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| Medical personnel evacuate patients at the Magnolia Rehabilitation and Nursing Center in Riverside, California, on April 8 after 39 cases of the coronavirus were found at the facility and staff stopped going to work. (Gina Ferazzi/Los Angeles Times via Getty Images) |
The long-term care industry resisted a federal mandate to plan for
disasters including pandemics. About 43% of nursing homes have been
caught violating the requirement, including facilities that have now had
deadly COVID-19 outbreaks.
by Bryant Furlow, Carli Brosseau
On
Dec. 15, 2016, the nation’s largest nursing home lobby wrote a letter
to Donald Trump, congratulating the president-elect and urging him to
roll back new regulations on the long-term care industry.
One
item on the wish list was a recently issued emergency preparedness
rule. It required nursing homes to draw up plans for hazards such as an
outbreak of a new infectious disease.
Trump’s election, the American Health Care Association, or AHCA, wrote, had demonstrated that voters opposed “extremely burdensome” rules that endangered the industry’s thin profit margins.
“Part
of the public’s message was asking for less Washington influence, less
regulation, and more empowerment to the free market that has made our
country the greatest in the world,” AHCA wrote. “We embrace that message
and look forward to working with you to improve the lives of the
residents in our facilities.”
The
letter was another salvo in the industry’s fight against regulations
designed to stop diseases like COVID-19 from devastating elderly
residents of the nation’s nursing homes, according to a review of
documents and data by New Mexico In Depth; The News & Observer of
Raleigh, North Carolina; and ProPublica.
The
lack of pandemic plans helps explain why nursing homes have been caught
unprepared for the new coronavirus, patient advocates and industry
observers said. Across the country, more than one in four nursing homes
have registered an outbreak, according to media reports.
More than 16,000 nursing home residents and workers have died,
accounting for 17% of COVID-19 deaths nationwide, according to an AARP tally on May 18. That figure is likely an understatement of the true scope of the harm.
Ongoing
questions about the regulations may also have played a role. The 2016
rules mandated planning for all kinds of hazards, citing Ebola as an
example. In 2019, the Trump administration clarified
that nursing homes needed to include a specific plan for outbreaks of
unfamiliar and contagious diseases — such as the coronavirus.
The plans must address
how facilities will respond in an emergency — specifying how nursing
homes will decide to shelter in place or evacuate and how they will
provide residents with food, water, medicine and power. Nursing homes
have to train their staff on these plans and practice them at least
twice a year, if possible by participating in a drill with local
agencies.
Some
nursing homes were slow to comply, according to an analysis of
inspection data, watchdog reports and interviews with ombudsmen and
advocates. Inspectors have found more than 24,000 deficiencies with
nursing homes’ emergency plans between November 2017, when the so-called
“all hazards rule” took effect, and March 2020, according to public
data reviewed by the news organizations. The violations occurred in
6,599 facilities, equal to about 43% of the country’s nursing homes.
Because
of how the Centers for Medicare and Medicaid Services tracks the data,
it’s not possible to say exactly how many of the emergency planning
violations related specifically to a failure to plan for an infectious
disease outbreak. Failures to meet routine infection control standards
were excluded from the analysis.
But
nursing home advocates say that more detailed plans accounting for
expected staff and equipment shortages would have likely resulted in
fewer deaths and illnesses at nursing homes stricken by the coronavirus.
The current rule requires nursing homes to make contingency staffing
preparations, but it doesn’t require stockpiles of personal protective
equipment, or PPE.
“It’s
just a river of grief, and it could have been prevented,” said Pat
McGinnis, executive director of California Advocates for Nursing Home
Reform.
Emergency
plans help facilities train their staff ahead of time and guide tough
decisions during a crisis, said Ted Goins, the president and CEO of
Lutheran Services Carolinas, a nonprofit based in Salisbury, North
Carolina, that runs several highly rated elder-care facilities.
“COVID-19
is a perfect example of why we have emergency plans in our facilities,
and I’m sure that’s why it’s a requirement,” Goins said.
AHCA
declined to make any executives available for an interview. In a
statement, the group said the pandemic shows that nursing homes should
be a bigger priority for resources but not for regulation.
“As
we assess the COVID-19 pandemic and how to prepare our healthcare
system for future outbreaks, more regulation is not necessarily always
the answer,” AHCA said in the statement. “There will be time to look
back and determine what we can do better for future pandemics or
crises.”
