Quality care indicators and staffing levels in a nursing facility subacute unit.

Objective: To determine whether admissions to a subacute unit in a university-affiliated nursing facility received equivalent care on weekdays as opposed to on weekends with regard to certified nursing assistant (CNA) and licensed nurse staffing levels.

Design/setting: A 6-month prospective analytical study conducted from January to July 2000. All subacute unit residents admitted to this unit were monitored for the presence of specific outcome measures that were correlated to CNA and licensed nurse staffing levels during the day shift. The setting was a 14-bed subacute unit within a 150-bed skilled nursing facility in Atlanta, GA.

Primary Outcome Measures: The quality care indicators used were measured by objective data obtained prospectively from the chart and medication administration record. The parameters monitored included medication errors, falls, presence of required daily nursing note and documentation of meals eaten. Each resident served as his or her own control for analyses conducted between Tuesdays and Thursdays (weekdays) as opposed to Saturdays and Sundays (weekends). Median staffing ratios compared the number of CNAs and licensed nurses on duty between weekdays with the number who were on duty on weekends during each resident's stay.

Results: From January until July 2000, a total of 31 residents (25 women, 6 men) were admitted to the subacute unit. Among these residents, the total of weekday and weekend 24-hour reviews was equal to 1,044 resident care days during this 6-month study. The age range of these residents was 65 to 104 years, with a mean age of 82.0 years. Median nurse staffing levels were lower on weekend than on weekday day shifts (3 vs. 4; P < 0.001). Median CNA staffing levels were also lower on weekend than on weekday day shifts (4 vs. 5; P < 0.001). A total of 12 (39%) of 31 of residents were missing a total of 22 of 1,044 total required notes. This was 2 (0.3%) of 522 for weekdays as compared with 20 (3.8%) of 522 for weekends (P < 0.001). With regard to documentation of food intake, data were omitted for 199 of 1,884 meals on weekdays as compared with 343 (18.2%) of 1,884 meals on weekends (P < 0.001). The rate for falls was 1 (0.19%) of 522 on weekdays as compared with 4 (0.77%) of 522 on weekends (P < 0.05). There was no significant difference in medication errors detected.

Conclusions: There was a significant decrease in staffing levels for both nurses and CNAs during the day shift on weekends. Increased omission of required daily nursing notes, of meal documentation and increased falls appears to be associated with lower levels of weekend staffing. There were no significant differences in medication errors during this study. Whether the lapses in documentation actually resulted in a lower level of delivered care cannot be determined at this time.