Revisiting Nursing Homes

“Couldn’t more have been done to protect the vulnerable, especially the elderly?”

It’s a question that will haunt many in the coming months, as investigations and analyses look at the cost that COVID-19 forced nursing homes to pay.

The death toll is staggering, stunning.

The New York Times reported in May that about one-third of all U.S. COVID-19 deaths were nursing home patients, and that this particularly defenseless population continues to suffer the brunt of the pandemic. In some states, residents of long-term care facilities account for 60% to 70% of the virus’ death toll, and in Canada that number is above 80%.

“I can’t care for my mother at home,” says Annita Weiss. “I wanted to take her out immediately when the virus started up, but I didn’t have the equipment or the expertise, so I was afraid to have her transferred to my house. Thank G-d, she is doing well, but she has so many underlying health issues. … It’s terrifying to consider she’s just sitting in this festering hot spot.”

A national alarm a few months back called for quick lockdowns of nursing homes — keeping visitors out and residents in — a call that was heeded. And while those precautions may have seemed militant to many back in March, they were starting to look like child’s play come April, as many states were waking up to the realities of the virus at hand, beginning to recognize the thing was already well within its borders, its cities, its facilities.

While the pandemic has done much to highlight the fragility of human control, academic omniscience, and public policy, were there human missteps in the handling of the pandemic within senior homes? And are there sturdier steps to take moving forward?

DOH Policy

Mr. Weinman*, an administrator at a New York-based nursing home, believes the Department of Health’s directive was a significant part of the problem. “Governor Cuomo issued an executive order that a patient cannot be turned away from a facility if they are COVID-19 positive,” he says.

On March 25, the state mandated: “No resident shall be denied readmission or admission to the [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.” It went further, stating that facilities could not require a resident to be tested before being readmitted.

The rationale behind the move was that hospitals were projected to be overrun, and once elderly patients were stable, sending them back to nursing homes would free up needed beds and equipment.

“I wasn’t surprised when the directive came down,” says Mr. Heller, another New York-based nursing home administrator. “It is a patient’s right, and the law is very patient-centered regarding care. If the patient is at our facility for a certain period of time, that patient is ours. We have a lot of pressure to take care of this patient forever. In general, if patients land up in the hospital and we don’t take them back, we get agencies after us. In this case, we knew it would be the same.”

Yet in hindsight, this decision proved to be disastrous.

Even back in March, it was recognized that the mandate would lead to severe consequences. The AMDA, the Society for Post-Acute and Long-Term Care Medicine, put out a statement that “admitting patients with suspected or documented COVID-19 infection represents a clear and present danger to all of the residents of a nursing home.”

With an Associated Press report claiming that more than 4,500 residents recovering from COVID-19 were sent back to nursing homes in the state, officials are quietly or not so quietly walking back the directive, with one state assemblyman even admitting, “It was a fatal error.”

“He’s trying to wiggle his way out of this,” says Mr. Weinman, referring to how Governor Cuomo has been passing the burden of responsibility to the federal government, claiming he was simply following CDC guidelines.

In late May, during a press conference, the governor’s secretary quoted federal standards which stated: “Nursing homes should admit any individuals from hospitals where COVID is present.”

“Not could, should …” the secretary stressed. “That is President (Donald) Trump’s CMS and CDC.”

With state officials pointing fingers, federal officials pointed back. The head of the Centers for Medicare and Medicaid Services (CMS) responded by saying that facilities which followed federal infection guidelines were better able to contain the virus. “Trying to finger-point and blame the federal government is absolutely ridiculous,” she said.

Leaving the blame game behind, even Mr. Weinman, who was upset by the state mandate, acknowledges it was likely not the primary cause of the rapid spread.

“News outlets have been slamming the governor and his DOH over this, but I’m not sure it’s an honest contention,” Mr. Weinman acknowledges. “We don’t know who was bringing the virus in. It was likely staff members, and likely also COVID-positive patients being sent back here. This is New York. It’s the densest city in the U.S. We have a crowded, often-used subway system which helps the virus fester, and many of our health care workers rely on it for transportation. And once the virus is in the building, it just hops from patient to patient.”

Harvard researcher David Grabowski, who advises Congress about Medicare, points to the asymptomatic nature of COVID-19 as the most likely explanation for the deadly spread of the disease within facilities, claiming that once COVID is in a community where the staff members live, it is only a matter of time until it will enter the facility where they work.

As for the DOH’s misguided policy, it may have exacerbated the issue, but it likely didn’t cause the issue. “Was the first person to bring in the virus one of those patients returning from the hospital?” says Mr. Heller. “I don’t know. I don’t know who the first one was, to bring it through my doors.”

Personal Protective Equipment

“The state was giving priority to hospitals regarding staffing and PPE, while our facilities were brushed over,” says Mr. Weinman.

As the world began to wake up to the realization that masks and various protective gear were crucial in the fight against COVID, many institutions treating the vulnerable found themselves scrambling.

“When we were asking for equipment, we weren’t getting it,” says Mr. Weinman. “Or we were getting 12 gowns. We needed hundreds, probably thousands. We had guys walking around in garbage bags.”

Facilities like Mr. Weinman’s tried purchasing their own PPE, but that didn’t always go so smoothly.

