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Nov. 25, 2020 -- Coronavirus cases in the nation’s 15,600 nursing homes have reached a record high, exceeding the 10,000 mark for the first time since the pandemic started. The surges in nursing home cases mirror community spread, which has increased at an alarming pace since October in every state and Washington, D.C.

The Midwest has 47% of all nursing home COVID-19 cases, followed by the South Central region at 23%, according to a new report from the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which represents more than 14,000 nursing homes and assisted living facilities.

“Our worst fears have come true as COVID has run rampant across the country -- nursing homes have become powerless to keep it from entering our buildings. That’s because it’s spread by asymptomatic and pre-symptomatic carriers. As long as people in the general public are acting irresponsibly, we can’t stop it,” Mark Parkinson, CEO of AHCA/NCAL, said in a recent video statement.

Just one positive COVID test can shut down a nursing home. For residents, that usually means no visitors, no group activities, and spending a lot of time in their rooms. If they are exposed, they have to be quarantined in their rooms. If they are infected, they have to be isolated in a separate COVID-19 unit or ward, away from their familiar surroundings.

“For residents, this can be very traumatic and disorienting and even lead to delirium,” says Christopher Laxton, executive director of the Society for Post-Acute and Long-Term Care Medicine in Columbia, MD.

If there is a large outbreak, the entire building can be turned into a COVID building and non-COVID residents sent to other nursing homes. With the current surges, routine visits from friends or family members are not allowed, although guidance from the Centers for Medicare and Medicaid Services allows for exceptions under “compassionate care.”

“It’s a heartbreaking experience for all of them. Some of them are losing weight and have an increased risk of depression,” says Jessica Van Fleet-Green, MD, chief medical officer at Daiya Healthcare in Bellevue WA, which operates more than 60 skilled nursing facilities in the Northwest and Hawaii.

“Some of them maintained their weight because they loved having social meals with not only other residents, but their families, who would bring in home-cooked meals and sit with them. I am concerned, as we’re entering the holidays, about the increasing social stress and rates of depression among residents,” says Van Fleet-Green.

Limiting Outbreaks

Since the pandemic started, nursing homes have taken several measures to limit outbreaks. They include screening everyone who enters the facility, increased cleaning, restricting visitors, switching to virtual activities, and using telehealth for doctors’ visits.

Since August, the Centers for Medicare and Medicaid Services has required nursing homes to test staff regularly and residents if they have symptoms.

How often the tests are given depends on how many positive cases there are in the surrounding county, says Van Fleet-Green. At least nine of her company’s 34 facilities in Washington have COVID-19 cases among residents or staff, she says.

The tests are done once weekly if the county’s rate of positive cases is between 5% and 10%, and twice weekly if the county’s rate exceeds 10%, according to Van Fleet-Green.

Most nursing homes were using the PCR tests that require laboratories to process and analyze the results with turnaround times of about 48 hours.

The federal government has sent three-quarters of a million free rapid point-of-care antigen devices and associated tests to nursing homes, which can be used without labs and return results within minutes.

But survey results on testing from LeadingAge, an association of nonprofit providers of aging services, including nursing homes. released in November show over a third of providers were not using them over concerns about accuracy, among other issues.

“Some providers have gotten a single positive test from the machines and have had to shut down entirely despite being no new cases for weeks or months. There’s no leniency from the Department of Health even if PCR tests later contradict the result,” says Adam Marles, president and CEO of LeadingAge Pennsylvania in Mechanicsburg.

“While testing is important, we’re hearing reports of people getting nosebleeds and ongoing pain in nasal cavities from the more invasive PCR testing,” he says. “This is particularly traumatic for residents with dementia or cognitive impairment who don’t understand why they’re being tested.”

“When you combine isolation, the inability for family relatives to visit, and this invasive process, the staff are dealing with a series of challenges that make ensuring high quality of life more difficult than it’s ever been,” says Marles.

How the Virus Gets In

Nursing home staff have also been hit hard by the virus. Weekly cases among employees more than quadrupled, from 855 to 4,050, from late May to late October, The Associated Press reported this month.

Nursing home staff had nearly double the rates of suspected or confirmed cases of COVID-19 as residents, according to a national LeadingAge survey of its aging service providers released last week.

“In my experience, when outbreaks occur in buildings (since there is no visitation), it is most commonly when healthcare professionals ‘introduce’ it to the building. They can be physical therapists, CNAs [certified nursing assistants], nurses, physicians, and advanced practice clinicians ... and it has been related to community spread. The staff member gets it from someone in the community or someone in their immediate family, they are completely asymptomatic and then come to the building and unknowingly are contagious,” says Van Fleet-Green.

