The coronavirus disease 2019 (COVID-19) pandemic continues to devastate US nursing homes. Adequate personal protective equipment (PPE) and staffing levels are critical to protect nursing home residents and staff. Despite the importance of these basic measures, few national data are available concerning the state of nursing homes with respect to these resources. This article presents results from a new national database containing data from 98 percent of US nursing homes. We find that more than one in five nursing homes reports a severe shortage of PPE and any shortage of staff. Rates of both staff and PPE shortages did not meaningfully improve from May to July 2020. Facilities with COVID-19 cases among residents and staff, as well as those serving more Medicaid recipients and those with lower quality scores, were more likely to report shortages. Policies aimed at providing resources to obtain additional direct care staff and PPE for these vulnerable nursing homes, particularly in areas with rising community COVID-19 case rates, are needed to reduce the national COVID-19 death toll.

5. Hopkins J. Mail-order drug delivery rises during coronavirus lockdowns. Accessed May 12, 2020. https://www.wsj.com/articles/mail-order-drugdelivery-rises-during-coronavirus-lockdowns-11589281203 6. Schmittdiel JA, Karter AJ, Dyer W, et al. The comparative effectiveness of mail order pharmacy use vs. local pharmacy use on LDL-C control in new statin users.

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Our findings suggest that while readmissions have decreased in New York State, these declines may not be directly attributable to HRRP penalties. The policy did produce significant potentially unintended effects in the form of greater postdischarge ED utilization among facilities facing proportionally larger penalties.

IMPORTANCEStaff absences and departures at nursing homes may put residents at risk and present operational challenges. OBJECTIVE To quantify changes in nursing home facility staffing during and after a severe COVID-19 outbreak. DESIGN, SETTING, AND PARTICIPANTSIn this cohort study, daily staffing payroll data were used to construct weekly measures of facility staffing, absences, departures, and use of overtime and contract staff among US nursing homes experiencing a severe COVID-19 outbreak that started between June 14, 2020, and January 1, 2021. Facility outbreaks were identified using COVID-19 case data. An event-study design with facility and week fixed effects was used to investigate the association of severe outbreaks with staffing measures.EXPOSURES Weeks since the beginning of a severe COVID-19 outbreak (4 weeks prior to 16 weeks after). MAIN OUTCOMES AND MEASURESTotal weekly staffing hours, staff counts, staff absences, departures, new hires, overtime and contract staff hours measured for all nursing staff and separately by staff type (registered nurses, licensed practical nurses, certified nursing assistants), facility selfreported staff shortages, and resident deaths. RESULTSOf the included 2967 nursing homes experiencing severe COVID-19 outbreaks, severe outbreaks were associated with a statistically significant drop in nursing staffing levels owing to elevated absences and departures. Four weeks after an outbreak's start, around when average new cases peaked, staffing hours were 2.6% (95% CI, 2.1%-3.2%) of the mean below preoutbreak levels, despite facilities taking substantial measures to bolster staffing through increased hiring and the use of contract staff and overtime. Because these measures were mostly temporary, staffing declined further in later weeks; 16 weeks after an outbreak's start, staffing hours were 5.5% (95% CI, 4.5%-6.5%) of the mean below preoutbreak levels. Staffing declines were greatest among certified nursing assistants, primarily owing to smaller increases in new hires of this staff type compared with licensed practical nurses and registered nurses. CONCLUSIONS AND RELEVANCEIn this cohort study of nursing homes experiencing severe COVID-19 outbreaks, facilities experienced considerable staffing challenges during and after outbreaks. These results suggest the need for policy action to ensure facilities' abilities to maintain adequate staffing levels during and after infectious disease outbreaks.