April 10, 2020 -- Family members are growing more concerned about whether nursing homes can keep their elderly relatives safe from COVID-19, as nearly 150 of the homes across 27 states have at least one resident with the disease. Residents and staff at 90 Maryland nursing homes and assisted living facilities have tested positive for COVID-19, Gov. Larry Hogan (R) reported Sunday.

The scenes that played out last week at the Pleasantville Nursing Home in Carroll County, MD, were reminiscent of Kirkland Life Care Center in Seattle -- the epicenter of the outbreak in Washington state. Ninety-nine residents and staff at Pleasantville tested positive, and six residents died, leaving relatives no time to say goodbye to loved ones, according to The Washington Post.

It also highlighted the problems facing nursing homes during an outbreak. With frequent staff shortages and a lack of personal protective equipment (PPE) and oxygen tanks, nurses struggled to care for patients as their health got worse, and they quickly became overwhelmed. Hogan ordered the Maryland National Guard to step in, and their medical personnel triaged the patients and sent 42 people to nearby hospitals in several ambulances, ThePost reported.

Given that 1.3 million elderly adults live permanently in about 15,000 nursing homes nationwide, more coronavirus outbreaks are expected.

Long-term care residents in nursing homes are the most vulnerable to viral infections, including COVID-19, because they are typically 65 or older, have other medical conditions such as heart disease and diabetes, and live in a group setting. Once they’re infected, these older adults are more likely to be hospitalized, admitted to an intensive care unit, and die, according to the CDC.

Gaps in Infection Controls

Relatives should be concerned about infection control procedures at nursing homes. The Centers for Medicare and Medicaid Services (CMS) started a 3-week round of targeted infection control inspections at long-term care facilities nationwide in late March. The first wave of inspections shows that 36% of facilities did not follow proper hand-washing guidelines, and 25% failed to show proper use of personal protective equipment (PPE). “Both of these are longstanding infection control measures that all nursing homes are expected to follow per federal regulation,” says CMS Administrator Seema Verma.

Kirkland Life Care Center now faces a fine of $600,000 and risks losing its Medicare/Medicaid certification for failing to comply with federal regulations. Inspectors found the nursing home put its residents in danger by failing to rapidly identify and manage ill residents, notify the Washington Department of Health about the increasing rate of respiratory infection among residents, and develop a sufficient backup plan when the facility’s primary clinician fell ill, according to CMS. It has until September to turn things around.

Problems Preceded COVID-19

Federal and state investigators identified several infection control problems at Kirkland Life Care that resulted in 129 people testing positive: 81 residents, 34 staff members, and 14 visitors. There were 26 deaths. As of March 9, at least eight other King County skilled nursing and assisted living facilities had reported one or more confirmed COVID-19 cases.

Nursing home employees contributed to the virus spread by working when they had symptoms (coughing, a fever, or trouble breathing) and working in multiple facilities in the Puget Sound region. The staff also lacked adequate PPE and hand sanitizers to properly control and prevent infection, according to the CDC report.

Kirkland is not alone. “Unfortunately, infection control and prevention has been a longstanding challenge for nursing homes, and one the Trump administration has been working to address for quite a while,” Verma said in a March 23 news release.

A recent analysis of federal records by Kaiser Health News found that 9,697 nursing homes, or 63%, were cited for one or more infection control problems in the past two regular inspection periods, which go as far back as 2016 for some facilities. The analysis also found that staffing levels matter because there were more violations in homes with fewer nurses and aides than at facilities with higher staffing levels.

The Kirkland investigation led the CDC to recommend long-term care facilities take stronger infection measures: identify and exclude (quarantine) potentially infected staff members, restrict visitation except in end-of life situations, cancel all group activities and communal dining, and screen all residents and nonessential health care personnel for fever and respiratory symptoms.

A Challenging Time for a New York Nursing Home

New York state is now the epicenter of the coronavirus outbreak, with more than 150,000 confirmed cases. The New York Department of Health reported March 30 that more than 1,000 residents of state nursing homes were sick from the new coronavirus. Officials said nursing home residents accounted for nearly 15% of the state’s 1,218 coronavirus-related deaths at that time.

The New Jewish Home has positive cases among its residents at both of its long-term care facilities in Manhattan and Westchester, according to president and CEO Jeffrey Farber, MD.

