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Maria
Davila with her husband, Anthony Hernandez. She is one of numerous
patients at a Brooklyn nursing home with a highly contagious
drug-resistant infection.Credit...Jeenah Moon for The New York Times
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Maria Davila lay mute in a nursing home bed, an anguished expression fixed to her face, as her husband stroked her withered hand. Ms. Davila, 65, suffers from a long list of ailments — respiratory failure, kidney disease, high blood pressure, an irregular heartbeat — and is kept alive by a gently beeping ventilator and a feeding tube.
Doctors recently added another diagnosis to her medical chart: Candida auris, a highly contagious, drug-resistant fungus that has infected nearly 800 people since it arrived in the United States four years ago, with half of patients dying within 90 days.
At least 38 other patients at Ms. Davila’s nursing home, Palm Gardens Center for Nursing and Rehabilitation in Brooklyn, have been infected with or carry C. auris,
a germ so virulent and hard to eradicate that some facilities will not
accept patients with it. Now, as they struggle to contain the pathogen,
public health officials from cities, states and the federal government
say that skilled nursing facilities like Palm Gardens are fueling its
spread.
“They are the dark underbelly
of drug-resistant infection,” said Dr. Tom Chiller, who heads the fungal
division at the Centers for Disease Control and Prevention, speaking
about skilled nursing facilities, particularly those with ventilated
patients, but not Palm Gardens specifically.
Such nursing
homes are playing a key role in the spread in New York, where 396 people
are known to be infected and another 496 are carrying the germ without
showing symptoms, according to public health officials. In Chicago, half
of patients living on dedicated ventilator floors in the city’s skilled
nursing homes are infected with or harboring C. auris on their bodies,
said Dr. Allison Arwady, the acting commissioner of the city’s
Department of Public Health.
Much of
the blame for the rise of drug-resistant infections like C. auris, as
well as efforts to combat them, has focused on the overuse of
antibiotics in humans and livestock, and on hospital-acquired
infections. But public health experts say that nursing facilities, and
long-term hospitals, are a dangerously weak link in the health care
system, often understaffed and ill-equipped to enforce rigorous
infection control, yet continuously cycling infected patients, or those
who carry the germ, into hospitals and back again.
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The story is far bigger than one nursing home or one germ.
Drug-resistant germs of all types thrive in such settings where severely
ill and ventilated patients like Ms. Davila are prone to infection and
often take multiple antibiotics, which can spur drug resistance.
Resistant germs can then move from bed to bed, or from patient to family
or staff, and then to hospitals and the public because of lax hygiene
and poor staffing.
These
issues have also vexed long-term, acute-care hospitals, where patients
typically stay for a month or less before going to a skilled nursing
home or a different facility.
A
recent inquiry by the New York State Department of Health found that
some long-term hospitals grappling with C. auris were failing to take
basic measures, such as using disposable gowns and latex gloves, or to
post warning signs outside the rooms of infected patients. At one unnamed facility, it said, “hand sanitizers were completely absent.”
Officials at the 240-bed Palm Gardens did not respond to repeated requests for comment.
Over the past year, the number of patients who were infected with or
were carrying C. auris there grew to 38 from six, according to a nurse
there and public health officials. The tally has now fallen into the
high 20s after some patients died or moved elsewhere.
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The New York health department issued a statement in response to queries from The New York Times: “The Department of Health has made controlling the spread of C. auris a high priority and has conducted extensive training and education on infection control policies and procedures for Palm Gardens and other nursing home providers throughout this region. The health and well being of nursing home residents is our primary concern and we take complaints regarding quality of care very seriously.”
Scientific research on nursing homes and drug resistance is sparse, but some recent studies offer evidence of the problem. A study published in June
in the Journal of Clinical Infectious Diseases found that patients and
residents in long-term care settings have alarmingly high rates of
drug-resistant colonization, which means they carry the germs on their
skin or in their bodies, usually without knowing it, and can pass them
invisibly to staff members, relatives or other patients. Elderly or
severely ill people with weakened immune systems who carry the germ are
at high risk of becoming infected. (Health officials in New York state said 14 percent of those now infected started out carrying it and then developed symptoms).
The study, which focused on Southern California, found that 65 percent
of nursing home residents in that region harbored a drug-resistant germ,
as did 80 percent of residents of long-term acute-care hospitals, where
their “status is frequently unknown to the facility.” By comparison,
only 10 to 15 percent of hospital patients carried such germs, the study
found.
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Experts said the
problem is pronounced in the United States, given changing economics
that push high-risk patients out of hospitals and into skilled nursing
homes. The facilities are reimbursed at a higher rate to care for these
patients, they said, providing an economic incentive for poorly staffed or equipped facilities to care for vulnerable patients.
C. auris, which is resistant to major antifungal medications, was
first identified in 2009 in Japan and, as of July 31, had infected 796
people in the United States, largely in New York, Chicago and New
Jersey, since its arrival here in 2015, according to the C.D.C. Another 1,540 people have been identified as carrying the germ on their skin or in their bodies without showing symptoms.
