There was a point, not very long ago, when I thought I understood the staffing crisis in America’s nursing homes.
Like most people, I had heard the statistics. We don’t have enough nurses. Too few certified nursing assistants are entering the profession. Caregivers are overworked, underpaid, and burning out. An aging population needs more care than the workforce can provide.
It all made sense.
When another story surfaced about a resident suffering a preventable injury or an avoidable death, the explanation usually arrived almost immediately.
“They were short-staffed.”
I accepted that explanation because, again, it sounded reasonable.
Then I started representing families.
The more records I reviewed, the more depositions I read, and the more conversations I had with people whose parents and grandparents had been harmed inside facilities they trusted, the more uncomfortable I became with that simple explanation.
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Today, I think “they were short-staffed” ends the conversation exactly where it should begin.
Before recently joining my current firm, I served as an assistant district attorney, prosecuting cases involving sexual abuse and human trafficking. Those cases were emotionally difficult, but they also shaped the way I think.
Very quickly you learn that there are really two investigations taking place.
The first asks what happened.
The second asks something much harder.
Who allowed it to happen?
That question has followed me into every nursing home case I’ve worked on.
At first glance, these cases all seem different. One resident falls while trying to get to the bathroom alone. Another develops a devastating pressure injury. Someone else becomes severely dehydrated. A medication isn’t given. An infection isn’t recognized until it has become life-threatening. A resident wanders away unnoticed.
Different families.
Different facilities.
Different tragedies.
Yet after a while, the similarities become impossible to ignore.
Again and again, somewhere inside thousands of pages of medical records, there is a sentence that quietly explains everything.
The unit was short-staffed.
There were not enough aides available.
The nurse was responsible for too many residents.
No one responded because no one was available.
Initially, I treated those statements as explanations. Now I read them as evidence. Evidence of decisions that were made long before anyone was injured.
Businesses do not accidentally operate without enough employees for years at a time. Someone prepares a budget. Someone decides how many positions will remain vacant. Someone weighs the cost of hiring against the cost of not hiring. Someone decides whether another nurse can wait another month.
Those decisions are not made in a resident’s room.
They are made in conference rooms.
That distinction matters because language matters.
When we describe chronic understaffing as though it were a natural disaster or an unavoidable consequence of modern health care, we unintentionally remove the people responsible for creating it.
Staffing shortages sound inevitable.
Management decisions do not.
I understand there are genuine workforce challenges throughout health care. Every hospital, rehabilitation center, and nursing facility in America is competing for talented professionals. Recruiting caregivers has become harder, not easier.
But that reality cannot explain facilities that repeatedly appear in inspection reports for the very same problems over the course of years.
At some point, hopefully now, the conversation has to evolve.
If a facility repeatedly fails to provide enough caregivers to safely care for its residents, why do we continue discussing staffing instead of accountability?
Why do we accept chronic understaffing as an operational challenge instead of asking whether ownership and management have demonstrated that they are capable of safely operating the facility at all?
That may sound like an uncomfortable question, and I really think it should be.
The nursing home industry has changed dramatically over the last generation, and I don’t believe most families fully appreciate just how much.
Many facilities that still look like neighborhood nursing homes from the outside are owned through layers of corporations, management companies, real estate investment entities, and financial partnerships. The people making decisions about staffing levels may be several states away. They may never set foot inside the building. They may never know the residents whose care depends upon those decisions.
That distance changes something. It becomes easier to think about staffing as a percentage on a spreadsheet than as the difference between whether someone gets to the bathroom safely.
Whether someone is turned often enough to prevent a pressure injury.
Whether someone notices that a resident who seemed fine yesterday is suddenly becoming septic.
Whether a frightened ninety-year-old waits five minutes for help.
Or fifty.
Every nursing home neglect case involves an individual tragedy. Collectively, however, they tell a story about priorities.
The longer I practice in this area, the more convinced I become that we have spent years debating the wrong issue.
We argue about staffing ratios. We debate labor shortages. We discuss reimbursement rates.
That’s great. Those conversations matter.
But they all risk overlooking the more fundamental question.
Who is accountable when predictable understaffing predictably leads to preventable harm?
As a young lawyer, I don’t pretend to have every answer to fixing America’s nursing homes, but I do know this.
When the same explanation appears in case after case after case, it stops being an explanation.
It becomes a warning.
And when the warning is ignored long enough, it becomes a business model.
That should concern every family with a loved one in long-term care. Because our parents and grandparents deserve more than enough staff to survive. They deserve leadership that refuses to treat safe care as a budgetary decision.
Until we begin asking who is making those decisions, and why they continue to make them despite the consequences, we will keep describing preventable tragedies as staffing problems.
I don’t believe they are.
I believe they are accountability problems.
And accountability has always begun with asking the right question.
Ashley Duffy is an attorney.
