What’s in a name? The Covid-19 pandemic should force a major change in the big misnomer of long-term care institutions: Let’s stop labeling them with the term nursing — as if they provide significant medical services to the elderly, sick, and injured.
Instead, the coronavirus may lead the public to bust the myth put forward by owners and operators of nursing homes, skilled nursing facilities, assisted living centers, and other similar centers about how they treat some of the nation’s most vulnerable people, especially based on growing evidence amassing in news reports.
The care facilities knew they were not hospitals, with extensive equipment and highly trained doctors and nurses. The facilities found they often were sorely lacking gear — especially personal protective equipment. They too many times did not have the staff with the skills or training to treat already fragile residents infected with the novel coronavirus or recuperating from significant bouts with a debilitating illness. They did not have the Covid-19 tests they needed. They struggled to isolate the infected.
Still, too many of these institutions decided to “treat in place,” the Washington Post reports, citing a “mantra pushed by federal health agencies, academic researchers, and geriatric physicians who argued that hospitals are not friendly environments for the frail and elderly, and that outcomes for those transported to one can include bedsores, dehydration, infections, exhaustion and delirium.”
When Covid-19 savaged their residents, the facilities “neglected” a crucial component of the “treat in place” approach, the newspaper found:
“To treat in place requires having effective means of treatment, staff who know how to deploy that treatment, and procedures to stop the spread of infection. When the novel coronavirus pandemic struck, nursing homes did not swamp hospitals with patients. But neither did they prevent the deaths of more than 30,000 of their residents or, in many cases, even provide decent palliative care. ‘These places are not designed for a pandemic,’ said John Rowe, a professor of health policy and aging at Columbia University’s Mailman School of Public Health, and the former CEO of Aetna. The result, said Lori Popejoy, a professor at the Sinclair School of Nursing at the University of Missouri, was ‘a Stone Age response to this virus, and we thought, ‘It’s better than nothing.’”
A combination of bad decisions and awful circumstances — a deadly mix that includes too little testing, both of staff and residents, as well as a dearth of PPE, and dubious owner-operator-regulator decision making — keeps the terrible Covid-19 toll rising for nursing homes and other long-term care facilities. The Wall Street Journal reported this:
“A Wall Street Journal tally of state data compiling fatalities from Covid-19, the disease caused by the virus, underscores the virus’s heavy cost to those living in long-term-care facilities. Deaths among senior-care center staff and residents appear to represent at least 40% of the overall count of more than 116,000 U.S. fatalities related to Covid-19 as compiled [by June 16] by Johns Hopkins University.”
The Washington Post compared nearby nursing homes in Buffalo, N.Y., to see huge differences in their coronavirus responses. One home the reporters focused on adjoins a hospital and had infection control protocols developed by experts from next door. This nursing home had a few cases of the coronavirus and immediately sent them to the hospital. This is what the reporters found occurred at the Terrace View Long-Term Care Facility:
“It has 390 beds. Four of its residents were infected with the coronavirus. All were transferred to the affiliated Erie County Medical Center. (Both facilities are part of a publicly owned corporation.) One died.”
In the meantime, at the other, free-standing facility, residents and their loved ones already had struggled with owner and operator challenges before the pandemic. This home also tried to care for its residents mostly by itself, declining to hospitalize them when ill. As the newspaper found of its outcomes in dealing with the virus:
“At Absolut Care of Aurora Park, a big nursing home with 310 beds, 153 residents were found to be infected as the disease swept through one floor after another, and 61 had died as of May 31, according to the Centers for Medicare and Medicaid Services. That figure includes deaths on site and among those taken to hospitals. The owners dispute that number but did not provide their own tally.”
Reporters found that the Absolut Care facility labored to keep low-paid staff, especially as the pandemic worsened. Many of them earned so little they needed to hold multiple jobs to make ends meet. They moved from care home to care home, spreading infection. They complained abut their own health risks because they said they lacked PPE. Testing was tough to get for residents and staff. The recently installed head of the home, ordered by owners to take personal charge of a floor of Covid-19 patients, told the newspaper that “he had two nurses and three aides working for him, taking care of 56 people…” As he was also quoted:
“’I couldn’t be one R.N. for 56 people. There should be two or three of me.’ He said he was never tested for the coronavirus and was told that as long as he took his clothes off when he got home, his family — he has two young children — should be fine. ‘Not if I have it in my body,’ he said.”
How hospitals pushed coronavirus patients out to nursing homes
ProPublica, the Pulitzer Prize-winning investigative news site, reported yet more details on New York state’s panicked policy of ordering nursing homes to support overwhelmed hospitals by taking in Covid-19 patients who were discharged to them, few questions asked. This policy helped Covid-19 infections flare like a “fire through dry grass,” as ProPublica found:
“New York Gov. Andrew Cuomo and his health commissioner, Howard Zucker, had all but made such discharges mandatory. If a hospital determined a patient who needed nursing home care was medically stable, the home had to accept them, even if they had been treated for Covid-19. Moreover, the nursing home could not test any such prospective residents — those treated for Covid-19 or those hospitalized for other reasons — to see if they were newly infected or perhaps still contagious despite their treatment. It was all laid out in a formal order, effective March 25. New York was the only state in the nation that barred testing of those being placed or returning to nursing homes.
“In the weeks that followed the March 25 order, Covid-19 tore through New York state’s nursing facilities, killing more than 6,000 people — about 6% of its more than 100,000 nursing home residents. In all, as many as 4,500 Covid-19 infected patients were sent to nursing homes across the state, according to a count conducted by The Associated Press.”
