Preventing another wave of nursing homes deaths

Editor's note: COVID-19 killed tens of thousands in the Northeast, caused massive unemployment and wrecked the economy. In an ongoing series of stories, the USA TODAY Network Atlantic Group examines what the government got wrong in its response to the virus, what policies eventually worked -- and why we remain vulnerable if the coronavirus strikes harder in the fall.

Tens of thousands of American elders died because nursing homes and other adult-care facilities were unable to hold back the novel coronavirus, and New York state was in the epicenter of the crisis.

More than 6,300 residents died of confirmed or presumed COVID-19 in the state's nursing homes. Another 175 or so residents of other adult-care facilities died as well.

Those numbers do not reflect residents sickened from coronavirus who were taken to hospitals and died there. Some have estimated the hospital casualties to number in the thousands.

New York nursing homes were on guard from early March, told by state officials to follow rules that were supposed to prevent coronavirus infiltration -- a ban on visitors, health checks of employees, stepped-up cleanliness. But in most nursing homes, those measures failed.

About two-thirds of the state's 613 licensed nursing homes reported COVID-19 deaths among residents. In nine homes, the toll was 50 or greater. Others had cases among staff and residents but avoided deaths.

What failed?

How did that happen? The primary sources of coronavirus in nursing homes were the homes' own employees, the state Department of Health concluded in a recent report.

Roughly 37,500 nursing home employees -- 1 in 4 -- had tested positive for the virus by early June; 20,000 were already positive by the end of April.

About 7,000 of the infected workers were on the job in early March, when it was not yet recognized widely that people who showed no obvious symptoms of illness could still spread the virus. This was the period that the virus first invaded many nursing homes and began transmission among their highly vulnerable, and largely immobile, residents.

What went wrong: How the Northeast is preparing for a second-wave of COVID cases

The health department concluded that the peak in employee infections matched neatly with the subsequent peak in residents' deaths.

"It is likely that thousands of employees who were infected in mid-March transmitted the virus unknowingly -- through no fault of their own -- while working, which then led to resident infection," the report said.

Employees who had been exposed to the virus but showed no signs of illness were not barred by rules from coming to work early on in the pandemic; the health department blames this on the belief, since proven wrong, that asymptomatic people don't spread the virus.

The report said family members and other visitors also may have brought the virus into some nursing homes before the ban was put in place on March 13. Regulators had not instructed nursing homes to screen the health of visitors before that date.

The health department report downplayed a third source of nursing-home infections -- the transfer of patients who were stable but infected with coronavirus from hospitals to nursing homes. The state issued a directive on March 25 informing homes they could not turn away prospective residents solely because they were COVID-positive.

The directive was issued because the epidemic was peaking in New York and there was deep concern that hospitals would run out of beds. About 6,300 hospital patients with COVID-19 were sent to nursing homes under this policy, the state health department report said.

Early reporting on the issue highlighted transfers from hospitals to elder-care facilities in metropolitan New York City, though Stephen Hanse, chief executive of the New York State Health Facilities Association, said it happened in all of the state's larger cities.

Nursing home operators and advocates have complained angrily that the policy had the effect of bringing the virus into nursing homes that previously had little or none. A startup advocacy group calls this approach "eldercide."

The health department disputes this conclusion in its report, saying many of those hospital patients weren't contagious when they arrived at nursing homes and that the peak in such admissions came after the peak in infections within nursing homes.

Gov. Andrew Cuomo, while insisting the policy had not been a mistake, nonetheless rescinded it May 10.

Conduct at some nursing homes has come into question as well.

Early on, nursing homes were responsible for obtaining masks, gloves, gowns, face shields and other equipment to protect staff against the coronavirus. Some had plenty but others did not; there were many anecdotal accounts of staff who were ordered to share or re-use masks.

Later in the spring, the state and some county governments began to provide basic personal protective equipment to nursing homes, easing that problem. State health officials say they supplied 13 million pieces of PPE. Concerns were also raised about the quality and efficacy of some of the equipment supplied by the Federal Emergency Management Agency.

As well, there were reports from employees and residents' family members of nursing homes with inadequate employee health screening, poor sanitation and failure to quickly segregate residents who tested positive from other residents.

"It goes back to administration. Where were the supervisors of the workers? Were they using masks and gloves, were they changing them as they should have been between residents?" asked MaryDel Wypych, co-chair of Elder Justice, an advocacy group in Rochester. "You can't just dump it on the workers. It goes back to infection control."

What worked?

Some argue that the best-run nursing homes -- those with the highest ratings from federal and state regulators, especially in the area of infection control -- fared best.

Elder Justice studied nursing homes in Monroe County. While there were exceptions, the group found on balance that "nursing homes that were highly rated weren't reporting as many deaths as the ones that were more low rated," Wypych said.

Federal health officials also pressed this same point.

Poor ratings on infection control -- a basic regulatory requirement to prevent, identify and control communicable infections and diseases such as influenza -- seemed predictive of poor results with coronavirus.

"If there were nursing homes that already had problems with that, then it's going to be like a fire in dry grass," Wypych said, using a phrase first voiced by Gov. Andrew Cuomo to describe the virus's passage through elder-care facilities

The governor's health department, however, disagreed with the conclusion that highly rated nursing homes fared better. It said it found no correlation between deaths and quality of care as based on previous inspections.

