Written by Danielle Amos

This past summer, I was fortunate enough to enroll in a certified nursing assistant (CNA) certification course and gain clinical experience in a long-term care facility. Unfortunately, the long-term care facility I was assigned to was understaffed. Most CNAs worked their eight–hour shifts, tending tirelessly to their residents, yet it still was not enough for each resident to receive adequate care. I recall some total dependent residents having mats in their hair, pressure ulcers and rashes along their fragile skin, and overall poor hygiene, which are classified as signs of neglect by the National Institute of Aging (NIA).

A major factor contributing to these rising instances of neglect is significant CNA shortages and understaffing across the United States. This has led to long-term care facilities assigning overwhelming numbers of residents to each of their CNAs in a given shift. Many state legislatures fail to mitigate the situation at hand, as their direct care staff ratio and hours per resident per day (HPRD) laws are below healthy standards or ineffective. According to Medicare.gov, HPRD refers to the “total number of hours worked by each type of staff divided by the total number of residents.” A healthy HPRD is around 3.48 for all nursing staff, and 2.48 is considered the healthy minimum for CNAs. However, some states set requirements below these healthy standards or lack specific regulations. In California, the direct care staff ratio is 16-100 residents to 1 awake staff member. In South Carolina, the minimum HPRD for CNAs is 1.63. These numbers tend to follow similar patterns across various other states in the nation that have specific ratios listed. Furthermore, laws in multiple states, such as Virginia and Texas, do not have measurable ratios or specific HPRD minimums to abide by. They are only listed under “sufficient staff” and “no minimum HPRD requirement,” which means these categories are up for interpretation and the discretion of each facility. 

While facilities can strive to hire more CNAs, retention remains a major issue. Although the CNA turnover rate has decreased slightly over the past year, studies show that the average attrition rate in 2024 was 42.34%. There are multiple reasons for the alarmingly high CNA turnover rate, including low wages, lack of respect, and burnout. In 2024, the average annual salary for CNAs was $39,530, which is around $30,000 less than the national average. With the cost of living increasing, the low wages drive many CNAs to pursue other better-paying jobs. A survey by the NAHCA found that almost 84% of former CNAs in long-term care facilities would come back to the job if they had higher wages. Lack of respect from colleagues, management, and residents is also a significant factor in the current shortage of CNAs. In the same survey, one CNA wrote, “Until society sees firsthand what CNAs do and recognizes the value we bring to patient care and experience, they will not take our jobs seriously.” Lastly, burnout not only contributes to the high turnover rate but is also a consequence of CNA shortages. Burnout often arises from the disproportionate resident-to-CNA ratio assigned by long-term care facilities. Since there is already a shortage of CNAs, the number of residents per CNA is higher. This causes the remaining CNAs to feel burnt out faster, prompting many to resign. This vicious cycle continues, leading to an unsafe number of residents being assigned to each CNA. This is shown by the NAHCA survey, which reports 35% of CNAs were assigned 15-20 residents, and 18% of CNAs cared for 25 or more residents.

CNA shortages lead to reduced quality of care and an increased risk of residents being neglected. According to a survey conducted in 2024 by The National Consumer Voice for Quality Long-Term Care, 88% of residents believed that their facility did not have enough staff to provide adequate care for all residents. The majority of respondents report a lack of timely assistance with feeding, bathing, and toileting. Throughout this survey, it is evident that many residents are being neglected. Several residents stated that there is a “lack of enough staff to handle showers for everyone,” and “some residents have not had a shower in months” due to staff shortages. Furthermore, 74% of respondents to this survey report personally experiencing neglect or knowing someone who has been neglected or hurt due to understaffing. 

CNA shortages and reduced quality of care provided to residents are widespread issues. across the nation. Ineffective state laws and high turnover rates have only exacerbated the issues of staff burnout and resident neglect in long-term care facilities. While many CNAs strive to provide high-quality care to their residents, this is unfortunately often far from feasible. These systemic issues of CNA shortages and resident neglect should not go unnoticed, and we must make improvements for both those providing and receiving care.

Edited by Lucy Zheng