Nursing homes face continued threats in COVID-19 response

When frail, elderly residents at a Seattle-area nursing home developed coughs and fevers earlier this year, medical staff suspected they were dealing with an obvious case of influenza, but when tests came back negative it was clear that something else was happening. 

Later, the operators of the facility, which was hit with the first known outbreak of COVID-19 in a nursing home in the United States, said in an online statement that “no medical professional or health care facility was prepared to fight” what became an unprecedented health care crisis.

By the time COVID-19 had swept through Life Care Center of Kirkland,  Washington, a suburban 190-bed facility, throughout February and March, dozens of residents had succumbed and dozens of workers fell ill. 

Life Care Center of Kirkland, which declined to comment, publicly put the death toll among residents at 39 — nearly one-fourth of its beds.  The Centers for Medicare and Medicaid Services fined Life Care $611,000.

“When I heard about Kirkland … I knew what was coming,” said Dr. Michael Wasserman, Thousand Oaks, California-based president of the California Association of Long Term Medicine, who has spent three decades in geriatric medicine. 

Serving as the medical director of the Eisenberg Village nursing home in Reseda, California, he assessed the immediate future while processing the news. “This would be the worst thing that hit nursing homes in our lifetime,” he said.

Elderly patients are often more at risk to disease due to weakened immune systems and comorbidities such as heart disease and diabetes, or the effects of old age such as organ failure, according to medical literature. When those vulnerabilities are coupled with the regular needs of nursing home residents, facilities trying to cope with an easily transmittable, highly infectious disease face the “worst of all worlds,” said Dr. Terrence O’Malley, a Boston geriatrician at Massachusetts General Hospital and medical director of Marquis North End, a nursing facility.

“What happens in a nursing home is you have a group of individuals (there) because they need hands-on care,” Dr. O’Malley said. “They have functional impairments. They need help bathing and dressing and eating. They literally need somebody to help them with everything, and that is up-close and personal. That makes it hard for these people to isolate because they can’t; because they need someone to help them.”

By April nursing homes in most major cities in the United States and abroad would report deadly outbreaks. By late September, more than 55,000 nursing home residents in the United States had died, making up about one quarter of the nation’s COVID-19 deaths, according to the Centers for Medicare and Medicaid Services. 

The problems that arose with the novel coronavirus were “all things that nursing homes have struggled with prior to COVID” when dealing with infectious disease outbreaks, said Priya Chidambaram, a Washington-based policy analyst with Kaiser Family Foundation’s Program on Medicaid and the Uninsured. 

In her analysis, Ms. Chidambaram found that one in three nursing homes nationwide in recent years reported either a staffing shortage or a lack of enough personal protective equipment, which are all issues that were highlighted during the pandemic. 

Money is a factor, said Dr. Wasserman, who once served as the CEO of Los Angeles-based Rockport Healthcare Services, one of California’s largest nursing home conglomerates, and has long called for reforms to the industry, including more money for safety equipment and more staff, such as a designated disease management specialist.

COVID-19 “is a wake-up call for the industry” in terms of risk management, he said, noting, however, that narrow profit margins keep nursing homes unprepared. 

“Prior to COVID we were looking at between 40% to 50% of facilities experiencing infection control-related deficiencies. … That can be anything from staff not washing their hands to cross-contamination of equipment to not using PPE,” Ms. Chidambaram said. “Nursing homes hit early in the pandemic weren’t ready for something that was quite this aggressive as coronavirus.” 

By late summer, the spread of infections in nursing homes slowed and experts say a quick deployment of materials, new rules that included quarantining the sick and isolating vulnerable patients, and expanded testing for the virus have helped. 

But some are wary of the coming flu season, as those at risk for severe reactions to COVID-19 are also at highest risk for complications from the flu. According to the Centers for Disease Control and Prevention, 70% to 85% of seasonal flu-related deaths are among people 65 and older. Outbreaks of flu in nursing homes are common, according to Ms. Chidambaram. 

