Association between nursing home staff turnover and infection control citations

Lacey Loomer, David C. Grabowski, Huizi Yu, Ashvin Gandhi

Research output: Contribution to journalArticlepeer-review

20 Scopus citations


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.

Original languageEnglish (US)
Pages (from-to)322-332
Number of pages11
JournalHealth services research
Issue number2
Early online dateSep 6 2021
StatePublished - Apr 2022

Bibliographical note

Funding Information:
Dr. Lacey Loomer reported doing past contract work for the American Health Care Association. Dr. Ashvin Gandhi reported receiving past funding from the National Institute on Aging through Grant Number T32‐AG000186 to the National Bureau of Economic Research, the National Institute of Health Care Management, the Harvard Institute for Quantitative Social Science, the Harvard Lab for Economic Applications and Policy, the UCLA Ziman Center for Real Estate, the UCLA Fink Center for Finance & Investment, and the UCLA Morrison Center for Marketing and Data Analytics. Dr. David C. Grabowski reported receiving past research support from grants from the National Institute on Aging; the Agency for Healthcare Research & Quality; the Arnold Foundation; and Warren Alpert Foundation; serving previously on the Scientific Advisory Committee for naviHealth; and receiving fees from the Medicare Payment Advisory Commission, Compass Lexecon, Analysis Group, the Research Triangle Institute, and Abt Associates. Ms. Huizi Yu reports no conflicts of interest.

Publisher Copyright:
© 2021 Health Research and Educational Trust


  • COVID19
  • employee turnover
  • health workforce
  • infection control
  • long-term care
  • nursing home

PubMed: MeSH publication types

  • Journal Article
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.


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