One
place to start: a nursing home and rehabilitation center in
Albuquerque, New Mexico, with five deaths and 42 infections tied to a
COVID-19 outbreak and no plan for dealing with a pandemic, according to
its employees and New Mexico public records.
“Pandemic
response? I mean, I don’t think anybody was really prepared for a
pandemic of this level or this quickly,” said Edwardo Rivera, the
facility’s administrator. “We did have some things in place, but nothing
could have prepared us for what COVID-19 was.”
An Emergency Call
Robert Potts, 91, once flew America’s leaders around the globe.
A
retired Air Force colonel who flew combat missions in Korea and
Vietnam, Potts returned to the United States to serve as pilot for Air
Force One and Air Force Two in the 1960s, according to service records
and a family member. He spoke of flying President John F. Kennedy and
first lady Jacqueline Kennedy.
After
he fell at home and hit his head in March, Potts wound up at Advanced
Health Care of Albuquerque, part of a nationwide network of 22
post-hospitalization rehabilitation and skilled nursing facilities.
The
Albuquerque facility is a top-rated rehabilitation center with personal
bedrooms and wine glasses in the dining hall. It takes care of patients
needing physical, occupational or speech therapy after hospitalization.
In
early April, AHC of Albuquerque staff and residents began testing
positive for the coronavirus. Concerned about her father’s health,
Potts’ daughter Susan wanted to bring him home. Somebody from the
facility — Susan could not remember exactly who — assured the family
that Potts had tested negative for COVID-19.
When
the AHC of Albuquerque van arrived at the Potts residence in the city’s
affluent Northeast Heights on the afternoon of April 10, the Potts
family’s caretaker was there to greet him. Rosemary Ortiz, 57, recalled
that the driver reassured her that Potts was negative for COVID-19.
Ortiz,
however, noticed that Potts had symptoms that corresponded with the
disease: a runny nose and a dry cough. The next day, Saturday, those
symptoms worsened. By Sunday morning, he complained of shortness of
breath and chest pain. He was dizzy, Ortiz recalled.
Ortiz
drove him first to an urgent care facility, where he registered a
temperature of 100 degrees. At a nurse’s recommendation, Ortiz drove
Potts to Presbyterian Hospital in downtown Albuquerque.
“Wouldn’t it be something if I had the COVID and I gave it to you guys, to the family,” she recalled him telling her.
“Don’t say that, we don’t want that!” Ortiz responded.
At Presbyterian, Potts tested positive for COVID-19. He was admitted to the fourth-floor ICU.
Ortiz returned to her home that evening, a two-room casita in Albuquerque’s South Valley that she shares with a roommate.
She worried that Potts was dying.
Something Pretty Basic
The drive to ensure that nursing homes were better prepared for emergencies began amid disaster and disease.
In the aftermath of Hurricane Katrina in 2005, the inspector general
for the U.S. Department of Health and Human Services found that nursing
homes were unprepared for emergencies despite complying with existing
federal standards. The watchdog recommended strengthening the federal
requirements to be more specific about the elements that must be in a
disaster plan and encourage more coordination with state and local
emergency management officials.
In 2009, the Government Accountability Office examined
preparedness for a flu pandemic and recommended that the federal
government do more to advise health care providers on emergency plans
and monitor their performance. The shortcomings were underscored by an
outbreak of swine flu that year, which sickened nursing home residents
nationwide.
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| Ambulances line up to take patients from the Magnolia Rehabilitation and Nursing Center. (Gina Ferazzi/Los Angeles Times via Getty Images) |
In
2013, the concerns over infectious outbreaks began to take concrete
form. The Centers for Medicare and Medicaid Services, or CMS, proposed
updating the emergency preparedness requirements for all health care
providers that participate in Medicare and Medicaid, including nursing
homes.
“This
was really something pretty basic,” said Richard Mollot, the executive
director of the Long Term Care Community Coalition, which advocates for
nursing home residents and their families.
But
nursing home operators didn’t see it that way. They objected to the new
requirements, arguing they would be costly and burdensome. Over the
next three years, they repeatedly voiced their concerns as CMS finalized
the new rule.