“We ordered 10,000 gowns from a vendor. He called me up, mazel tov, the gowns landed. He had ordered 100,000. What ended up happening? They confiscated them at customs. The law the federal government was operating under was that they have access to whatever they need. Not only weren’t we getting help from the state, even our vendors were competing against the government. Here in New York they left us out to dry. There was no support.”

Other facilities and even state governments complained about the ambiguity surrounding FEMA’s (Federal Emergency Management Agency) authority to seize PPE, with shipments arriving and then federal agents stepping in to commandeer the goods.

“We weren’t prepared with enough PPE,” says Mr. Heller, although he describes governments both municipal and state as taking a more supportive role. “We had some, but not enough to make it widespread.”

His central theme — early on, there wasn’t enough awareness that PPE was the best line of defense. “By the time we gave out fully protective gear, it was too late,” he says. “We didn’t have enough from the start to cover all personnel on all floors, but back then no one was recommending that. We got some masks from the government, but not enough to have prevented what happened. The science and the government didn’t know enough at the time to tell us otherwise. At the beginning of the outbreak here it was ridiculous. One day they were telling us if a person had been in contact with someone who had been to China they should quarantine, and the next week they were telling us if you were sick but feeling better, then just come back to work!”

As for Mr. Heller’s PPE, he originally had a small supply of N95 masks, but was advised by officials to hold onto them in case the situation got worse. “We were told not to release them, but I decided to anyway. Staff kept them in paper bags in between use and reused them a few times. It was the best option we had back then.”

Mr. Weinman says they followed state and federal recommendations regarding PPE, but there was a lag between the events unfolding and the guidelines being handed down.

“When the order came out to shut the facility to visitors, we did that. When they advised we start wearing PPE, we followed. They were changing things as we went. Nobody knew! People forget that so quickly. Nobody knew. No one had COVID wings.”

And once the virus entered a facility, PPE, while helpful, was only a modest defense. “It was like walking on dry grass with a spark in your pocket.”

And…Politics

“Not for nothing, let’s remember, this is a pandemic,” Mr. Weinman says, reflecting a frustration felt by some in the nursing-home industry that there is a lot of blame being directed at them, particularly by governments that left them to flounder on their own and then began to point a finger at their failures. “During conferences, politicians were up there reading names of facilities, stressing how many had died there each day — it was a public lynching. Everyone was so busy with how many died in nursing homes. How many died in hospitals?! That’s a question too.”

Pointing at the confusion surrounding the number of COVID-19 deaths, Mr. Weinman says it felt like officials wanted every death to be a COVID death. “People in hospice who died with COVID did not die of COVID,” he stresses. “It’s almost like nobody died from heart attacks or strokes. Only COVID was a killer.”

Then there was the double standard.

“When Governor Cuomo needed ventilators, he went to the federal government,” says Mr. Weinman. “President Trump’s knee-jerk reaction was, it’s not a federal responsibility to provide them, and the governor went nuts — how can the president say that? But when he was asked why he’s not sending staff and gear to the facilities, he said, they’re private, it’s their responsibility.”

“It was a combination of factors,” says Mr. Heller, regarding the challenges nursing homes faced during the worst of the outbreak. “It was lack of PPE, lack of knowledge, depleted staff, asymptomatic cases, the state mandate regarding taking back COVID patients … it was the perfect storm, and it ravaged so many facilities.”

But both administrators report a similar and abrupt halt to the storm. “The minute it stopped, it just stopped cold,” says Mr. Heller. “It’s almost like a light switch was turned off.” Now neither facility has had a case in over a month, and staff members are tested twice a week. This includes everyone from contractors to cleaning staff to every employee.

“If, G-d forbid, this should happen again, we are now a little more prepared,” says Mr. Heller. “We’d need PPE for each staff member, and rapid tests for patients and staff members, to make sure no one is bringing it into the building.”

• • •

Annita Weiss misses her mother. She worries about her, and wonders daily if the staff is doing its utmost to protect her. “I read an article recently about high general infection rates in nursing homes, and I can’t help wondering if everyone inside the facility is really doing their utmost to safeguard the elderly.”

The U.S. Government Accountability Office (GAO) released a report in May stating: “Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic,” underscoring how nearly half of all nursing homes fell short of federal standards in infection prevention. With caregivers moving between patients who live in close quarters, it is understandable that infection is a constant threat to this population, although Mrs. Weiss contends differently: “Our society doesn’t properly value the elderly. I don’t have full confidence that each staff member goes into the facility each day trying to protect the human life before them to the utmost.” She points to the distribution of supplies as a sharp indicator. “It’s telling that the effort to fight the virus was on the hospital front line. Who gave nursing homes any attention, except to send them back sick patients? Where was the great effort to send extra staff and funds to desperately depleted nursing homes?”

While it is easy to get stuck in the analysis of policy failures and facility operations, PPE shipments and confiscations, the only thing that stands out starkly from this terrible tale is the tragic, devastating loss of life of the people we value most to connect us to the past and to inform our future, and the toll weighs heavily on all of us, even if we have not felt its impact directly.

“We did everything we could,” Mr. Heller concludes softly. “I’m sure every facility did everything they could.”