Nursing homes across the country had less staffing in states where legislatures granted the facilities immunity from COVID-19-related lawsuits filed by patients and their families, according to findings from a new UCLA-led study.
Researchers examined data from 13,205 skilled nursing facilities; those in states with litigation immunity reduced staffing by 2.5 percent compared to facilities in states that did not pass similar protections for nursing homes. That reduction translated to an average of almost 8 hours per day of staff conducting clinical care and other duties per nursing home. The data were collected from 2018 to 2023.
“During the pandemic there was a lot of understaffing. It was even worse in these states with immunity from lawsuits,” said Jill Horwitz, an Emerita Professor of Law at the UCLA School of Law, where she began the research published June 1 in the Journal of the American Medical Association. She also is an expert on health policy and continued to work on the study at Northwestern University’s law and medical schools, where she is now based.
Researchers were surprised by the numbers, they said. “These policy changes are not associated with a defined monetary reward or fixed staffing target,” said Dr. David S. Zingmond, corresponding author and professor-in-residence at the UCLA David Geffen School of Medicine’s Division of General Internal Medicine and Health Services Research. “So the robust magnitude of change was surprising.”
Across the country, 86 percent of states enacted some kind of tort immunity for nursing homes during the pandemic. Some of the laws had an end-date and others were indefinite; 23 states had retroactive immunity covering a period before the legislation was passed. The scramble to pass legislation was sparked by an anticipated deluge of medical malpractice lawsuits alleging that negligent care caused patients to contract the virus or to die from it.
However, medical malpractice law also can help protect quality of care by deterring negligence, the authors wrote in the research that published June 1 in JAMA Health Forum.
“Relaxing medical liability results in a worse staffing environment,” Zingmond said. “Lower staffing negatively impacts care, and nursing home residents are among the most vulnerable patients.”
The study found that Certified Nursing Assistants (CNAs), who provide direct clinical care for patients, made up the primary group that saw reduced staffing. Hours worked by Registered Nurses (RNs), who often serve in administrative roles, stayed consistent in their staffing rates.
Researchers acknowledged the financial challenges and the general instability of health care staffing during COVID-19, which at nursing homes would have compromised the amount of time caregivers could devote to patients. But the numbers suggest that facilities with reduced tort exposure “may have been less likely to employ nursing staff or work to find replacements during shortages,” the authors wrote.
The study did not chronicle the clinical effects of reduced staffing, and that kind of analysis could be the next step in painting a full picture of nursing home care during the pandemic, Zingmond said.
“Nursing home staffing is a predictor of quality of care that we could not directly measure with the data used in this study,” he said. “We would like to see how these policies are related to measurable quality and clinical outcomes.”
The information analyzed was from two data systems operated by the Centers for Medicare and Medicaid Services (CMS): the Nursing Home Compare (NHC) quality initiative and the Payroll Based Journal Daily Nurse Staffing dataset.
The study was authored by: Jill R. Horwitz, PhD, JD, MPP, Northwestern University Pritzker School of Law and Feinberg School of Medicine; Dr. David S. Zingmond, UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research;
Dr. Neil S. Wenger, UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research;
David P. Powell, University of Pennsylvania Perelman School of Medicine; Dr. Jose J. Escarce, UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research; Dr. Lee A. Jennings, University of Oklahoma Health Services Center; Li-Jung Liang, UCLA David Geffen School of Medicine, Division of General Internal Medicine and Health Services Research; Punam Parikh, Kaiser Permanente Southern California