“We
are concerned that CMS has underestimated the amount of time, training
and resources necessary to implement many of these requirements,”
Catholic Health Initiatives, which operates 40 long-term care,
assisted-living and residential-living facilities, said in a formal response to the CMS proposal.
The
Continuing Care Leadership Coalition, which represents nonprofit and
public post-acute and long-term care providers in the New York
metropolitan area, told CMS that the additional personnel and equipment —
such as backup generators — needed to comply with the new regulations
risked the economic stability of some of its members. “We view the
proposed changes as considerable from a financial standpoint, in excess
of appropriate minimum standards to participate in the Medicare and
Medicaid programs, and we expect they would necessitate significant
staffing and operational enhancements,” the organization said.
CMS rejected the appeals, issuing its final rules in September 2016. Nursing homes and other facilities had one year to implement the changes.
A few months later, AHCA sent its letter to Trump. The group followed up by asking
Tom Price, Trump’s first HHS secretary, to stop implementing the new
requirements and write a new rule. “We are happy to work with your team
and CMS staff to provide more specific suggestions,” the industry group
said.
The following year, the Trump administration proposed fulfilling some of AHCA’s wishes. The organization had warned that creating and updating the plans risked taking time away from patients.
Advocates for nursing home residents objected
that CMS was contradicting its own conclusions. Public health officials
said a rollback would undo potentially life-saving improvements.
CMS ultimately decided to remove the mandate for nursing homes to document coordination with local authorities.
But
the agency remained insistent on the need to plan for pandemics and
other outbreaks of new diseases: “CMS determined it was critical for
facilities to include planning for infectious diseases within their
emergency preparedness program,” it said in a memorandum issued in February 2019.
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| A resident at the Life Care Center of Kirkland in Washington on March 16. The home became one of the first reported outbreaks of the virus in the United States. (Grant Hindsley/The New York Times via Redux) |
A Confused Response
On
March 10, just a day before authorities announced New Mexico’s first
positive COVID-19 case, Kate Brennan was listening to sports radio on
her way to work at AHC of Albuquerque, located in a neighborhood of
industrial and business parks. The most senior physical therapist at the
facility, she listened with alarm to news about the spread of the
coronavirus.
She
pulled into the parking lot at the same time as Edwardo Rivera, the top
administrator. What were they going to do to protect patients and staff
from a COVID-19 outbreak, she asked.
“Katie, it’s nothing more than the flu. It’s not a big deal,” she said he told her.
Rivera
said he could not recall making such a statement. But on March 13, CMS
issued new COVID-19 measures for nursing homes nationwide. The agency
recommended the screening of residents and staff for fever and
respiratory symptoms, restricting “all visitors, effective immediately,”
except for end-of-life visits, and canceling all group activities and
communal dining.
The
measures appeared to catch Rivera and his management team by surprise.
Their response over the next several weeks was confused and uncertain,
employees and patients’ family members said.
By
March 15, AHC of Albuquerque announced a halt to family visits. Staff
and contractors were checked at the facility door for fever. But group
therapy in the gym did not immediately stop, according to former
employees who were there at the time. Patients were given the option of
eating meals in their own rooms, according to an employee’s cellphone
text, but meals in the facility’s dining room continued.
Brennan
grew increasingly worried that AHC was not adequately preparing.
Despite the CMS regulations, Brennan and several others said they had
never received any kind of training on how to handle an epidemic.
“We never talked about COVID-19 training, I know that. Never. Never,” Brennan said.
Nurse
Carole J. Welch agreed, as did two other AHC of Albuquerque employees
interviewed on the condition that they remain anonymous. Fire drills
were the only disaster planning and exercises about which Welch and
Brennan were aware, they said.
“There
was never anything mentioned about COVID-19,” Welch said. “At all-staff
meetings, everybody signs a sign-in sheet. If state inspectors ever ask
them for documentation for in-service training or sign-in sheets for
COVID-19 trainings, unless they’ve made them up, there aren’t any.”
Nor
did the facility participate in any community drills or exercises in
recent years other than fire drills, Welch and Brennan agreed.
Rivera
said several COVID-19 training sessions had been held since early
January. Asked if AHC of Albuquerque had conducted staff training to
prepare for the pandemic — explaining how the coronavirus can be
transmitted and what precautions are needed to avoid its spread — Rivera
said they’d been doing such training “for a while now,” a claim
vociferously denied by staff.
