Nursing homes are a perfect-storm environment for the coronavirus, pairing residents at greater risk of serious illness with facilities that may be ill-equipped to prevent the spread of infection within their walls and beyond.
Seventy-five
percent of U.S. nursing homes have been cited for failing to properly
monitor and control infections in the last three years — a higher
proportion than previously known, according to a USA TODAY analysis of
federal inspection data. Those citations have been as mild as a
paperwork problem, and as serious as a nursing home not telling state
officials about an outbreak as unmonitored workers spread disease to
patients.
In each case, the citation is a
warning signal for practices and shortcomings that could become crucial
factors in an outbreak both inside and outside the facility. North
Carolina’s governor has said the state’s first coronavirus case came through Washington state, where the virus has devastated the Life Care Center in Kirkland.
Failed infection control means nursing homes can spread the new coronavirus,
also known as COVID-19, far beyond their walls, said Charlene
Harrington, a professor emeritus of nursing at the University of
California, San Francisco.
"Nursing homes are
viewed only as a problem to residents and maybe the staff, but in this
case you can see it can affect the entire community," she said. “Poor
care in one nursing home becomes an epicenter for the entire community.”
Underscoring the link between infection control
and the spread of the coronavirus, on Wednesday the Centers for Medicare
& Medicaid Services announced that its inspections would focus
solely on issues related to controlling infection and other serious
health and safety threats, such as allegations of abuse — beginning with
nursing homes and hospitals.
The agency made that shift effective immediately, allowing inspectors to focus on addressing the spread of COVID-19.
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Nikia
Wilson's mother has been in a Santa Monica, California nursing home for
just over a year, where she's suffered repeated bouts of scabies, a
skin infestation caused by microscopic mites, and other care-related
problems.
“God forbid anything such as
coronavirus reached that facility,” Wilson said. “You know, I don’t
think that they’ll do a good job in preventing the spread.”
Dr. David Gifford, who represents the nation’s
nursing homes as chief medical officer at the American Health Care
Association, cautioned that the vast majority of citations do not relate
to situations that have caused significant harm. He said inspectors
catch most issues early enough that facilities can address them before
anyone is hurt.
“It’s always helpful when the
federal surveyors come in and identify areas that could be better on
infection control,” Gifford said. “What the public needs to know is… if
they aren’t corrected, the regulations require (the government) to shut
the nursing home down within six months.”
‘An infection-rich environment’
The Life Care Center, which U.S. authorities believe to be the site of the first outbreak in a long-term facility, received a five-star overall rating by federal regulators but previously had been criticized for its infection control procedures.
Federal
regulators assign points for violations — no points at all for the most
benign infractions that affect few people, many points for violations
that threaten lives or are widespread. U.S. nursing homes averaged about
10 points over three years, the USA TODAY analysis shows. Life Care
Center’s single violation last year accounted for 16 points. It had
received no infection control citations in the previous two years.
The 2019 inspection report described a resident’s daughter saying her mother’s open heel wound often touched the ground while nurses were working. Inspectors found other basic problems at Life Care, such as kitchen staff not properly washing their hands or changing gloves, federal records state.
After the recent COVID-19 outbreak, the Life Care Center said
it implemented infection control recommendations from the Centers for
Disease Control and Prevention and from state and local health
departments. The facility also said it is limiting visitors, monitoring
residents and employees, and asking staff to stay home if they are sick.
“The
coronavirus in long-term care facilities is a horrible example of a
perfect storm,” said attorney Steven Levin, of Levin & Perconti in
Chicago, a practice focused on representing nursing home residents and
their families. “In my opinion, the nursing homes that we deal with have
extreme difficulty in handling everyday infections, and it’s an
infection-rich environment.”
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About 26.8 percent of nursing homes have received at least as many violation points as Life Care Center in the past three years, USA TODAY’s analysis shows. And thousands of nursing homes — more than 15 percent of them — were cited for individual problems at least as bad as those at Life Care. About 1 percent had problems that were worse.
The
worst over the three-year analyzed period was The Westbury Place in
Houston, cited for two 8-point violations and two 150-point violations.
Among failures cited: Not using sterile equipment for tracheotomy care;
not keeping patients in isolation when they had the hard-to-cure
infection known as MRSA; and not properly cleaning a catheterized
patient for five days.
More common were the
types of mistakes at Wheat State Manor in Whitewater, Kansas, which
accumulated 64 points from federal inspectors. In one inspection, an
employee checked a patient for incontinence, cleaned up another
patient's incontinence, helped both patients move into chairs and then
left — all without washing hands between patients or after the work was
done. Regulators said that kind of infection control problem affected
many residents, but caused little actual harm.
Wheat
State Manor was one of more than 300 nursing homes that racked up four
citations for infection control problems over the three years. Six
nursing homes had seven violations each: Lakeview Terrace, York
Healthcare & Wellness Center, and Country Villa Rehabilitation
Center, all in Los Angeles; Champaign Urbana Nursing and Rehab in Savoy,
Illinois; Aperion Care Forest Park in Forest Park, Illinois; and The
Enclave in San Antonio.
All accumulated more points than the Life Care Center.
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One inspection report for Lakeview Terrace ran 28 pages. Among the problems: A worker who may have been infectious handed out food trays. Workers there weren’t washing their hands before helping someone with a drug-resistant infection, and then didn’t wash their hands before going on to help other patients.
One inspection report for Lakeview Terrace ran 28 pages. Among the problems: A worker who may have been infectious handed out food trays. Workers there weren’t washing their hands before helping someone with a drug-resistant infection, and then didn’t wash their hands before going on to help other patients.