Public health officials in several cities are warning of the possibility of a “twindemic,” where the usual flu outbreaks will exacerbate the strain on resources as COVID-19 cases continue to climb in the fall. 

“We’re going into the winter months and what comes with winter is flu season, so our facilities are really focusing on the effectiveness of infection control,” said Alex Burton, Birmingham, Alabama-based managing director of Arthur J. Gallagher & Co.’s senior living practice. 

Best practices include requiring the flu vaccine for both workers and residents, adequate testing for both types of virus, the availability of sufficient staff in case workers get sick, designating areas for sick patients and providing adequate personal protective equipment, according to experts. Mr. Burton said hiring a full-time infectious disease “preventionalist” to oversee a facility’s plan is an essential step.

Of all the measures, Dr. Wasserman and Dr. O’Malley said regular testing of staff and anyone who has access to a nursing facility, many of whom can carry the COVID-19 virus while being asymptomatic, will be a top strategy. 

“What needs to happen is that facilities have to set up procedures whereby they can rapidly identify anyone who comes into their building who is COVID-19 positive,” said Dr. O’Malley. Workers at the facility he works at in Boston are tested weekly, and visitors are treated cautiously, he said.

“You have to limit who can come into your facility, and that includes contractors, clinical staff, families and patients from other facilities,” Dr. O’Malley said. 

“Very limited visitation” has been among the most effective policies put in place at facilities nationwide, said Joanne Wankmiller, Philadelphia-based managing director and U.S. senior care practice leader for Marsh LLC. “By and large long-term care (facilities) are not open to visitors,” she said. 

Availability of personal protective equipment is also a top concern. Assessments of whether adequate protective gear is available are mixed: Some nursing care and risk management experts say it hasn’t been an issue in the months since the outbreak and some — including a number of state and national nurses unions — say equipment shortages are a safety concern. 

Nationwide, from April 20 to Sept. 22, the U.S. Occupational Safety and Health Administration tallied 377 workplace safety complaints from nursing home workers, although the federal data does not break down complaints by alleged violation. As of September, numerous health care organizations in several states were facing fines in the tens of thousands of dollars for not having enough respiratory protection for health care workers.

Liz Spink, St. Louis-based health care practice leader for Lockton Cos., said nursing home operators are diversifying their suppliers of personal protective equipment to ensure they don’t face shortages. Having backup suppliers will be essential, she said. 

Lainie Dorneker, Miami-based president of IronHealth, a subsidiary of Liberty Mutual Insurance Co., is confident that nursing homes are better prepared for flu season than in recent years because of the focus on COVID-19. 

And lower numbers of nursing home COVID-19 patients in the summer and into September indicate that “the infection control measures are working,” she said.

One hole in strategies to prevent COVID-19 outbreaks could be employee burnout, said Dr. Benjamin Miller, a Chattanooga, Tennessee-based psychologist and chief strategy officer for Well Being Trust, a national foundation that provides resources on workplace mental health. 

“With health care workers, more than half of workers experience burnout,” he said, citing recent medical literature. “COVID hits and it exacerbates the problem. It’s hard to sustain that type of go-go-go.”

“Health care workers have spent the last six to seven months in absolute crisis,” said Jeff Duncan, Boston-based senior vice president and chief underwriting officer in the health care practice of Liberty Mutual. “Nursing home staff have seen themselves as the last lines of defense; this trench warfare can weigh on anybody’s mind.” The result is “alarm fatigue and procedure fatigue,” he said. 

The risks of fatigue include lax safety practices that sometimes are not intentional, Dr. Miller said. “You stop seeing to all the details that you saw to before because you are so overwhelmed yourself.” 

Dr. Miller’s advice is for organizations to “own it,” admit there could be a problem and then provide employees resources for mental health. “There’s a lot of trauma that is coming from long-term care facilities especially,” he said. “Sometimes the helpers in these situations need the most help themselves.”