In
March, the New Mexico Department of Health rushed inspectors to AHC of
Albuquerque as part of a statewide effort to review facilities’
emergency response plans in anticipation of the coronavirus pandemic. No
deficiencies were noted in either planning or training. Health
Department officials did not respond to questions about whether
inspectors specifically examined the pandemic response portion of the
facility’s emergency plan.
But
Rivera acknowledged that AHC had no pandemic response plan, as federal
rules require, just a more general disaster response plan. He noted he
had not coordinated with local health officials to plan or drill for an
epidemic to identify potential problems.
“We
did not coordinate much when it comes to an epidemic of this fashion
with the [state] Department of Health,” Rivera said. “They did review
all of our policy procedures and emergency preparedness plan and
everything was checked off and OK’d. But there was never any official
training with the Department of Health.”
When
asked directly whether AHC of Albuquerque had a generic emergency plan
rather than one specific to the needs of a pandemic (such as infection
control and PPE supplies), Rivera said: “Correct.”
To
Brennan, Rivera’s attitude was too lax for the situation facing the
facility’s patients and residents. She believed the lack of guidance was
putting her and her patients at risk.
Brennan
said she would not work with patients without appropriate PPE and
announced she was taking personal leave on March 16. She was fired.
Welch asked to be changed from full time to an on-call nurse on April 5
because of similar concerns as Brennan’s. She later learned she, too,
had been fired.
“I
think in 2 weeks we will see a lot occur … and perhaps our standards
will rise … or won’t need to,” Brennan texted to a supervisor. “But in
the meantime, I felt we should do more, be more.”
Rivera declined to comment on personnel matters.
“The Cost Is Human Lives”
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| A memorial in front of Louisburg Healthcare and Rehabilitation in North Carolina, where 56 residents caught the virus and 19 died. (Robert Willett/The News & Observer) |
AHC of Albuquerque’s failure to create a pandemic plan is not unique among nursing homes. A 2018 report
by Democratic staff of the U.S. Senate Finance Committee concluded that
nursing homes are still unprepared even for more common emergencies
like hurricanes.
While
some homes have devoted a lot of energy to protecting their residents
from disasters, many facilities are doing the bare minimum, according to
David Grabowski, a professor of health care policy at Harvard Medical
School.
“I
don’t think it’s ever been a major area of focus,” Grabowski said,
“somewhat because CMS hasn’t forced this and really held their feet to
the fire.”
The
inspectors who verify whether a nursing home meets emergency
preparedness standards are supposed to read the plan to make sure it’s
updated and “encompasses potential hazards.” They should also confirm
that the nursing home has been training its employees on the emergency
plan and ensure that the facility has made preparations for
communicating and delegating authority in a crisis.
The
most commonly cited problem for nursing homes’ emergency preparedness
is failing to rehearse their plans in a community drill, usually
organized by local emergency management or a hospital-led health care
coalition.
Since
inspectors are tasked with identifying immediate hazards, they may be
less focused on scrutinizing emergency plans, said Eric Carlson,
directing attorney of Justice in Aging, which advocates for impoverished
seniors.
In 2019 and 2020, the HHS inspector general found that inspectors in at least five states — California, New York, Florida, Texas and Missouri
— were not thoroughly policing the new emergency preparedness rule. CMS
has said it will expand its oversight of states’ enforcement.
Another
indication of underenforcement is how much violations vary across the
country. Advocates and experts say the variation more likely reflects
different states’ inspection priorities rather than how much facilities
are actually doing.
California
has one of the highest citation rates, with inspectors finding more
than three emergency-preparedness violations per facility since November
2017, according to the analysis. At least 56 facilities have been cited
for failing to plan for potential pandemics.
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| Warning notices at Cedar Mountain Post Acute, a nursing facility in Yucaipa, California, that was cited for lacking a pandemic plan. There have been 21 deaths linked to the facility by San Bernardino County. (Chris Carlson/AP Photo) |
New
Mexico cited nursing homes for emergency-preparedness deficiencies at
about the same rate, but it’s not possible to say how many of those
deficiencies related specifically to failing to plan for confronting a
new infectious disease. Today, nursing homes account for 31% of all
COVID-19 deaths in New Mexico.
