home in the United States has provided a combined total of 3.5 to 3.6 hprd of RN, LVN/LPN, NA, and director of nursing time (see Figure 5-1). Most of this time (58 percent or 2.1 hours) is provided by NAs, who on average care for 11 residents. Each RN and LPN/LVN (at 0.7–0.8 hprd) typically oversees care for 32 to 34 residents, although these ratios may vary across shifts and on weekends and holidays (Harrington et al., 2002).
Staffing levels vary widely by facility characteristics. SNFs that admit only Medicare residents have almost double the staffing levels of nonskilled (Medicaid-only) nursing facilities (Harrington et al., 2002). For-profit facilities generally have lower staffing levels than nonprofits, even though there can be high variability in this regard (Aaronson et al., 1994; Harrington et al., 2001). There are also wide variations in staffing levels across states (Harrington et al., 2002).
Federal nursing home regulations require that each facility receiving Medicare or Medicaid payments (the majority of nursing homes) have “sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident, as determined by resident assessments and individual plans of care.”8 These regulations also require all Medicare- or Medicaid-certified nursing homes to have an RN who is the director of nursing; at