C. auris up close
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But
during two recent visits to Palm Gardens by a Times reporter,
accompanying Ms. Davila’s husband as his guest, orderlies and nurses
moved in and out of her room without the required protection.
“The nurses and
janitors are just spreading this thing from room to room,” her husband,
Anthony Hernandez, said on a visit in August, shortly after a nurse, who
was wearing gloves but no mask or gown, poured liquid nourishment into
his wife’s feeding tube. During a brief interview in the lobby, Pamela
Delacuadra, the center’s director of nursing, said employees had
initially struggled with the infection-control protocols required for C. auris.
“It was overwhelming at first but with help from the health department, we’ve gotten much better,” she said.
Ms.
Davila’s medical records, reviewed by The Times, do not identify the
specific date when she got C. auris. But a chart written by a Palm
Gardens doctor in December 2018 includes a note listing her as a carrier
of the fungus. She was put in
isolation for C. auris patients, and her records subsequently referred
to her as having the infection and taking antifungal medications for it.
Palm
Gardens occupies a nondescript seven-story brick building in a
working-class neighborhood in central Brooklyn. Magenta banners promote
its dialysis center and adult day care services, as well as a
“respiratory pavilion” for patients on mechanical life support.
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Palm Gardens’s performance is poorly rated by the federal government; it received two stars, a below-average rating for staffing and overall care, from the Centers for Medicare and Medicaid Services, an agency that ranks nursing home care on a scale from one star to five. In 2018, the agency investigated
the deaths of two ventilator patients at Palm Gardens, finding that
employees had failed to turn their ventilators back on after performing
mechanical checks. The patients died within minutes of each other, the
report said.
C.M.S. declined to comment on Palm Gardens.
The ownership of Palm Gardens is controlled by someone identified as Shimon Lefkowitz, according to public filings.
Mr.
Lefkowitz did not respond to efforts to reach him through Palm Gardens.
Calls to several law firms that represent Palm Gardens in lawsuits were
not returned.
Not all Palm Gardens residents with C. auris contracted the germ there, and it is not clear how many did. One patient who died was infected at Maimonides Medical Center in Brooklyn, according to the man’s family.
A changing role in health care
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Advances in
medical technology have made it possible to prolong the lives of
desperately ill patients, while changes in Medicare reimbursement rates
created a financial incentive for the expansion of such facilities, said
Neale Mahoney, an economist at the University of Chicago who studies the industry’s growth. There are now about 400 long-term care hospitals across the country, up from about 40 in the early 1980s, he said.
Since
2012, the number of skilled nursing homes with ventilator units rose to
436 from 367 — a significant jump but still a fraction of the nation’s
15,000 nursing homes — according to C.M.S.
“Ventilator units
are the poster child, the best example of a place that has challenges,”
said Dr. Alexander Kallen, an outbreak expert at the C.D.C.
The federal government reimburses facilities for ventilator patients at significantly higher rates than for other patients, according to C.M.S. Ventilated patients can bring in $531 a day compared to $200 for a standard patient. That’s about $16,000 a month compared to $6,000.
The reimbursement rates reflect the significant care required for vulnerable patients, and the cost of equipment.
C.M.S. contends the majority of skilled nursing homes do well with staffing and overall care. Yet roughly 1,400 nursing homes received a one-star rating for staffing in 2018 from the agency.
“It
is impossible for them to do a good job with the way their staffing
is,” said Dr. Mary Hayden, a professor at Rush Medical College who
studies the rise of drug-resistant infections in health care, adding of
the challenges of curbing drug-resistant infection: “The way they’re set
up, they can’t do it.”
Ms. Davila’s path
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In
early August, after a routine blood test found her white cell count
plummeting, she was taken by ambulance to Methodist Hospital in Brooklyn
for a blood transfusion. Doctors discovered an infection and put her on
two different antibiotics. Heavy use of antibiotics, while often
necessary, can kill off the nonresistant infections and allow resistant
ones to thrive.
Her condition
stabilized after two weeks and she returned to Palm Gardens. It was one
of at least a dozen trips she had taken to the hospital since she first
arrived at Palm Gardens.
Her sharp
decline began in 2017 after pain from a suspected hernia sent her to the
hospital. A lifelong smoker, Ms. Davila had emphysema, which led to a
litany of complications and infections, according to a review of her
medical records.
Now she spends her days frozen in bed, serenaded by a Latin music radio station and the mechanical whir of her respirator.
Mr. Hernandez doubts his wife will recover. “If I can take her home to die that would be a blessing,” he said.
He
pulled the blanket higher, turned up the radio and told his wife he
loved her. Momentarily alert, she fixed her eyes on his and then
mouthed: “I love you, too.”
Benjamin Ryan contributed reporting.Nursing Homes Are a Breeding Ground for a Fatal Fungus
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