The
citation rate in New York, where more than 5,800 nursing home residents
died with confirmed or presumed infections, was much lower, roughly one
deficiency per nursing home.
North
Carolina registered few deficiencies. Although the state has more than
400 nursing homes, its inspectors issued just 44 emergency-preparedness
citations to 40 facilities, none related to a nursing home’s failure to
prepare for an epidemic.
Despite
this apparently clean record, North Carolina’s nursing homes have been
ravaged by COVID-19. Nursing home residents make up more than half of
the state’s deaths. About 20% of facilities have had outbreaks, and some
have been unable to stop the virus’s spread before virtually every
resident was infected.
At
Louisburg Healthcare and Rehabilitation, all but five of the facility’s
61 residents caught the virus and 19 died. Despite the federal
directive to coordinate with local emergency managers, the nursing home
didn’t submit its plan for review.
Jeff
Bright, the emergency manager of Franklin County, where the nursing
home is located, said the first time he talked to the facility’s
administrator was after the outbreak began. “The initial conversation
was, ‘Oh good gracious, we’re overwhelmed,’” he said.
In
a statement, the nursing home’s management company, Liberty Healthcare,
acknowledged that local emergency officials had not reviewed the
facility’s emergency plan. But the company said its plan contained a
section on pandemic influenza response that proved helpful. State
inspectors have reviewed the nursing home’s emergency plan three times
since the new rule took effect, the company noted, and each time the
facility was found in compliance.
Regulators should do more to make sure that nursing homes and local emergency officials work together, advocates said.
“Facilities
should have been better prepared for this,” Melanie McNeil, Georgia’s
long-term care ombudsman, said. “The cost is human lives. That’s the
cost of not being prepared. We know that people in long-term care are
vulnerable.”
The Outbreak Begins
Brennan’s concerns proved prescient on April 3 — the 13th day at AHC of Albuquerque for an elderly Navajo patient in Room 222.
That
day, the man had coughing fits in the dining room and therapy gym,
according to current and former employees. The next day, on Saturday, he
was still coughing and had a fever, so staff quarantined him in his
room and administered a nasal swab to test for COVID-19.
Word
of his positive test result came the following day, April 5 — Palm
Sunday. He was the first person known to have become infected at the
facility.
That
morning, the facility’s nursing director told staff to assign only one
certified nursing assistant, or CNA, to enter the patient’s room, Welch
said. But the CNA working in Room 222 was not told to avoid contact with
other patients to avoid the risk of spreading the coronavirus,
according to Welch. Several people who the CNA attended were later
diagnosed with COVID-19.
Rivera
said the CNA took necessary precautions, including the use of personal
protective equipment. But employees present at the facility on April 5
said the CNA was wearing a surgical mask, not one of the more protective
N95 masks.
Rivera acknowledged that staff likely played a role in spreading the virus by mid-April.
“I
would say it was indirect” spread between residents by staff, Rivera
said. “At that time, we had all of our patients, remember, in isolation
at that time, in their rooms.”
Between
April 5 and May 8, 42 people — 18 patients and 24 staff — at AHC of
Albuquerque would test positive for the disease, according to the state
Health Department. Patients were sent home or to other nearby facilities
like The Watermark assisted living center and the Canyon Transitional
Rehabilitation Center, but only after testing negative twice, Rivera
said.
Five
residents died, including two men and two women in their 70s and 80s,
and Roslyn K. Pulitzer, 90, a distant relative of the newspaper family
who created the Pulitzer Prize, the nation’s highest journalistic honor.
Pulitzer,
a psychotherapist and fine arts photographer, drew her final breath
holding the ungloved hand of Kay Lockridge, her partner of 36 years, at
8:45 a.m. on Thursday, April 30, at the University of New Mexico
Hospital’s intensive care unit.
“If we had known they had a case, Roz wouldn’t have gone there,” said Lockridge, a journalist. “I wish we’d known.”
Outbreaks, Staff Cuts and a Disengaged Doctor
AHC
of Albuquerque had a history of problems with containing infectious
outbreaks, according to employees and a review of state Health
Department inspection reports dated 2009 to 2020.
