liability for harms to nursing home residents, creating a natural experiment.”
Average of 8 hours less staff time per day
From 2018 to 2023, roughly 43 US states began granting some form of tort immunity to nursing homes from lawsuits filed by patients and their families. Of the 13,205 nursing homes included in the study, 86.2% were granted tort immunity, and 13.8% weren’t.
Some of these laws had automatic end dates (eg, six months post-adoption), while others were indefinite; 23 states provided immunity retroactive to a period (median, 2.8 months) before the law was passed, and some are still in effect.
Nursing homes in states that adopted such laws tended to be larger and non–hospital based and were more likely to have a greater proportion of White residents.
Facilities immune from tort liability began providing less staff time per patient per day than those in states that didn’t grant such protections: a 2.5–percentage point (pp) reduction in overall daily staff hours and a 1.2-pp reduction in staffing hours per patient per day. The 2.5-pp decrease translated to, on average, nearly eight hours’ less staff time per day for clinical care and other duties.
The authors noted a 2.0-pp decrease in hours of care per patient per day for certified nursing assistants (CNAs), who provide direct patient care, whereas staffing rates for registered nurses (RNs), who often have administrative roles, stayed the same.
“These policy changes are not associated with a defined monetary reward or fixed staffing target,” corresponding author David Zingmond, MD, of the University of California Los Angeles, said in a university news release. “So the robust magnitude of change was surprising.”
Less likely to employ, look for staff
The authors said the liability-limiting laws were triggered by anticipation of a surge of medical malpractice lawsuits alleging that negligence caused patients to contract or die from COVID-19.
This amount of time (5.2 minutes) might seem small, but for a patient in need, nearly 8 hours of time could make a substantial difference.
Although they acknowledged that the financial problems and general instability of healthcare staffing during COVID-19 would have shortened the time caregivers could devote to patients, the researchers said the numbers suggest that nursing homes with lower tort exposure may have been less likely to employ nursing staff or try to find replacements during worker shortages.
The laws, they said, “appear to have had the unintended consequence of reducing staffing levels, perhaps impairing the deterrent effects of exposure to tort law by lowering incentives for administrators to search for nursing staff during a period when there were extreme shortages, thus, high nursing prices.”
That RN staffing rates were largely uncorrelated with immunity is consistent with the need for nursing facilities to maintain staff in their administrative and medical roles, the authors said.
“However, CNAs and LPNs [licensed practical nurses] provide nearly all the direct care to nursing home residents: it is among the CNAs, who comprise two-thirds of the clinical staff, where we find the association between staffing and tort immunity,” they wrote.
With the average nursing home protected against tort liability was estimated to have 7.9 fewer daily staff hours, if the time had been spread equally among all residents, “this amount of time (5.2 minutes) might seem small, but for a patient in need, nearly 8 hours of time could make a substantial difference,” they wrote.
The authors said that research into the clinical effects of reduced staffing could help paint a more complete picture of nursing-home care during the first years of the pandemic.
Nursing-home study finds reduced staffing in those in states giving them immunity from COVID lawsuits
Mary Van Beusekom, MS
Today at 5:13 p.m.
COVID-19 A study of more than 13,000 US nursing homes concludes that those in states that adopted laws granting them immunity from COVID-related lawsuits operated with 2.5% less daily staff than those in states without those protections, potentially compromising patient care.
Northwestern University researchers led the study, publishing their findings yesterday in JAMA Health Forum.
The team used a difference-in-differences model to assess staffing levels in all 13,205 US nursing homes that reported data from January 2018 through March 2023. Data were derived from the Centers for Medicare & Medicaid Services’ Nursing Home Compare and Payroll Based Journal Daily Staffing Averages websites, as well as weekly nursing home COVID-19 cases.
“A central goal of medical malpractice law is to ensure quality of care by deterring negligent treatment,” the authors wrote. But “during the COVID-19 pandemic, many states adopted immunity from tort liability for harms to nursing home residents, creating a natural experiment.”
Average of 8 hours less staff time per day
From 2018 to 2023, roughly 43 US states began granting some form of tort immunity to nursing homes from lawsuits filed by patients and their families. Of the 13,205 nursing homes included in the study, 86.2% were granted tort immunity, and 13.8% weren’t.
Some of these laws had automatic end dates (eg, six months post-adoption), while others were indefinite; 23 states provided immunity retroactive to a period (median, 2.8 months) before the law was passed, and some are still in effect.
Nursing homes in states that adopted such laws tended to be larger and non–hospital based and were more likely to have a greater proportion of White residents.
Facilities immune from tort liability began providing less staff time per patient per day than those in states that didn’t grant such protections: a 2.5–percentage point (pp) reduction in overall daily staff hours and a 1.2-pp reduction in staffing hours per patient per day. The 2.5-pp decrease translated to, on average, nearly eight hours’ less staff time per day for clinical care and other duties.
The authors noted a 2.0-pp decrease in hours of care per patient per day for certified nursing assistants (CNAs), who provide direct patient care, whereas staffing rates for registered nurses (RNs), who often have administrative roles, stayed the same.
“These policy changes are not associated with a defined monetary reward or fixed staffing target,” corresponding author David Zingmond, MD, of the University of California Los Angeles, said in a university news release. “So the robust magnitude of change was surprising.”
Less likely to employ, look for staff
The authors said the liability-limiting laws were triggered by anticipation of a surge of medical malpractice lawsuits alleging that negligence caused patients to contract or die from COVID-19.
This amount of time (5.2 minutes) might seem small, but for a patient in need, nearly 8 hours of time could make a substantial difference.
Although they acknowledged that the financial problems and general instability of healthcare staffing during COVID-19 would have shortened the time caregivers could devote to patients, the researchers said the numbers suggest that nursing homes with lower tort exposure may have been less likely to employ nursing staff or try to find replacements during worker shortages.
The laws, they said, “appear to have had the unintended consequence of reducing staffing levels, perhaps impairing the deterrent effects of exposure to tort law by lowering incentives for administrators to search for nursing staff during a period when there were extreme shortages, thus, high nursing prices.”
That RN staffing rates were largely uncorrelated with immunity is consistent with the need for nursing facilities to maintain staff in their administrative and medical roles, the authors said.
“However, CNAs and LPNs [licensed practical nurses] provide nearly all the direct care to nursing home residents: it is among the CNAs, who comprise two-thirds of the clinical staff, where we find the association between staffing and tort immunity,” they wrote.
With the average nursing home protected against tort liability was estimated to have 7.9 fewer daily staff hours, if the time had been spread equally among all residents, “this amount of time (5.2 minutes) might seem small, but for a patient in need, nearly 8 hours of time could make a substantial difference,” they wrote.
The authors said that research into the clinical effects of reduced staffing could help paint a more complete picture of nursing-home care during the first years of the pandemic.