For nursing home operators looking to avoid complaint investigations, researchers have a resoundingly clear message: Staff retention matters just as much at the top of the managerial chain as it does on the frontlines.

Hold on to your directors of nursing and administrators as well as your nurse aides and you’ll likely face fewer consumer complaints — and have fewer of them substantiated, according to new work from the Miami University in Ohio.

A review of four different data sets across hundreds of Ohio nursing homes found that administrator and DON turnover was significantly associated with an increase in both total complaints and substantiated complaints.

Conversely, when the researchers crossed nearly 10,000 complaints against building-level data, they found higher CNA retention rates and family satisfaction scores were significantly associated with fewer total complaints and substantiated complaints. 

They also cited previous research that showed better administrator retention feeds stronger retention among CNAs.

“Leadership instability has been found to be significantly associated with high turnover of direct care workers, which influences the overall quality of care,” they wrote in a JAMDA study published online first Friday. “Similarly, NHA stability is associated with a higher CNA retention rate as well as a fewer number of deficiencies. Although the current concerns around nursing home quality will require an array of solutions, the influence of management stability is certainly critical in decreasing the number of complaints.”

The findings come as providers report increasing turnover among their leadership teams, and operators adopt new benefits, higher pay and bigger bonuses to entice them to stay in the field. The Centers for Medicare & Medicaid Services also began tracking and publicly reporting administrator turnover early in 2022. At the time, the agency said reduced administrator turnover can provide “leadership stability” and direction and may help staff “provide care more consistently or effectively to residents.”

For this study, researchers from the Miami University Department of Sociology and Gerontology and the Scripps Gerontology Center used consumer complaints as a real-time signal of care quality concerns.

They noted that, nationally, the average number of annual complaints per 100 residents rose from 3.2 to 5.2 from 2005 through 2016.

Similar to other states, Ohio saw an increase in the average number of nursing home complaints received annually from 2.6 per 100 residents in 2005 to 5.0 in 2016. The number of complaints continued to grow by 40% between 2016 and 2021.

The researchers focused on Ohio, in part, because it has the fourth-highest number of nursing home beds of any state, and owing to that, has a long-term care system with ownership and payment characteristics similar to that of the entire US system.

“Considering the rapidly increasing number of people aged 65+ across the nation, the findings of this study can [highlight] similar concerns that other states might face and help providers and policymakers take preemptive actions to improve nursing home quality,” co-author and PhD candidate Jenny Kwon told McKnight’s Long-Term Care News Tuesday.

Ohio also one of only three states in the nation that collects satisfaction data from residents and families, which was used to assess complaint trends. While it had 950 nursing homes in 2017, the analysis examined only the 629 that responded to either a state biennial survey or resident and family satisfaction surveys during the study period. 

‘A more fundamental problem’

Nursing homes with higher administrator and DON turnover were more likely to be in a group of facilities with 6 or more substantiated complaints, as were those with lower CNA retention and lower family and resident satisfaction scores. That means that not only were complaints made, but that upon investigations, state surveyors documented actual deficiencies in care.

But even when complaints were unsubstantiated, the researchers said they served “as the canary in the coal mine to suggest that something is not right in the system.”

“No industry will ever eliminate complaints, and, in fact, many argue that receiving complaints is not necessarily a bad thing as it provides evidence that consumers can exercise their voices,” the researchers wrote. “However, receiving an increasing number of complaints every year indicates a more fundamental problem that needs to be addressed.”

They recommended more state-level research to inform policymakers on the “large effects” both administrative and direct care staff turnover have on overall quality and how such factors might lead to more complaints and tax inspection resources.

“On a related note, state and federal officials are exploring staffing requirements for nursing homes to address the shortage of workers,” they added. “However, if the reimbursement rates are not addressed, mandated staffing patterns are simply unachievable as states and nursing homes will not have the funds to support such initiatives.”

Study authors were Kwon; Xiao Qiu MGS; Katherine M. Abbott, PhD, MGS; Jane K. Straker, PhD; and Robert Applebaum, PhD.