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J Am Med Dir Assoc. 2014 Feb;15(2):102-7. doi: 10.1016/j.jamda.2013.09.003. Epub 2013 Oct 15.

Are nursing home survey deficiencies higher in facilities with greater staff turnover.

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University of Maryland School of Nursing, Baltimore, MD. Electronic address:
University of Maryland School of Nursing, Baltimore, MD.
Chung-Ang University Red Cross College of Nursing, Seoul, South Korea.



To examine CNA and licensed nurse (RN+LPN/LVN) turnover in relation to numbers of deficiencies in nursing homes.


A secondary data analysis of information from the National Nursing Home Survey (NNHS) and contemporaneous data from the Online Survey, Certification and Reporting (OSCAR) database. Data were linked by facility as the unit of analysis to determine the relationship of CNA and licensed nurse turnover on nursing home deficiencies.


The 2004 NNHS used a multistage sampling strategy to generate a final sample of 1174 nursing homes, which represent 16,100 NHs in the United States.


This study focused on the 1151 NNHS facilities with complete deficiency data.


Turnover was defined as the total CNAs/licensed nurse full-time equivalents (FTEs) who left during the preceding 3 months (full- and part-time) divided by the total FTE. NHs with high turnover were defined as those with rates above the 75th percentile (25.3% for CNA turnover and 17.9% for licensed nurse turnover) versus all other facilities. This study used selected OSCAR deficiencies from the Quality of Care, Quality of Life, and Resident Behavior categories, which are considered to be more closely related to nursing care. We defined NHs with high deficiencies as those with numbers of deficiencies above the 75th percentile versus all others. Using SUDAAN PROC RLOGIST, we included NNHS sampling design effects and examined associations of CNA/licensed nurse turnover with NH deficiencies, adjusting for staffing, skill mix, bed size, and ownership in binomial logistic regression models.


High CNA turnover was associated with high numbers of Quality of Care (OR 1.53, 95% CI 1.10-2.13), Resident Behavior (OR 1.42, 95% CI 1.03-1.97) and total selected deficiencies (OR 1.54, 95% CI 1.12-2.12). Licensed nurse turnover was significantly related to Quality of Care deficiencies (OR 2.06, 95% CI 1.50-2.82) and total selected deficiencies (OR 1.71, 95% CI 1.25-2.33). When both CNA turnover and licensed nurse turnover were included in the same model, high licensed nurse turnover was significantly associated with Quality of Care and total deficiencies, whereas CNA turnover was not associated with that category of deficiencies.


Turnover in nursing homes for both licensed nurses and CNAs is associated with quality problems as measured by deficiencies.


Nursing home; deficiency; nursing assistant; resident outcome; staffing; turnover

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