Beth Ann Appleby-Murphy was snoring when her nurse entered the room one morning.
The nurse, Emily Pratt, told Appleby-Murphy's husband, A.J., she initially left the room to give Appleby-Murphy time to sleep. But Pratt returned quickly when she realized two things — Appleby-Murphy doesn't ordinarily snore and is usually an early riser.
Turns out, Appleby-Murphy, 58, had pneumonia that was making it hard for her to breathe. Leaving her unattended could have been deadly, A.J. Murphy said.
“She saved her life,” Murphy said of Pratt, who recently left Manor Care of Cedar Rapids, a 105-bed nursing and rehabilitation center at 1940 First Ave. NE, to work at Mercy Hospital.
Quick thinking and knowledge of patients' habits develop as a caregiver spends time on the job. Many nursing home employees unfortunately don't stay long enough to learn these skills.
Iowa's nursing homes lost, on average, 41 percent of their employees each year from 2010-2012, according to data collected by the Iowa Department of Human Services and analyzed by The Gazette. Turnover for nurses was even higher with a 47 percent average annual turnover among more than 400 Iowa nursing homes that submitted data to the state.
The median turnover rate nationally for all employees in America's skilled nursing care centers in 2012 was 44 percent, according to a survey of facilities by the American Health Care Association.
Windmill Manor in Coralville had the highest turnover in the state with 162 percent average annual turnover for 2010-2012 for all staff and 185 percent for nurses only. In 2011, Windmill Manor's nursing turnover was 218 percent — which equates to losing the entire nursing staff twice in the year.
High staff turnover at nursing homes is linked to worse outcomes for residents. Infections, pressure sores and hospitalizations increase when staff members don't stay in their jobs, research shows.
Taxpayers and nursing home residents spend millions of dollars a year to pay for the hiring and training of nursing home staff that will be gone a year later.
And yet, Iowa agencies do very little analysis of the turnover numbers. The DHS report, which is 28 pages of unwieldy raw data, was not analyzed by the Iowa Department of Public Health and there's no evidence lawmakers reviewed it.
“We need to get beyond just the issuance of reports,” said John Hale, an Ankeny-based consultant on long-term care public policy. “We really need to analyze the data and see what it's telling us.”
Nursing homes in Linn and Johnson counties have higher turnover rates than the state average. The 18 local facilities that submitted data to DHS lost a median 47 percent of their total staff each year from 2010-2012.
The median nursing turnover for Linn County and Johnson County nursing homes was 55 percent for each of those three years.
ManorCare of Cedar Rapids had the lowest average annual turnover for total staff with 32 percent. The facility lost 39 percent of nurses during that period, which is also below the state average.
“I worked at three other facilities before I came here,” said Quinton Twilla, assistant director of nursing at ManorCare of Cedar Rapids. “I've never seen a place that's so well run and so patient-centered. People feel like their job matters.”
Twilla has been with ManorCare nearly five years after starting as a nursing supervisor. While the pay is similar to other Iowa nursing homes, the center provides benefits and higher pay for working weekends and evenings, he said.
Maggie Hebert, 69, of Marion, has come to ManorCare three times in recent years after joint replacement surgeries. She likes seeing familiar faces, such as Mary Ellen Dunford, who has been an occupational therapist at the center for four years.
“It means a lot to the patients to have someone who's been here a length of time,” Hebert said. “It says something good for ManorCare.”
Research shows high turnover can lead to poor care.
Patients had significantly higher rates of low-risk pressure ulcers, pain and urinary tract infections in nursing homes with high turnover among Certified Nursing Assistants (CNAs), according to a study published in the December issue of the Journal of Nursing Administration.
High CNA turnover also increased the odds of a nursing home being cited for deficiencies by 54 percent, according to a 2014 study comparing 2004 turnover and deficiency data. The results were published in February by the Journal of American Medical Directors Association.
Windmill Manor was cited 63 times from 2010-2012 — more than double any other Linn or Johnson county nursing home. The facility has been in hot water with the state several times in recent years.
In 2008, a male resident was found having sex with a female resident who suffered from Alzheimer's disease. State inspectors said the woman could not have consented to sex because of her illness.
The Iowa Board of Nursing Home Administrators fined Windmill Manor's former administrator, Steve Drobot, $1,000 in 2012 for discharging a resident without giving the family written notice or the right to appeal.
It's hard to know whether these issues are linked to high turnover at the 120-bed facility. Administrator Stacey Cremeens as did not return calls for this story.
Sue Anthony of Coralville said she's been happy with the care her father, Duane Stock, 91, has received over two years at Windmill Manor.
“Staff have been accommodating to Dad's needs,” she said.
Short staffing was the top concern for 490 CNAs surveyed in 1998 by the Iowa Caregivers Association. The not-for-profit was attempting to learn why about 80 percent of direct caregivers leave the field within the first year.
“The No. 1 reason was not enough help,” said Di Findley, association executive director. “They felt like they couldn't do a good job and would fall short.”
Fifteen years later, high turnover still is a problem and Findley said the reasons are the same.
Federal law requires Medicare- and Medicaid-certified nursing homes to have a director of nursing, a registered nurse on duty at least eight hours a day and a licensed nurse on duty the rest of the time.
But for CNAs, who provide the bulk of day-to-day care, there are no minimum staffing levels. Nursing home administrators may decide what is “sufficient staff” to maintain the “highest possible level of physical, mental and psychosocial well-being for each resident.”
Iowa's administrative rules list only a daily requirement of staff time per patient of two hours, with 24 minutes of that provided by a registered nurse or licensed practical nurse.
“When I see a report about a nursing home resident being injured or dying, it often goes back to staff not having enough training and staff turnover,” Findley said.
A Storm Lake nursing home was recently fined more than $30,000 after a resident died after striking her head on the floor when staff dropped her while trying to move her to the bed.
Staff used a sling not approved for the mechanical lift they were using to move the resident, the Iowa Department of Inspections and Appeals (DIA) reported. The administrator of North Lake Manor reported the accident was caused by “tragic human error.” One of the nurse's aides involved had been with the nursing home less than four months.
Low pay, benefits and prestige also are persistent problems for maintaining quality caregivers, Findley said.
A 2010 survey by the organization reported a median wage of $11.50, well below the median hourly wage of $14.40 for all jobs. One-in-four direct care workers at that time had no health insurance.
“People enter the field with unrealistic expectations,” Findley said. “They want to help people, but it's hard work, sad work.”
There's also perception that nursing home staffers wouldn't work there if they could find other employment.
“Being portrayed as a butt-wiper is not a very glamorous job,” Findley said.
Iowa agencies are trying to stop the churn of nursing home staff.
The state Public Health Department developed an online course called Prepare to Care that introduces students to the concepts of caring for another person. The six-hour course has been piloted at several nursing homes around the state.
The department has been working with the Caregivers Association to help nursing home workers sign up for health benefits through the Affordable Care Act, said Angie Doyle Scar, executive office of the department's Office of Healthcare Transformation.
Elder care advocates would like to see Iowa agencies pool their nursing home data to look for trends or links between seemingly-unrelated factors. For example, the number of certified beds, violations and ownership status of each nursing home tracked by the DIA could be paired with turnover numbers, Hale said.
State officials also could identify facilities that succeed in retaining quality staff and learn from them.
Keeping good employees is about hiring a good team that supports each other, ManorCare of Cedar Rapids Human Resource Director Kathy Clarahan said.
“The best thing you can do for a great nurse is to hire another great nurse,” she said. “That way when they leave at the end of the day, they can relax and know their patients are taken care of.”
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