Nursing staff turnover has long been considered an important indicator of nursing home quality. However, turnover has never been reported on the Nursing Home Compare website, likely because of the lack of adequate data. On July 1, 2016, the Centers for Medicare and Medicaid Services began collecting auditable payroll-based daily staffing data for US nursing homes. We used 492 million nurse shifts from these data to calculate a novel turnover metric representing the percentage of hours of nursing staff care that turned over annually at each of 15,645 facilities. Mean and median annual turnover rates for total nursing staff were roughly 128 percent and 94 percent, respectively. Turnover rates were correlated with facility location, for-profit status, chain ownership, Medicaid patient census, and star ratings. Disseminating facilities' nursing staff turnover rates on Nursing Home Compare could provide important quality information for policy makers, payers, and consumers, and it may incentivize efforts to reduce turnover.

Objective

To describe the association between nursing home staff turnover and the presence and scope of infection control citations.

Data sources

Secondary data for all US nursing homes between March 31, 2017, through December 31, 2019 were obtained from Payroll-Based Journal (PBJ), Nursing Home Compare, and Long-Term Care: Facts on Care in the US (LTC Focus).

Study design

We estimated the association between nurse turnover and the probability of an infection control citation and the scope of the citation while controlling for nursing home fixed effects. Our turnover measure is the percent of the facility's nursing staff hours that were provided by new staff (less than 60 days of experience in the last 180 days) during the 2 weeks prior to the health inspection. We calculated turnover for all staff together and separately for registered nurses, licensed practical nurses (LPNs), and certified nursing assistants.

Data collection/extraction methods

We linked nursing homes standard inspection surveys to 650 million shifts from the PBJ data. We excluded any nursing home with incomplete or missing staffing data. Our final analytic sample included 12,550 nursing homes with 30,536 surveys.

Principal findings

Staff turnover was associated with an increased likelihood of an infection control citation (average marginal effect [AME] = 0.12 percentage points [pp]; 95% confidence interval [CI]: 0.05, 0.18). LPN (AME = 0.06 pp; 95% CI: 0.01, 0.11) turnover was conditionally associated with an infection control citation. Conditional on having at least an isolated citation for infection control, staff turnover was positively associated with receiving a citation coded as a "pattern" (AME = 0.21 pp; 95% CI: 0.10, 0.32). Conditional of having at least a pattern citation, staff turnover was positively associated with receiving a widespread citation (AME = 0.21 pp; 95% CI: 0.10, 0.32).

Conclusions

Turnover was positively associated with the probability of an infection control citation. Staff turnover should be considered an important factor related to the spread of infections within nursing homes.