Tort immunity tied to lower nursing home staffing

Clinical takeaway: Removing the threat of being sued was followed by thinner staffing, a reminder that malpractice risk may prop up staffing levels.

Malpractice law is meant to deter negligent care, but prior research has rarely found a clear link between liability exposure and how care is delivered. The COVID-19 pandemic created an unusual test. As states braced for a wave of litigation, roughly 80% abruptly granted nursing homes some form of immunity from tort liability. The staggered, patchwork rollout let researchers examine whether removing that legal pressure changed staffing, an indirect but well-validated marker of care quality.

Nursing homes covered by immunity staffed more thinly than those in states without it. Overall staff time per resident fell by a small but significant margin, and the effect grew over time rather than fading, peaking roughly a year after adoption.

The drop was not spread evenly across staff types. It landed almost entirely on certified nursing assistants (CNAs), who make up about two-thirds of clinical staff and deliver nearly all hands-on resident care. CNA time per resident fell about 2%. Registered nurse time barely moved, consistent with the fact that nursing homes must keep RNs on hand for both administrative and clinical roles regardless of liability exposure. Licensed practical nurse time also dropped, but the change was not statistically significant. The analysis covered all US nursing homes reporting to two federal staffing and quality systems from 2018 through early 2023, about 13,000 facilities.

For an individual facility, the average reduction came out to about 7.9 fewer staff hours per day, or roughly 5 minutes per resident. That sounds trivial, but for a resident who needs help cumulative aide time can matter. Lower aide staffing has been tied repeatedly to worse outcomes, and during a period when residents were already isolated and short-staffed, further cuts may have been especially harmful.

"These laws, some of which are still in effect, appear to have had the unintended consequence of reducing staffing levels," the authors wrote, by lowering incentives for administrators to find nursing staff during a period of extreme shortages. They concluded that the study "suggests that the threat of liability may contribute to quality of care even though some evidence suggests that tort suits themselves do not seem to improve care."

Source: Horwitz JR. JAMA Health Forum. 2026 Jun 1. Tort immunity and nursing home staffing