There
have been recurring infections involving Clostridium difficile,
commonly called C. diff, according to current and former AHC of
Albuquerque employees and state inspection reports. C. diff is a
drug-resistant bacterium that causes diarrhea and potentially lethal gut
inflammation. Rivera said the facility has had no C. diff cases in
2020. He did not return calls regarding previous outbreaks.
Repeated
problems with C. diff are a red flag for infection control problems,
said Dusti Harvey, an Albuquerque attorney who previously worked for Sun
Healthcare Group, a long-term nursing and post-hospitalization
rehabilitation company.
Federal regulations for nursing homes, including those for infection control, have been in place since 1989, Harvey noted.
“This
is something that nursing homes should have been doing for the last 30
years,” Harvey said. “Nursing homes should have been set up for COVID-19
way before it happened.”
AHC
of Albuquerque was also short-staffed, according to employees. Changes
in billing for physical therapy had led to layoffs in September 2019.
The facility had also begun to accept older, more fragile patients.
The
situation was a “perfect storm for things to go awry with the
introduction of COVID-19 into the facility,” Brennan said. “Less staff,
less cohesion, less communication, less direction. They brought in more
patients that were inappropriate for effective group therapy due to
their numerous medical issues.”
Rivera insisted the changes to Medicare payments did not affect patient demographics and that staffing was not a problem.
A
final concern for some employees was Dr. Ralph S. Hansen, the
facility’s medical director and one of its two designated infection
control specialists. Neither Hansen nor the other designated specialist,
a nurse, have a current credential in infectious disease management,
according to records from the American Board of Medical Specialties and
the New Mexico Board of Nursing.
“Dr.
Hansen has an infectious disease background,” Rivera said. But Hansen
had not conducted any staff training, he acknowledged.
Current
and former workers described Hansen as “disengaged” and “disconnected.”
Patients’ missed doses of antibiotics and delayed lab results went
unpursued.
Hansen
was fired by a medical group in California and subsequently surrendered
his California medical license after he allegedly stole other
physicians’ prescription pads and self-prescribed Ritalin under his own
and fictitious names 326 times between 2004 and 2007, California Medical
Board records show. He was charged in 2007 with 15 felony counts of
burglary, forgery and obtaining controlled substances by fraud, the
records show. In a November 2007 plea bargain, he admitted only to
obtaining a controlled substance by fraud.
But
the following year, he moved to New Mexico, where he was issued a
conditional medical license in March 2009 requiring monitored drug-abuse
treatment and quarterly self-reports on his compliance with treatment,
board records show. He went to work for the state prison in Los Lunas
and the state Health Department. In 2014, the New Mexico Medical Board
granted Hansen an unrestricted medical license, records show. He stopped
working for the state in October 2015.
Hansen did not return repeated calls and messages.
By
May 7, the COVID-19 outbreak at AHC of Albuquerque had peaked and
largely resolved, Rivera said. As of Monday, May 11, the facility had
only five patients who tested positive.
Rivera did not return recent phone calls seeking updated figures.
Uncounted Victims
At least two other people might be uncounted victims of the outbreak at AHC of Albuquerque.
After
Rosemary Ortiz dropped off Robert Potts at the hospital, she drove back
to her own home, the two-room casita where she has lived since
childhood.
The
following week, Ortiz developed a cough and shortness of breath. She
soon became dizzy and feverish, with terrible headaches. Despite the
small size of her home, she had trouble walking to the front door.
Ortiz tested positive for the coronavirus.
“I was so sick I thought I was not going to see my kids or my mother ever again,” she said. “I thought I was going to die.”
At home, Ortiz had kept her distance from her roommate, fearful of infecting her. But then she heard the woman coughing.
The roommate, too, tested positive for the coronavirus.
Reached
by phone, Ortiz stopped to catch her breath and announced that she had
been weeding her yard, back on her feet. As of Tuesday, May 26, she had
still tested positive for the coronavirus, even though she felt better.
Inside, Ortiz’s roommate was still sick and coughing.
“But I think she’s doing better,” Ortiz said.
Ortiz
had learned that Potts had been transferred to the Canyon Transitional
facility for hospice care after several weeks at Presbyterian hospital.
Ortiz said Potts’ health has improved and he may be released to go home
in a few weeks.
Ortiz paused.
“I miss him. I miss Mr. Potts very much,” she said.
Full Article & Source:
Nursing Homes Fought Federal Emergency Plan Requirements for Years. Now, They’re Coronavirus Hot Spots.
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