The department's report said they saw considerable benefit from two steps the agency took after the nursing-home epidemic was in full swing -- barring employees who were exposed to the virus but asymptomatic from coming to work, and requiring universal testing of employees. To date, 1.3 million employee tests have been conducted and several thousand infected workers found, the health department said in a statement.

Wypych suggested looking at the numbers the other way around. "There are a number of nursing homes that didn't report having any deaths. What were they doing?"

Three such nursing homes are operated by UR Medicine in Rochester. They recorded infections in 10 employees but not a single one among the homes' residents.

Managers of those nursing homes said there were no silver bullets. If they've been successful at holding the coronavirus at bay, it's due to having staff that fully bought in to the need for extra precautions and then following all guidelines and best practices.

"We haven't stopped," said Elisa Chambery, executive director of one of the UR homes, Highlands Living Center. "We go over COVID infection information every day. We remind staff that as the community opens up, they have to be careful."

State health department spokesman Gary Holmes said this degree of attentiveness is now commonplace.

"There are a number best practices advanced during this pandemic response that will help these facilities prepare for a potential second wave, or beyond," he said. "The steps we've taken to implement, educate and enforce strong infection control practices have reached heightened levels of awareness and will have a lasting impact on future care."

What needs to be done better?

Several recent developments, if they come to pass, could lead to significant improvements should a second wave of coronavirus occur.

The U.S. Department of Health and Human Services Federal announced recently it will be sending testing equipment and an initial batch of test kits to every nursing home in the country for use on residents and employees. The newly developed equipment can run 20 tests an hour for viral antibodies. Should the equipment arrive and work as promised, "that would be really helpful," Hanse of the New York State Health Facilities Association said.As well, the state has now required that all providers have at least two months' supply of PPE on hand. Advocates say that if nursing homes are held to that requirement, and if the state or local governments will commit to helping replenish supplies if they run low during a second wave, that would be an advantage.

Some other ideas

The state must be more diligent with inspections to ensure nursing homes maintain their infection control programs going forward, building on federally ordered inspections underway now. "They need to enforce their regulations, using meaningful fines. If nursing homes are really bad, close them, don't just keep them open," Wypych said. "Until that happens, if we get another pandemic like this, it's going to be just as bad."

Operators must be told to use protective N-95 masks more often. Jack Caffey, national field director for the Retail, Wholesale and Department Store Union, which represents several hundred employees at nursing homes across the state, said at present, state rules require that nursing-home staff wear only surgical masks, which are considerably less protective, until an infection is confirmed in the home. "It's like waiting for a disaster to happen before you react to it," he said.

Specialized facilities for COVID-positive nursing home residents should be set up. The state arranged for several such facilities in the New York City area during the initial surge in cases. Some say it would be good to have such facilities in place throughout the state if a new wave emerges.

Dr. Joseph Nicholas, medical director of the Highlands at Brighton, another UR Medicine home, said such facilities would be especially helpful for infected residents with behavioral problems who are unable to observe distancing or wear masks, or for infected residents on ventilators or with other serious medical problems who can only be moved with careful preparation. "That would be nice to have as a backup plan," he said.

Find a way to hire and retain more staff. Numerous advocates say nursing homes staffing, already in short supply before the pandemic, is in even worse straits now. "Low staffing made New York state nursing home residents particularly vulnerable to the worst impacts of the coronavirus, both directly and through the serious neglect we have been hearing about from families," said Richard Mollot, executive director of the Long Term Care Community Coalition in New York City.

Caffey and others said employees should be given essential-worker raises as an incentive to take the risk of coming to work during the pandemic. The question is how to pay for raises. Caffey said he believes New York nursing-home operators have the financial means to raise pay levels but many have chosen not to do so.

Hanse, on the other hand, said more funding is needed to provide employees with a financial incentive to come to work. He said New York reduced Medicaid payments to homes this year, and has not joined other states in providing short-term increases in payments to help combat coronavirus.

"Those funds could be used for hazard pay, if you will, to incentivize staff to want to continue to work in long-term care," he said.

Holmes, from the health department, said the state has helped nursing homes by providing equipment and services during the pandemic, but it is unable to provide additional funding without help from Washington.

"The reality is that the state is contending with a 14% drop in revenue -- amounting to $61 billion over four years -- and we need federal funding or we will have no choice but to make permanent spending reductions," he said. "Any area where we don't reduce funding will simply mean deeper cuts in another, and we hope that our partners in long- term care will join with us in calling on the federal government to act responsibly and deliver the resources states need."

Don't forget the wider community. Nicholas said the fate of people residing in nursing homes during a second wave depends on what happens with people residing elsewhere. "There's no nursing home that could withstand a serious community outbreak," he said. "The most important thing is that it doesn't get out of control in the community."

Contact watchdog reporter Steve Orr at sorr@democratandchronicle.com or at (585) 258-2386. Follow him on Twitter at @SOrr1. This coverage is only possible with support from our readers. If you don't already have a digital subscription, please sign up today.

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