A 60-Year Math Error May Be Causing Texas Hospitals to Understaff Nurses. Here Is What That Means for Patients.

By J.T. Borah | Texas Medical Malpractice Attorney | Texas Super Lawyer
The Borah Law Firm, PLLC — Austin, Texas
May 8, 2026
The hospital told you there were enough nurses. The paperwork said so. The administrator may have walked you through the staffing plan. But a nursing informatics specialist just published an analysis revealing something the healthcare industry has built its workforce budgets on for more than 60 years: a structural math error that systematically produces a nursing shortfall before the fiscal year even begins.

For Texas patients and their families, this is not an abstract accounting problem. It is a direct explanation for why nurses are routinely unavailable when call lights go unanswered, why patients wait too long for pain medication, why pressure injuries develop on patients who should have been repositioned, and why post-surgical complications go undetected until it is too late.

And it is relevant in a courtroom. When a Texas hospital or nursing home defends an understaffing-based malpractice claim by arguing that it met its own internal staffing targets, those targets may now be shown to rest on a calculation that has been wrong since 1960.

What Is the Nursing Staffing Calculation Error, and How Long Has It Gone Undetected?

The structural calculation error embedded in hospital nursing workforce planning since at least 1960 produces a shortfall of approximately four nurses per 100 patient-care positions before a single shift is scheduled, translating to 160 hours of unplanned missing nursing coverage every week in a mid-sized unit. The analysis was published in Becker’s Hospital Review and first reported by KFF Health News on April 30, 2026.

The analysis was published by Robert Wingo, a board-certified nursing informatics specialist and nursing economics fellow with the Commission for Nurse Reimbursement. He documented the problem across more than 30 sources spanning more than 66 years. The earliest confirmed instance traces to a 1960 monograph published by the Catholic Hospital Association. The error has since migrated into U.S. nursing finance textbooks, professional organization publications, government frameworks, and credentialing programs used across the country.

The calculation is how hospitals convert patient-care nurse needs into total full-time equivalent (“FTE) budget numbers. An FTE is the equivalent of one full-time employee. When a hospital plans for 80 patient-care nursing FTEs, it needs to add a non-productive replacement rate to account for nurses who are on paid leave, vacation, or training at any given time. The correct formula divides the patient-care FTEs by the patient-care percentage. The flawed method in widespread use instead multiplies the patient-care base by the non-productive rate and adds the result.

The difference might sound minor. It is not. At a 20 percent non-productive rate, the flawed multiply method applied to 80 patient-care FTEs produces a budget for 96 total nursing positions instead of the mathematically correct 100. That four-FTE-per-100 shortfall translates to 160 hours of coverage per week that were never planned for or funded. Scale that to a 500-FTE nursing department and the shortfall grows to 20 nursing positions translates to 800 hours of coverage per week. 

William Ward Jr., an associate professor of health finance and management at the Johns Hopkins Bloomberg School of Public Health, identified the same structural problem in his 2016 healthcare finance textbook, writing that the commonly used approach will always produce a budget with insufficient staff.

Why Does a Staffing Shortage Cause Real Harm to Real Patients?

The relationship between nurse staffing levels and patient outcomes is among the most thoroughly documented in medical research. A 2024 University of Pennsylvania study of more than 6.5 million Medicare patients found that a 10 percent reduction in registered nursing staff raised the risk of patient death by 7 percent. A landmark study published in the New England Journal of Medicine in 2011 found a significant and direct association between below-target nurse staffing and increased patient mortality across a large hospital sample.

What understaffing looks like at the bedside is familiar to anyone who has spent time with a sick family member in a Texas hospital or nursing home. Call lights that go unanswered for 30 minutes or more. Nurses apologizing as they rush between rooms. Repositioning schedules for bedbound patients that exist on paper but are skipped because there is no time. Vital sign checks that are delayed. Post-surgical patients who develop serious infections because wound assessments were missed. These failures are directly linked to inadequate nursing staffing levels and the injuries caused by them can form the basis of a Texas medical malpractice claim.

These are not random failures. They are predictable consequences of a workforce that has been systematically undercounted in budget documents for more than six decades. A facility cannot argue that its care was adequate when the staffing model it relied upon was structurally incapable of producing adequate care from the start.

How Does This Affect a Texas Hospital or Nursing Home Malpractice Case?

In Texas, the legal standard is not whether a hospital or nursing home met its own internal staffing budget. The standard is whether the care provided met the accepted standard of care for a reasonably prudent health care provider under the same or similar circumstances. Texas medical malpractice cases are governed by the Texas Medical Liability Act, Chapter 74 of the Civil Practice and Remedies Code, which requires Plaintiffs to establish the applicable standard of care, a breach of that standard, and how that breach, or those breaches, caused harm to a particular patient.

When a hospital defends an understaffing case by testifying that its nurse-to-patient ratios were within its budgeted parameters, the Wingo finding gives plaintiff experts a documented basis to challenge the adequacy of those parameters themselves. A staffing budget built on a formula that produces a structural shortfall before the year starts cannot be offered as evidence that staffing was adequate. The budget was wrong. And that mathematical wrongness translated into real and foreseeable patient harm.

In nursing home cases specifically, Texas residents are protected under both federal regulations at 42 CFR 483.25 and the parallel state requirements of Texas Health and Safety Code Chapter 242 and 26 TAC Chapter 554. These statutes require that sufficient nursing staff be present to meet each resident’s needs as identified in the care plan. A facility that budgeted incorrectly and then staffed to that incorrect budget has not met the standard simply because its headcount matched its flawed calculation.