She also says recent COVID-19 cases among residents have come from emergency room visits and new admissions from the hospital. Although less frequent, “I had one widespread outbreak attributed to an outpatient appointment.”

Once the virus gets inside the building, it can spread through the ventilation system. In one of the facilities Van Fleet-Green directs, at least 10 staff members in one building tested positive in spite of practicing infection prevention techniques. “Mid-outbreak, it was discovered that not only was the staff break room small, but it also shared a ventilation system with the COVID unit. This triggered us to close the break room and use a separate location for staff meal time when they remove their PPE [personal protective equipment], particularly since eating outside was becoming more difficult in the fall.”

Some nursing homes have upgraded their ventilation systems, and others have brought in portable air scrubbers or upgraded their filters, says Van Fleet-Green.

But, “older designed buildings may have less robust ventilation systems that do not do as well during outbreaks. Staff can be doing everything perfectly, and then the outbreak spreads like wildfire. It’s the most awful, desperate feeling.”

Sharing staff between nursing homes, or even buildings within nursing homes, is common practice, but may contribute to outbreaks.

While doctors and specialists can avoid doing rounds at different facilities by using telemedicine, that is not the case for staff such as CNAs, therapists, and nurses. “We are all in agreement that it is not ideal but, unfortunately, necessary due to staffing crises,” says Van Fleet-Green.

Staffing challenges are particularly acute during COVID surges, when staff also fall ill, have conflicting work and personal/family obligations due to the pandemic, and new hires or temporary staff are in short supply, according to LeadingAge.

“I worry about staff fatigue who have been at this for so long -- we can only ask so much of people,” says Van Fleet-Green.

Parkinson, the AHCA/NCAL CEO, implored the public to be responsible around holidays, wear masks, engage in social distancing, and limit gatherings to their households.

“This is important to not just save lives in nursing homes, but to keep them open to visitors and see loved ones. Without this, the crisis will only become worse.”

Show Sources

Mark Parkinson, CEO, American Health Care Association and National Center for Assisted Living (AHCA/NCAL), Washington, D.C.

Jessica Van Fleet-Green, MD, chief medical officer, Daiya Healthcare, Bellevue, WA.

Terry Robertson, CEO, Josephine Caring Community, Stanwood, WA

Adam Marles, president and CEO, LeadingAge Pennsylvania, Mechanicsburg.

Katie Smith Sloan, president and CEO, LeadingAge, Washington, D.C.

Gregory Johnson, MD, chief medical officer, Good Samaritan Society, Sioux Falls, SD.

Christopher Laxton, executive director, Society for Post-Acute and Long-Term Care Medicine, Columbia, MD.

COVID Tracking Project: “The Long-Term Care COVID Tracker.”

U.S. Department of Health and Human Services: “Trump Administration Announces Initiative for More and Faster COVID-19 Testing in Nursing Homes.”

Centers for Medicare and Medicaid Services: “COVID-19 Nursing Home Data,” “FAQs on Nursing Home Visitation,” “Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements and Revised COVID19 Focused Survey Tool.”

LeadingAge: “As COVID-19 Death Toll Approaches 100,000 in Long-Term Care Settings, Aging Services Providers Need Immediate Congressional Relief,” “LeadingAge Releases Survey Results: Aging Services and Testing.”

Journal of the American Geriatrics Society: “Characteristics of U.S. Nursing Homes with COVID‐19 Cases.”

The Associated Press: “Nursing home COVID-19 cases rise four-fold in surge states.”

Modern Healthcare: “Nursing home COVID-19 cases rise fourfold in surge states.”

The Washington Post: Covid-19 surges back into nursing homes in coronavirus hot spots.”

American Health Care Association and National Center for Assisted Living: “Report: COVID Cases in U.S. Nursing Homes.”

HeraldNet: “Big COVID outbreak at Josephine Caring Community in Stanwood.”

Becker’s Hospital Review: “Nevada reverses block on rapid COVID-19 tests in nursing homes.”

Skilled Nursing News: “HHS Will Send 750K Abbott Point-of-Care Tests to Nursing Homes Next Week.”

CDC, National Center for Health Statistics: “Nursing Home Care.”

BusinessWire: “Jessica Van Fleet-Green Joins Daiya Healthcare as Chief Medical Officer.”

Daiya Healthcare.

Josephine Caring Community.

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