At least 11 people have died from COVID-19 in New Orleans nursing homes in the past week, just after the deaths at a Seattle nursing home weeks ago showed the extreme danger of the virus in nursing home settings.
Nursing homes provide care for 1.3 million Americans every day in the U.S. Under normal circumstances, these residents are more vulnerable to illness because they frequently are of advanced age and have multiple chronic conditions, such as diabetes and heart disease. COVID-19 now presents a new and dangerous threat.
Residents of the Life Care Center in Kirkland, Washington, near Seattle, were among the first in the U.S. to die from COVID-19. The frightening speed with which the virus has emerged in other long-term facilities raises urgent questions: How can nursing homes protect their residents? Should they admit patients with the virus? And what should they do if a resident becomes infected? These questions require immediate answers.
As a research team, we study quality of care in long-term care. That includes disaster planning for nursing homes. Based on recent decisions made by our government, we are not certain all is being done to stop the spread of the virus within these facilities.
CDC regulations aren’t stringent enough
More than two weeks ago, the Centers for Medicare and Medicaid Services imposed strict limitations on nursing home visits, albeit with some exceptions for end-of-life situations. While these measures are undoubtedly protecting nursing home residents across the country, they have not been universally effective, as we see from the cases now erupting.
Extreme vigilance to these limitations is essential, meaning that families and friends must accept the precautions and find alternatives to communicating with those they care about, not only in nursing homes but assisted living communities and all other senior care homes. Also, every possible step must be taken to ensure that nursing home staff are not carrying the virus.
That said, there are alarming gaps in the government’s plan for protecting nursing homes. There are no requirments that nursing homes keep known or suspected COVID-19 residents in isolation rooms. Instead, the Centers for Disease Control and Prevention recommends only that they be placed in private rooms, preferably with their own bathrooms. What’s more, facilities are advised they can accept new residents diagnosed with the virus as long as they follow the prescribed CDC precautions.
These guidelines ignore the extreme risk the disease poses to other nursing home residents and staff. They also ignore the lapses, evident in many nursing homes, in adequate infection control.
A ‘clear and present danger’
Medical professionals working in long-term care are alarmed, particularly over the prospect that nursing homes will be forced to accept COVID-19 patients. A March 19 resolution from the Society for Post-Acute and Long-Term Care Medicine says the infection poses a “clear and present danger” to nursing home residents. The resolution also highlights a lack of preparedness at nursing homes to handle the “severity and complexity” of managing COVID-19 patients.
The resolution urges local, state and federal governments to establish specialized care sites for COVID-19 patients, away from nursing home residents to whom contact with the virus may well be deadly. Others have made similar recommendations.
Viral outbreaks are not new to nursing homes. Exposure to influenza and gastrointestinal illnesses such as norovirus causes a multitude of infections in these facilities every year. Regulations already require nursing homes to create and maintain their own prevention and control programs for communicable diseases. Despite that, a recent University of South Florida analysis of federal nursing home records found some disturbing statistics: Nearly 60% of nursing homes were cited at least once for inadequate infection control between 2017-19; 15% were cited multiple times. Equally disturbing is that new regulations were to include requirements for a full-time staffer in every facility with specialized training to manage the infection control program. However, this past November the Centers for Medicare and Medicaid Services delayed the regulatory training required to implement the rule.
Enabling nursing homes to operate effectively during a pandemic requires a clear-eyed understanding of their capabilities, and limitations. They are obligated to follow regulatory requirements, yet limited by reimbursement rates. While nursing homes routinely accept previously hospitalized patients for convalescence and rehab as part of their role in the health care system, the novel coronavirus presents an unprecedented challenge: The homes don’t have the equipment or staff to care for a COVID-19 level of infection.
To prevent more deaths in nursing homes, the nursing home industry must begin to aggressively advocate for their patients through increased reimbursement and resource allocation. Bottom line: These facilities urgently need more equipment, including effective facial protection and gowns and staff with the necessary infectious disease training. Alternate sites, away from uninfected patients, must be established to care for patients being treated for and recovering from COVID-19. Dedicated staffing should be established for all COVID-19 patients to minimize transmission of the virus within the facility through staff. Additional Medicare reimbursement for nursing home patients with COVID-19 would also help to defray some of the costs borne by nursing home facilities during this outbreak.
In the meantime, all of us need to remember this: Even places with the best infection control program will have difficulty caring for COVID-19 patients. Nursing homes provide skilled care for a specific, highly impaired segment of the population – but they are not hospitals. They are not designed or equipped to provide the hospital level of containment and care that COVID-19 patients require. While the Monday morning quarterbacking that will most certainly occur downstream will be imperative to prepare nursing homes for future outbreaks of COVID-19 or other such pathogens, the findings should not become fodder for punitive action against staff or management who are simply trying to do the best they can under dire circumstances.
ABOUT THE AUTHORS
Kathryn Hyer, Professor, Director Florida Policy Exchange Center on Aging, University of South Florida; David Dosa, Associate Professor of Medicine and Health Service, Brown University, and Lindsay J. Peterson, Instructor, School of Aging Studies, University of South Florida