The coronavirus pandemic is a nightmare for nursing homes, their staffs, residents, and their families. While we know much less about them, the situation is likely similar for Assisted Living Facilities (ALFs) and other residential care for older adults.
As of March 30, more than 400 of 15,000 US nursing facilities had an outbreak of coronavirus—among residents, staff or both– according the Centers for Disease Control and Prevention (CDC). There are indications, however, that those reports dramatically understate the situation. Minnesota, one of the few states publicly disclosing outbreaks in care facilities, reported 42 facilities with COVID-19 on April 4. This despite a relatively low infection rate among its overall population.
It is likely that COVID-19 is far more widespread in US facilities. According to one report, 90 percent of care facilities in Belgium have reported cases.
Staff with COVID-19
McKnight’s Long-Term Care News reports that nearly half of nursing homes it surveyed reported COVID-19 related illness among staff. Those still working struggle with shortages of masks, gloves, and gowns that appear to more serious than hospitals. Most facilities still have no access to test kits for staff, patients, or residents.
The federal government has authorized facilities to hire nurse’s aides who are not yet fully certified. Those inexperienced direct care workers are being asked to work in extremely difficult circumstances. The likelihood that they will make mistakes is unfortunately high.
At the same time, facilities are losing much of their normal business. Doing rehabilitation for knee and hip replacement patients usually is a major revenue-producer. But with elective surgeries effectively banned nationwide, that business has come to a near-halt.
Residents of long-term care facilities are the most vulnerable to serious illness or death from COVID-19. Many fit the profile of those most at risk—people with underlying medical conditions such as heart or lung disease, diabetes, or compromised immune systems.
Worse, the environments in many facilities encouraged spread of the disease. Residents and staff congregated in day rooms or dining rooms. Staff moved from resident to resident, often without any protective equipment. Unrelated residents often shared rooms, especially those low-income residents on Medicaid.
Much of this has changed in recent weeks, but the damage has been done.
In an attempt to protect residents and staff from COVID-positive residents, some facilities are doing little more than using plastic sheeting to separate those who are sick from those who are not. Some operators are struggling with the once-unimaginable question of how to remove large numbers of bodies from their facilities.
Too little, too late
To prevent the spread of coronavirus, facilities have been closed to visitors for weeks, and likely will be for months to come. That means no family members, friends, or volunteers may visit. But neither can state ombudsmen who advocate for residents. The federal government has stopped routine inspections of nursing facilities so it can focus on infection control and those hardest-hit with COVID-19.
Like much of its reaction to coronavirus, the federal government’s response to the crisis in care facilities has been too little too late.
On Friday, the Centers for Medicare and Medicaid Services issued new guidance for nursing facilities responding to coronavirus. But they were little more than suggestions for the facilities and local authorities, and included no additional resources.
For example, CMS said it “urges State and local leaders to consider the needs of long term care facilities with respect to supplies of PPE [personal protective equipment] and COVID-19 tests” and says “nursing homes should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.” In the absence of masks, gloves, and gowns, what does that even mean?
It also suggested that nursing facilities separate COVID-19 patients from others by designating separate units for each group. What does a facility do if it does not the physical space or financial resources to do that? CMS could order a facility without that capacity to close, or to transfer non-COVID patients. But it does not say what it would do.
20 percent death rate
On Friday, the Associated Press reported 2,300 confirmed cases in long-term care facilities and 450 deaths—a staggering mortality rate of nearly 20 percent. Some nursing home medical directors think one-third of residents eventually could die of COVID-19 related illness.
Now, governors in New York and New Jersey are ordering skilled nursing facilities to take COVID-19 patients who are discharged from hospitals, in an effort to reduce the burden on overwhelmed hospitals. But without far more testing (and perhaps impossible) efforts to separate patients, that will only increase risks for those without the disease.
A better way, as I and several others have suggested, is to designate specific facilities in a community to take only COVID-19 positive patients.
It is fair to say the nursing homes and assisted living facilities are facing the biggest challenge in their history. So are their staffs, residents, and their families. It is likely that many facilities, as well as their patients, will not survive.