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How public health failed nursing homes



The unfolding tragedy in American nursing homes, where patients are dying in clusters, is another consequence of the coronavirus testing debacle.

While America wasn’t looking, family visitors, staff and other health professionals unknowingly brought the virus into long-term care facilities, spreading it among the population least likely to withstand it.

On top of that, the shortages of protective gear for health workers exacerbated the situation because nursing homes, hospices and other outpatient settings have a tough time getting scarce equipment like masks and gowns, provider groups said.

This combination of lack of preparedness, inadequate testing capacity and misunderstanding of how the virus could spread seeded death in scores of nursing homes across the country, where patients are not only dying quickly, but often without family and loved ones at their side. Nationally, at least 400 long-term care facilities had at least one resident infected as of one week ago, Centers for Disease Control and Prevention Director Robert Redfield said. That’s likely an undercount. The CDC hasn’t been formally tracking the numbers of homes, nor the number of people infected in them.

“There is an ample amount of evidence, and I think you’ve seen it again in long-term care facilities, that it’s the asymptomatic workers who are going into these facilities who are unknowingly, unwittingly potentially passing on the virus,” New Jersey’s Democratic governor, Phil Murphy, said last week. In his state, the number of long-term care facilities with infections ballooned from around 1 in 20 to 1 in 3 in the last two weeks.

One distraught nurse, who works in a South Dakota nursing home, fears she may have been a textbook case of the asymptomatic health worker. Her job is to distribute medication to each and every resident in the home. She may also have distributed the virus, according to a woman whose elderly mother lives in that home and who has seen a social media post from the nurse.

Another problem for public health experts trying to slow the virus in long-term care settings: Not all states are publicly identifying which homes have infections. In addition to the stress on families, that makes it harder to track how the virus is spreading within nursing homes, or how it hopscotches from one to another, for instance via a health care provider who works at several centers.

The intense focus on hospitals is understandable, given their central role. But Nancy Berlinger, an expert on aging at the Hastings Center, a bioethics think tank, said there’s a second simmering health care problem outside the hospital walls that needs to be addressed. “We also have to think of people in the community,” she said.

The federal government has issued several batches of instructions or guidance affecting nursing homes. Some came shortly after the first batch of nursing home deaths in Kirkland, Wash., and some more than a month later.

The Center for Medicare and Medicaid Services, which regulates nursing homes, although much of the inspection work is done by the states, is part of an administration nursing home task force that meets daily, along with the CDC and other health officials.

“CMS is using every tool at our disposal to keep nursing homes free from infection. CMS’s guidance and actions are based upon the most recent CDC recommendations informed by real-time information being gathered from experts on the ground in areas with large numbers of COVID-19 cases,” an agency official said.

CMS said on March 4 that inspections should focus on infection, not other possible infractions, unless there were serious threats like abuse. That was four days after the first coronavirus death in Kirkland was publicly reported. It took another 9 days to issue a lockdown order — on March 13.

“It was a very heavy decision to restrict the interaction between residents and their loved ones, but it was necessary to protect the lives of residents,” an agency spokesperson said.

It wasn’t until April 2 — by which time some long-term care facilities reported having dozens of sick patients and staff — that CMS recommended nursing homes separate those with Covid-19 from those who don’t have the infection, and designate separate staff to work with each group. Yet without widespread accessible testing, it’s hard to know who is infected, given that scientists now know the disease can be spread by people with no symptoms or very mild ones.

The nursing home sector has had well-documented challenges with infection control and adequate staffing over the years. The Life Care Center in Kirkland, now linked to about three dozen deaths, was cited for failing to quickly identify and manage sick residents and for lacking a much-needed back-up plan when the main clinician fell ill. It was fined more than $600,000 for its faulty response, and could be barred from Medicare and Medicaid if it doesn’t take corrective action.

But the coronavirus outbreak challenges even meticulous homes. This is one powerful virus, and the nursing home population is exquisitely vulnerable.

Long-term care usually involves conditions like dementia and physical disability. Shorter-term skilled nursing facilities focus on rehabilitation and recovery. A fast-spreading ferocious infectious disease is quite different, requiring physical isolation and other kinds of care.