New York was not alone in this approach, ProPublica found:
“States that issued orders similar to Cuomo’s recorded comparably grim outcomes. Michigan lost 5% of roughly 38,000 nursing home residents to Covid-19 since the outbreak began. New Jersey lost 12% of its more than 43,000 residents. In Florida, where such transfers were barred, just 1.6% of 73,000 nursing home residents died of the virus. California, after initially moving toward a policy like New York’s, quickly revised it. So far, it has lost 2% of its 103,000 nursing home residents.”
Cuomo, who has drawn national praise for his administration’s pandemic response, continues to push back at criticism of the since-repealed nursing home edict, which New York lawmakers want investigated and which health researchers say will be the subject of years of scrutiny.
Inspections still lagging
Critics also are having a field day, demanding to know why facility owners and operators, as well as federal and state regulators — all knowing what they know now — have not stepped up to deal with crucial safeguards for vulnerable residents like increased testing and greater availability of PPE. The news site Politico reported as of June 15 that:
“Thousands of nursing homes across the country have not been checked to see if staff are following proper procedures to prevent coronavirus transmission, a form of community spread that is responsible for more than a quarter of the nation’s Covid-19 fatalities. Only a little more than half of the nation’s nursing homes had received inspections, according to data released earlier this month, which prompted a fresh mandate from Medicare and Medicaid chief Seema Verma that states complete the checks by July 31 or risk losing federal recovery funds.”
Politico, echoing other reporting on this issue, said federal regulators effectively have pulled back on their oversight of long-term care facilities, relying instead on state officials who are receiving a stream of directives from Washington, D.C.
At the state level, however, many key staffers involved in inspections were directed to other responsibilities. Or they decided, due to PPE shortages, to ensure front-line health care workers got taken care of ahead of themselves. The state inspectors, instead, turned to distanced checks on facilities. As Politico reported:
“Some states chose to assess facilities remotely, conducting interviews over the phone and analyzing documentation, a process many experts consider inadequate. In places where state officials claimed that in-person inspections have taken place, the reports found no issues in the overwhelming majority of cases, even as Covid-19 claimed more than 31,000 deaths in nursing homes. Less than 3% of the more than 5,700 inspection surveys the federal government released this month had any infection control deficiencies, according to a report … by the Center for Medicare Advocacy, a nonprofit patient activist group. ‘It is not possible or believable that the infection control surveys accurately portray the extent of infection control deficiencies in U.S. nursing facilities,’ the report states. Noting the vast and unprecedented danger that the coronavirus presents to the elderly and people with disabilities, patient advocates described the lack of inspections as a shocking oversight. ‘If you’re not going in, you’re essentially taking the providers’ word that they’re doing a good job,’ said Richard Mollot, the executive director of the Long Term Care Community Coalition.”
This is not good. In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by abuse and neglect in nursing homes and other long-term care facilities.
As the Wall Street Journal reported, even as serious deficiencies persist in long-term care facilities’ efforts to safeguard residents, the centers slowly are reopening — notably to outraged and distressed loved ones:
“The pace of reopening elder-care facilities is uneven around the U.S., with a patchwork of rules that is frustrating some of their operators. States are trying to strike a delicate balance. Allowing more visitors heightens potential exposure to a virus that is particularly dangerous to frail seniors living in close quarters, and some facilities say protective gear can still be hard to find. On the other side, bans on family visits also carry health risks for residents, including the potential for cognitive decline, experts say.
“Many family members have grown frustrated with months of limited contact through electronic devices and closed windows, with exceptions mainly in end-of-life situations. ‘The psychological effects of isolation and not being with family and loved ones are significant,’ said Joseph Ouslander, a geriatrician who is a professor at Florida Atlantic University. ‘On the other side of the scale, you have the nightmare of someone bringing the virus into a building, and many people get sick, and some die.’”
NPR reported that families are seeing “shocking” declines in lonely, frightened, and isolated loved ones in locked-down long-term care facilities. The broadcaster’s news article also underscores this point:
“[F]amily members say that talking via FaceTime and holding up signs at windows are no substitute for the hands-on care and emotional support their visits provide. Family members often are an integral part of the care residents in nursing homes receive. They make sure meals are being eaten, clothes are being changed. They also offer invaluable emotional support. Without it, the consequences can be dire.”
That’s quite a statement in itself about institutional care for which loved ones pay on average $100,000 annually (for a single room). Owners and operators have insisted they offer safe, excellent care for the old, sick, and injured, with appropriate facilities and staffing.
Wasn’t this myth falling apart, though, after the facilities’ sketchy responses to hurricanes and wildfires? Hasn’t the coronavirus stripped away the last pretense of this empty promise? Exactly how much nursing care can a home offer, if one such trained individual is expected to care for dozens of residents, even with the well-intentioned assistance of low-paid and little-trained aides? The facilities have medical directors, of course. What is the pandemic telling us about how thin these doctors may be spread? How much better are the medical services in assisted living or skilled nursing facilities?
Regulators, lawmakers, and politicians have many questions to dig into from the Covid-19 disaster in nursing homes and long-term care facilities. Congress is asking an important one already: Why isn’t the Trump Administration delivering to the institutions — and their residents — appropriated aid that all agreed was desperately needed? We need to hold owners and operators accountable for abuse, neglect, and even criminal conduct that has allowed so many of the old, sick, and injured to be needlessly infected or killed by the coronavirus. We have much work to do.