Nursing home neglect is often the result of a lack of adequate staffing, both in terms of an insufficient number of providers to meet patient care needs and in the type of providers on site. In 2010 the Affordable Care Act began requiring nursing homes to submit payroll data to Medicare so the government could see actual staffing levels at every facility. Prior to 2010, the government relied on nursing home self-reported staffing levels. The actual payroll reporting has shown overall staffing levels are lower than what nursing homes had been previously reporting.
Approximately 70% of the nursing home industry is made up of for-profit facilities. One way costs can be cut is to reduce the level of staffing overall, as well as reduce the amount of time the most skilled providers are on site. Registered nurses are the highest-trained caregivers in nursing homes and they provide direct patient care as well as supervise other nurses (LPNs, for example) and aides. Medicare mandates every facility have a registered nurse working at least eight hours every day. Even though that requirement may be met, nurses often have too many residents to care for at one time. For example, in for-profit nursing homes one registered nurse averages forty-three residents.
Medicare uses the staffing data, as well as various other sources of data, to give nursing homes star ratings. There are several categories, staffing being one, in which nursing homes are given star ratings, as well as an overall star rating. The reporting of actual payroll data resulted in Medicare lowering star ratings and giving many nursing homes one star ratings. On July 25, 2018, Medicare gave 1,387 nursing homes a one out of five-star rating because it either failed to produce payroll data to prove it met the registered nurse requirement, or the data produced proved that it did not meet the requirement for seven or more days over a three-month period.