The spread of the coronavirus in these settings also means trying to have difficult conversations with patients and families about end of life wishes — which is not done routinely upon nursing home admission and is particularly difficult in a crisis. But when options are carefully laid out, some patients or families decide against ventilators and intensive care for people who already have advanced illnesses and poor prognosis, several physicians and experts in end of life care said.

And while nursing homes do provide some end of life care, the respiratory symptoms from the coronavirus are difficult, said Joanne Lynn, a physician and specialist on aging policy at the Altarum Institute. “You need both skills, morphine and oxygen,” she said.

Hospices can work in nursing homes — but the lockout creates barriers to getting in. The National Hospice and Palliative Care Organization said CMS recently granted some emergency flexibility so hospice workers can use telemedicine and phone calls to help the nursing home staff care for dying patients.

But even essential personnel — nurses, therapists and others who come in and out and often work at more than one long-term care setting — can spread the disease among a population that is by definition fragile.

“We have said, and we repeat again, that our providers do not have sufficient supplies of personal protective equipment and other resources to adequately protect staff and to ensure the well-being of residents,” Katie Smith Sloan, president and CEO of LeadingAge, an association of nonprofit providers of aging services, said in a statement.

Hospitals, which do risky invasive procedures and are seeing large numbers of Covid-19 patients, are frantically trying to acquire enough gear, and they generally get priority.

By the time testing began at St. Joseph’s Senior Home in Woodbridge, N.J., two dozen residents had been infected and nurses were also calling in sick. It was particularly hard to figure out what was going on there as St. Joseph’s had both a flu outbreak and coronavirus at the same time, according to information the town provided, based on its communication with the home. To better control the infection, residents were actually transferred to a different facility. Nobody from St. Joseph’s was available to speak when POLITICO called.

It’s easy to see how the virus can spread in a nursing home. Residents eat together, and congregate together for activities. Reducing isolation, creating connection, building a more home-like setting has been the goal of elder care for years — although CMS directed nursing homes in mid-March to stop communal activities.

“Now, it’s no visitors, no communal meals,” said David Grabowski, an expert in aging and long-term care at Harvard Medical School. “It’s absolutely necessary now but by no means is it good nursing home care.”

And as state and public health officials eye where to send people who no longer need to be in the hospital but can’t go home, some have suggested using nursing homes. But given that nursing home residents are already so vulnerable to contracting severe cases, that creates a new set of problems. Some health experts have considered designating some nursing homes as for people with the virus, and some that are not. That would require quick and reliable testing. Abbott’s newly approved rapid test is not yet widely available.

Meanwhile, states and nursing homes are battling the virus, and some state officials are being transparent. Maryland, New Jersey and West Virginia, for instance, have been open about the hard truth. Despite measures to limit visitors, the infection got into nursing homes and quickly spread to, in some cases, dozens of residents.

“Now, it’s no visitors, no communal meals. It’s absolutely necessary now but by no means is it good nursing home care.”

In West Virginia, the last state to report a confirmed case, Sundale Nursing Home became the epicenter of the outbreak. Staff sent a resident with a fever to a local hospital, which then sent her back to the nursing home. Her health continued to decline; the next day, she was sent to a second hospital, which tested her March 22. She had the virus.

“At that point [March 23], we felt it necessary to start testing everybody in the facility,” said Donna Tennant, Sundale’s admissions and marketing director.

In Carroll County, Md., 77 residents and 24 staff had tested positive at Pleasant View Nursing Home as of Saturday night, and “they were following all the guidelines they were supposed to follow,” said Maggie Kunz, a health department spokesperson.

Louisiana is among the states that do public disclosure. The health department updates on its website daily the long-term care facilities with clusters, which are defined as two or more related infections. As of Sunday, 40 of 436 nursing homes reported clusters. Given the testing backlog, it could be higher.

Mississippi, whose governor has yet to invoke shelter-in-place instructions, a few days ago started reporting the number of active nursing home cases and the county in which they occur. But it doesn’t name the home. As of Sunday, there were 35 long-term care facilities with outbreaks — up from 28 on Friday.

A spokesperson for the state health department said the state is releasing the facility names to “surveillance teams and others for planning purposes,” but wasn’t aware when the first nursing home outbreak was reported. And any extra surveillance and testing doesn’t come until after a nursing home shows a positive case.

“Even one case of Covid-19 in these facilities among residents or employees is considered an outbreak,” the state’s health department website notes.