RN staffing bill set to increase minimum hours

The "Put a Registered Nurse in the Nursing Home Act" (HR 5373) was introduced July 31 to the House Committee on Ways and Means and the Committee on Energy and Commerce. Although the name of the bill may seem a little awkward, the goals are not. HR 5373 would require that each Medicaid- and/or Medicare-certified nursing home provide a registered nurse (RN) on duty 24 hours a day, seven days a week.

Current federal law requires that each nursing home have at least one RN in the facility for eight hours a day, seven days a week. In some cases, facilities can apply for a waiver and can share an RN with one or more other facilities. Often, the director of nursing functions as the RN on duty to meet the current requirements. This bill would expand these minimum staffing levels so that a direct care–focused RN would be on duty 24 hours a day.

Why is this so important? RNs are the only nursing personnel with the education and licensure to conduct head-to-toe physical assessments, interviews and record reviews in order to draw conclusions about nursing diagnoses, appropriate nursing interventions and care planning; to continuously monitor and evaluate interventions; and, finally, to lead the healthcare team in providing care for each patient. RNs are also the nursing home staff members who work directly with patients and with other medical professionals to develop plans of care that promote the patients’ highest level of health and well-being.1

The RN assessment function is especially critical when a patient has an acute episode or a flare-up of a chronic condition. When a patient experiences a decline in status during the evening or night shift and there is no RN in the facility, the assessment and coordination functions may suffer. Although the licensed practical nurse (LPN) plays a critical role in caring for patients, according to most states’ nurse practice acts, it is the responsibility of the RN to assess and coordinate patient care. Several staffing studies have shown that a higher level of RNs leads to higher quality of care for patients.2-4

A strong coalition of associations has joined together to support this initiative. One member organization that has done a lot of work on nursing home staffing issues is the National Consumer Voice for Quality Long Term Care. This summer, it rolled out a staffing campaign called Better Staffing: Key to Better Care. The resources are designed to inform consumers and providers of the importance of staffing levels in nursing homes.

For many months, representatives from member organizations of the Coalition of Geriatric Nursing Organizations (CGNO) have been working with Congress to propose this RN staffing bill. One CGNO member organization is the American Association of Nurse Assessment Coordination (AANAC). Diane Carter, president of AANAC, said she is thrilled to see this legislation move forward in Congress, stating, “With higher registered-nurse staffing, patients have fewer pressure ulcers and urinary tract infections and catheterizations. They stay out of hospitals longer. Their care improves, but it costs less. And these homes get fewer serious deficiencies from state inspectors. This is one of the most significant pieces of nursing home legislation that could impact positive patient care outcomes since the introduction of OBRA ’87 [Omnibus Budget Reconciliation Act of 1987].” OBRA ’87 mandated that nursing home staff provide care that helps patients attain and maintain their highest practical physical, mental and psychosocial well-being. Nursing homes have come a long way in 20 years, but more work is needed.

Under Carter’s direction, AANAC assessed staffing data from the OSCAR (Online Survey, Certification and Reporting) reports in 2012. Through this analysis, it was discovered that only 1,777 nursing homes reported staffing fewer than four RNs per day. This was good news. Carter determined that only 11.4 percent of facilities fail to cross that critical threshold; filling the gap is not an insurmountable task.                            

So what can you do to support this important initiative? Please contact your representatives and ask them to contact Waverly Gordon in Rep. Jan Schakowsky’s office, (205) 225-2111 or email waverly.gordon@mail.house.gov, and sign on to this bill. Additionally, contact your senators and ask them to introduce this bill in the Senate. By supporting continuous direct-care RN staffing, they will ensure that some of America’s most vulnerable citizens have the care they deserve in nursing homes. With a groundswell of public support from patients, families, and nursing home staff, we can see this bill enacted.

Judi Kulus, NHA, RN, MAT, RAC-MT, C-NE, is vice president of curriculum development for the American Association of Nurse Assessment Coordination.


  1. Castle NG, Engberg J. The influence of staffing characteristics on quality of care in nursing homes. Health Services Research. 2007;42:1822–47.
  2. Coalition of Geriatric Nursing Organizations, 2014. Available at: https://hartfordign.org/advocacy/cgno/.
  3. Harrington C, Kovner C, Mezey M, Kayser-Jones J, et al. Experts recommend minimum nurse staffing standards for nursing facilities in the United States. The Gerontologist. 2000; 40:5–16.
  4. Simmons S F, Schnelle  JF. Feeding assistance needs of long-stay nursing home residents and staff time to provide care. Journal of the American Geriatric Society. 2006;54: 919–24.

Topics: Advocacy , Articles , Executive Leadership , Facility management , Medicare/Medicaid