“Given the widespread nature of the virus in New York, we are presuming that some residents and staff have the coronavirus based on their symptoms and are taking the same precautions until we can get them tested and confirm their diagnosis,” he says. These include placing residents in a private room, staff wearing PPE, and more cleaning and disinfecting of rooms and surfaces.

But people without symptoms may also be spreading the virus. The CDC now estimates that up to 25% of people with COVID-19 don’t have symptoms. A study of skilled nursing facility residents infected with COVID-19 from a health care worker showed that half were asymptomatic or pre-symptomatic when contact tracing evaluation and testing were done.

“We know that the virus can be spread from asymptomatic individuals, including staff and patients. This is what underlies the wide community spread of this pandemic, and nursing homes are no exceptions,” says Farber.

Staff members get sick, supplies run short. It’s a daily struggle, he says.

Meanwhile, staff at the New Jewish Home continue to monitor residents three or more times daily with vital sign checks, including respiratory rate and temperature, and the staff are screened at building entrances for symptoms and their temperature is checked, says Farber.

Due to the increased screening, cleaning, and other precautions, Farber is hiring more security, housekeeping, and food service personnel. He has also applied to the newly created New York medical corps for help.

“The staff are more anxious than the residents. I worry about burnout and the workforce feeling hopeless,” says Farber, who says he sees a lot of his job as working on staff morale, engagement, visibility, and appreciation. “I thank the staff for coming in and when they leave. I also greet them when they recover from illness and return to work.”

 The facility’s rabbi now sends out inspirational messages on the loudspeaker twice a day.

Since family members can no longer visit their relatives in long-term care facilities, their main concern is that they still connect with loved ones, says Farber. “They can call and speak to a nurse who says Mom’s doing well and here’s what’s happening. Or someone can arrange a FaceTime call so they can see how Mom is doing and have a conversation.”  

Where to Put COVID-19 Patients

Placing potential or confirmed COVID-19 patients has become more of a problem as hospitals prepare for the anticipated surge and want to discharge patients to nursing homes.

Although the New Jewish Home admits COVID-19 patients discharged from hospitals in the recovery phase of the illness, other nursing homes in New York have refused to admit patients unless they test negative.

New York officials recently ordered all nursing homes to admit or readmit patients who are medically stable regardless of their COVID-19 status, and other states are considering similar orders, according to the American Health Care Association.

“Who is responsible for treating COVID-19 patients shifts on a daily basis, depending on the direction coming from the CDC and state health officials. For example, last week, long-term care facilities were told to send residents to the hospital right away if they tested positive. Then last Friday, the CDC said to treat them in place due to the expected surge in hospital patients,” says Dan Stockdale, a certified nursing home administrator and consultant.

LeadingAge, which represents nonprofit aging providers nationwide, including 2,000 nursing homes, says its members want to take care of these patients, but each administrator has to decide whether the nursing home has enough resources, including workforce, PPE, supplies, and the ability to segregate infected people within the organization.

The Centers for Medicare and Medicaid Services waived requirements for nursing home participants last week so they can use areas normally reserved for activities or dining to isolate and care for COVID-19 patients. “The waivers will allow administrators to move residents into these spaces without having to go through paperwork procedures and ensure that residents stay healthy in that space,” says Janine Finck-Boyle, vice president of regulatory affairs for LeadingAge, which advocated for the waivers.

CMS also relaxed its 3-day hospital requirement for Medicare beneficiaries so they can be moved directly from the community to nursing homes and qualify for 100 days of skilled nursing, according to Finck-Boyle.

The Solution: Separate COVID-19 Units

The CDC has advised nursing homes to further limit exposure by creating COVID-19 units on separate floors or wings.

Nursing homes in Minnesota, New York, and Connecticut have partnered with local hospitals and other organizations to create these COVID-19 units. All three states have reported outbreaks of COVID-19 in several nursing homes.

A new 50-bed skilled nursing facility will open Friday in the metro Twin Cities, MN, area. It’s the result of a partnership between Allina Health, which operates 11 hospitals in Minnesota, and Presbyterian Homes and Services, which operates 31 skilled nursing and assisted living facilities in Minnesota, according to Emily Downing, MD, vice president of medical operations at Home Care Services at Allina Health.

Patients will come from hospitals and skilled nursing facilities, and the average stay is expected to be 12 days, she says. “The goal is to reduce long-term care residents’ exposure to the coronavirus and to support our hospitals’ efforts to free up capacity for the expected surge of new patients.”