Family trusts facility, but later sues
 |
| Felicia Jefferson Wilson |
Felicia
Jefferson Wilson could not speak or make her own decisions, and she
needed help with all basic tasks, such as moving, eating and personal
hygiene.
The family hoped Jefferson Wilson’s
condition would improve. Instead, Nikia Wilson said the facility left
her mother unsupervised and lying in her own feces, failed to prevent
her mother’s pressure sore from becoming so deep it exposed bone and
failed to prevent her from repeatedly contracting scabies, according to
interviews and court records.
The facility,
which accumulated 40 points from infection inspections, has denied any
wrongdoing in response to a suit Nikia Wilson has filed on behalf of her
mother.
Her attorney, Ben Yeroushalmi, said
people could be vulnerable to the coronavirus in even the best
facilities, but that danger is exacerbated at those with a pattern of
problems.
“The concern about the spread of the
coronavirus or any infection is particularly more concerning in
poor-performing facilities that have a history of quality problems,
understaffing and a culture of poor infection control,” he said.
In
court records, the company argued the “care and treatment given to
plaintiff by these answering defendants was proper, appropriate and
reasonable” for Jefferson Wilson’s medical and psychological conditions.
Nikia Wilson disagreed. The family is trying to arrange to care for Jefferson Wilson at home.
“This is my mom,” she said. “Treat your patients as if they were your loved ones.”
Some states have more problems than others
In Washington state, where the nursing home outbreak began, about 85 percent of nursing homes received an infection control citation, USA TODAY’s analysis found. But it California and Michigan both fared worse, with more than 90 percent cited. Guam's one nursing home was cited, as were all six of those in Puerto Rico.
In Rhode Island and North Carolina, though, only about a third of nursing homes were cited for infection control violations.
Even
among nursing homes that received federal regulators’ highest overall
ratings and highest healthcare ratings, 41 percent still had problems
with infection control. This is of particular concern because, in a
healthcare crisis, nursing homes often become a key escape valve.
“Part
of the resource crisis we are facing is ensuring that there is enough
good care available in skilled nursing facilities to take some of the
load off acute care hospitals in a widespread epidemic,” said Mike Dark,
staff attorney for California Advocates for Nursing Home Reform.
He
said skilled nursing facilities in the U.S. already take hundreds of
thousands of patients a year when they are discharged from acute care
hospitals.
‘A societal judgment you have to make’
Even
before the coronavirus appeared, as many as 380,000 people were dying
of infections every year in long-term care facilities, according to the Centers for Disease Control and Prevention.
Some studies cited by the CDC have suggested that 1.5 million Americans
in long-term care, including nursing homes, may get an infection every
other year, sending perhaps 150,000 of them to the hospital.
Some
of that, advocates say, stems from the way nursing homes are operated.
Typically understaffed, nursing homes can be places where making money –
or even just making it through a shift – depends on cutting corners.
Wendy Meltzer, executive director of Illinois Citizens for Better Care, said good infection control takes time.
“If
you don't have enough staff to begin with, then the time you take to
wash your hands and put on gloves and change gloves and make sure that
linens are changed appropriately and take people's temperature and what
you need to do," she said, “that all takes away from the day-to-day,
minute-to-minute, hour-to-hour pressures.”
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Often
when people think about nursing homes, they focus on doctors and
nurses, said Greg Kelley, president of SEIU Healthcare Illinois Indiana
Missouri & Kansas, a union that represents more than 91,000
healthcare, child care, home care and nursing home workers.
But
Kelley said nursing homes rely on housekeepers, dietary workers and
others to keep their facilities operating. Those workers, on the front
lines of infection control, may make poverty-level wages and not receive
enough sick days or paid time off.
And there is no one to replace them. That means sick employees often show back up to work.
A
U.S. Department of Health and Human Services plan for addressing
nursing home infections said the flu can spread easily among residents
who live near each other and frequently see healthcare workers.
But healthcare workers themselves, the plan said, contribute to the problem, with many not getting the annual flu shot.
Residents also often routinely suffer from illnesses like pneumonia that threaten their lives, and those of other residents.
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Few
nursing homes have full-time infection-control specialists. One study
found less than 10 percent of infection prevention specialists in
nursing homes and skilled nursing facilities had specific training, such
as a certification, in infection control procedures. In acute care
environments like hospitals, 95 percent had that training.
Gifford,
of the American Health Care Association, said nursing homes are
required to have infection control and emergency preparedness plans that
include how to deal with an outbreak or pandemic.
“I
think that even with all the planning that you do, things come up that
are really hard and complicated that need to be addressed to sort of a
broader community,” Gifford said, “and I think that’s what we’re seeing
up in Washington.”
In Washington, he said many
workers were exposed to the virus and could not come to work. Initially,
part of the plan was to backfill with nurses from other facilities. But
the facility learned that the state doesn’t allow nurses to move
quickly and easily across state lines. When they tried to mobilize
federal workers, Gifford said, that led to various challenges, including
with pay.
Other problems emerged, too. Test
results weren’t readily accessible, he said, and the facility quickly
ran out of some key supplies, like masks. When it located supplies, he
said, some suppliers were afraid to deliver them.
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Meltzer
said there are simple-sounding ways to prevent the coronavirus from
spreading at nursing homes: Take visitors' and employees' temperatures
as they come into the buildings, require every facility to have someone
working in infection control, and mandate that assisted living
facilities and other places follow the federal governments' regulations
for nursing homes. All of that requires more staffing, which means more
money.
While those solutions may sound simple, they can be costly.
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Coronavirus a concern in nursing homes, where 75% have been cited for infection control errors
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