In an understaffing case, an expert must be able to address how the staffing levels fell below the standard of care and how that shortfall caused the specific harm to the patient. The Wingo analysis provides a documented, peer-reviewed foundation for that expert opinion. You can review the nursing negligence practice page on our website for additional context on how staffing failures are evaluated in Texas cases.

What Should Texas Families Do If They Suspect Understaffing Caused Harm?

If your loved one was harmed in a Texas hospital or nursing home — whether by a pressure injury, a fall, a post-surgical complication, or a failure to respond to a worsening condition — documenting what the actual staffing looked like at the time of the injury is one of the most critical first steps in evaluating a malpractice claim. Take these steps immediately.

1. Document the timeline of the harm alongside nursing response times. If your loved one pressed a call light and a nurse did not arrive for 40 minutes, document it. If a repositioning schedule was supposed to occur every two hours and the wound assessments in the chart show gaps, request those care plan records.
2. Note specific failures at the bedside. Missed medication doses, skipped vital sign checks, unanswered calls for pain relief, and delayed wound assessments are all relevant and recoverable from facility records.
3. File a complaint with Texas Health and Human Services. The HHSC Long-Term Care Complaint Portal creates an official record and can trigger a state investigation that produces independently verified findings about staffing at the facility.
4. Contact a Texas medical malpractice attorney before accepting the facility’s account of its staffing. A hospital’s assertion that it met its budgeted staffing targets is now, in light of the Wingo analysis, a claim that deserves scrutiny rather than deference. The budget may have been wrong from the start.

We Can Help
At The Borah Law Firm, PLLC, we only handle medical malpractice cases, nothing else. As part of our practice, we represent patients and families across Texas in cases just like the ones discussed in this blog. If you believe a loved one received substandard care at a Texas hospital or nursing home, we can help you understand whether a case exists and what your options are.
Contact us today so can tell us your story.
Frequently Asked Questions
Can a Texas hospital defend a malpractice case by showing it met its own internal staffing budget?

A hospital’s compliance with its own internal staffing budget is not a complete defense to a Texas medical malpractice claim. The legal standard under the Texas Medical Liability Act is whether the care provided met the accepted standard of care, not whether the facility followed its internal policies or stayed within its budgeted parameters.

The custom and practice within an industry does not insulate a defendant if that custom itself is below the standard of reasonable care. A staffing formula documented to produce a systematic shortfall since 1960 is precisely the kind of widespread industry practice that qualified expert testimony can challenge in a Texas courtroom. The facility’s own records — scheduling software data, payroll logs, and staffing matrices — often provide the evidentiary foundation for that argument.

What types of patient harm are most commonly linked to nurse understaffing in Texas hospitals?

The most common harms linked to nurse understaffing include pressure injuries from inadequate repositioning, patient falls from delayed response to mobility needs, post-surgical complications from missed wound or vital sign assessments, medication errors from rushed drug administration, and failure to recognize and report deteriorating conditions in time to prevent serious injury or death.

Each category corresponds to a specific duty that nurses are required to perform on a scheduled, documented basis. When staffing is insufficient, those tasks are delayed or skipped. The result is patient harm that could have been prevented if an adequate number of nurses had been present and available. Texas medical malpractice law recognizes each failure type as actionable when it results from a breach of the standard of care and causes demonstrable injury.
What does Texas law require hospitals and nursing homes to provide in terms of nurse staffing?
Texas hospitals must staff at levels that are sufficient to meet each of their patient’s needs under the accepted standard of care for the clinical setting and the patient’s condition. 

Texas nursing facilities operate under both federal regulations at 42 CFR 483.25 and state requirements under Texas Health and Safety Code Chapter 242 and 26 TAC Chapter 554, which require adequate staffing to meet each resident’s individualized care plan needs.

Unfortunately, under current law, there is no single statutory nurse-to-patient ratio for Texas hospitals or nursing homes. The Biden-era federal minimum staffing rule was vacated by a Texas federal court and formally repealed in February 2026. What constitutes adequate staffing is therefore a question of expert testimony in each case, evaluated against the standard of care for the specific patient population and clinical context. The Texas Health and Human Services website provides access to inspection records and compliance history for licensed nursing facilities across Texas.
What is the deadline for filing a medical malpractice lawsuit in Texas?
In Texas, a health care liability claim must be filed within two years of the date the alleged negligence occurred, or two years from the date of death in wrongful death cases, under the Texas Medical Liability Act, Chapter 74. Missing this deadline permanently forfeits the right to sue, regardless of the strength of the evidence.

Unlike states that use a discovery rule where the clock starts when you discover the injury, Texas generally starts the clock on the date of the negligent act. For patients harmed by ongoing understaffing, determining exactly when the actionable negligence began can be legally complex. That complexity is one of the primary reasons families should consult a Texas medical malpractice attorney as soon as possible after a serious hospital or nursing home injury.

About the Author: J.T. Borah is a Texas-licensed medical malpractice attorney and Texas Super Lawyer at The Borah Law Firm, PLLC in Austin, Texas. He has testified before both the Texas House and Senate on patient safety issues and focuses exclusively on medical malpractice cases statewide.

About this article: AI writing tools assisted Mr. Borah in drafting this article. All legal analysis reflects his independent professional judgment. This article is for general informational purposes only. It is not legal advice and does not create an attorney-client relationship.

Link: https://www.beckershospitalreview.com/quality/nursing/decades-old-formula-error-may-be-causing-hospitals-to-underbudget-nursing-staff-4-notes/
KFF Health News Context: https://kffhealthnews.org/morning-briefing/friday-may-1-2026/
Federal Regulation: 42 CFR 483.25 — Quality of Care
Texas Statute: Texas Health and Safety Code Chapter 242
Texas Regulation: 26 TAC Chapter 554 — Nursing Facility Requirements