The nursing homes will provide the bulk of the nursing and operational staff, and Allina will provide medical staff including doctors, nurse practitioners, infection prevention specialists, and respiratory therapists, according to Downing.

A major goal is to “prioritize PPE to this site -- so there is the right equipment for staff and that they are supported and trained in using the equipment correctly,” she says.

In New York, two dedicated COVID-19 units have opened -- one in Amherst and another in New York City, the latter a result of a partnership between RiverSpring Health and New York Presbyterian Hospital.

Meanwhile, Connecticut’s governor is working with long-term care facilities there on a medical surge plan that will involve moving some residents without COVID-19 there and creating spaces for residents who have COVID-19. Previously closed nursing homes may be reopened to serve these populations.

CDC’s Top 10 Questions to Ask Nursing Homes

1. What infections commonly occur among residents in this facility?

2. When was the last outbreak (in other words, infection spreading among residents) in this facility?

3. How does the facility communicate with residents, family, and visitors when there’s an outbreak?

4. Is the flu vaccine mandatory for all staff working in this nursing home?

5. If a staff member is sick, are they allowed to stay at home (or go home from work) without losing pay or time off?

6. How are facility staff trained to respond to questions about hand hygiene from residents and family?

7. Are residents with new diarrhea given separate toilet facilities until the cause of their diarrhea is determined and/or the diarrhea is resolved?

8. How is shared equipment (such as objects in the therapy area or common room) managed to prevent the spread of germs?

9. Does the facility have private rooms for residents who develop signs or symptoms of a potentially contagious infection, like new coughing and a fever, or new vomiting and belly pain?

10. Does the facility provide educational materials for residents and families on the these topics?

Show Sources

Jeffrey Farber, MD, president and CEO, New Jewish Home.

Dan Stockdale, certified nursing home administrator and consultant.

Janine Finck-Boyle, vice president of regulatory affairs, LeadingAge.

Emily Downing, MD, vice president of medical operations at Home Care Services at Allina Health.

CDC: “Groups at Higher Risk for Severe Illness,” “COVID-19 in a Long-Term Care Facility -- King County, Washington, February 27-March 9, 2020,” “Preparing for COVID-19: Long-term Care Facilities, Nursing Homes,” “Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19) -- Asymptomatic and Pre-Symptomatic Infection,” “Core Elements for Antibiotic Stewardship in Nursing Homes: Top 10 Infection Prevention Questions to Ask a Nursing Home’s Leaders.”

Centers for Medicare and Medicaid Services: “CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19,” “Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments,” “CMS Administrator Seema Verma’s Remarks as Prepared for Delivery: Updates on Healthcare Facility Inspections in light of COVID-19.”

The Washington Post: “Dozens of cases, and 10 deaths. Inside Maryland’s worst coronavirus outbreak.”

The Seattle Times: “Coronavirus daily news updates, April 2: What to know today about COVID-19 in the Seattle area, Washington state and the nation.”

The New York Times: “Coronavirus in the U.S.: Latest Map and Case Count.”

Kaiser Health News: “Coronavirus Stress Test: Many 5-Star Nursing Homes Have Infection-Control Lapses.”

Patch, Hamden, CT: “CT Coronavirus Updates: Some Nursing Home Patients Will Be Moved.”

The Buffalo News: “Special Covid-19 unit set up at Amherst nursing home.”

Hartford Courant: “State will pay nursing homes $35 million to cover COVID-19 costs; plans to reopen closed facility in Meriden.”

The Wall Street Journal: “More Than 1,000 Coronavirus Cases Among New York Nursing Homes.”

WCCO News Talk 830: “32 long-term care facilities have COVID-19 outbreaks in Minnesota.”

Skilled Nursing News: “CMS Bans Most Visits to Nursing Homes, Waives Three-Day Stay Rule in Coronavirus Battle.”

American Health Care Association: “Long Term Care Leaders Address State Orders on Hospital Admissions to Nursing Homes.”

LeadingAge, letter to Seema Verma, administrator, U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, March 26, 2020.

The Gerontology Institute Blog, University of Massachusetts Boston: “Institute Talk: A Conversation with Dan Reingold on Leading a Nursing Home in America’s Worst COVID-19 Hot Spot.”

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