by Cameron Evans
Four certified nursing assistants who have worked at a Missoula senior care facility that experienced the largest known coronavirus outbreak in Montana this fall said Village Health & Rehabilitation could have done more to protect its residents.
The one current and three former employees cited numerous issues including unclear communication about COVID-19 safety protocols, staffing shortages, and controversial directives from management.
The Goodman Group owns Village Health and two other senior care facilities in Missoula. In extensive responses to the Missoulian, Goodman Group spokesperson Amy Rotenberg disputed the employees’ claims that the facility fell short. Rather, Rotenberg said Village Health was "fully prepared when the spike in cases occurred both in terms of staffing and in terms of appropriate and safe protocol(s)." She counted an average staffing level at 106% above (more than double) the state's recommended minimum from Oct. 1 to Nov. 19.
The Missoula City-County Health Department investigated similar anonymous complaints against the facility, but did not issue any violation-based citations as a result. However, Village Health did not pass a state COVID-19 infection control audit in early November, according to the Montana Department of Public Health and Human Services and confirmed by Rotenberg.
Rotenberg said the facility passed a subsequent state inspection. Tuesday, Rotenberg said Village Health no longer had any active cases.
But neither state inspection document is yet available to the public. And the situation is complicated by the opaque way COVID-19 statistics are provided and updated by local, state and national agencies (see related story from Nov. 29).
As COVID-19 cases continue to rise in Missoula and across the nation, nursing homes and long-term care facilities have become ground zero for outbreaks. The older residents that nursing homes serve are considered most vulnerable to the effects of the coronavirus. And the number of cases can skyrocket quickly.
The Village Health & Rehabilitation is the largest nursing home in Missoula, with 193 beds. In late September, Village Health reported a couple of positive cases among staff. By Nov. 15, 80 percent of its total residents had tested positive for COVID-19, according to a database from the Centers for Medicare and Medicaid Services (CMS), a federal agency that licenses skilled nursing homes. The most recent CMS data show 18 deaths due to COVID-19, or roughly half of the 42 deaths in Missoula County since the pandemic began.
Tabitha Power, a former CNA at Village Health, told the Missoulian that management increased attention to safety protocols as the facility experienced the first cluster of cases among staff this fall. Power said she left her job to care for her father. However, she and the three other CNAs also raised concerns that illustrate the challenges of keeping the virus at bay in such settings. The following issues are the ones CNAs each noted separately and were identified in the anonymous complaints to the local health department.
The Missoulian is not naming three CNAs. Two no longer work at Village Health and fear they may not get hired in Missoula as the Goodman Group manages two other nearby facilities. The third is a current employee.
Communicating safety protocols
Employees who spoke with the Missoulian said they received mixed messages about how to best keep residents and themselves safe from infection.
“I was told by a nurse that I was supposed to don and doff in every room," an anonymous employee said of wearing personal protective equipment. "I was told by another nurse that I'm supposed to reuse gowns."
The Missoula City-County Health Department conducted a site visit at Village Health following an anonymous Oct. 2 complaint that stated Village Health was not taking proper precautions to protect employees and residents from COVID-19. The investigation found Village Health to be in "generally good compliance with the Health Officer’s Order, including employees wearing face coverings, no communal dining or group activities, and a visitor restriction policy."
The report summarizing the visit did not note any conversations with non-administrative staff, apart from an exchange with staff who confirmed that no group activities were taking place. During the visit, administrative staff at Village Health told the inspector that residents were required to wear cloth face coverings in the hallway but not in their rooms, which most residents share with another resident.
In response to claims that Village Health did not clearly communicate COVID-19 protocol with staff, Village Health said in a statement that staff were trained on an ongoing basis beginning in February and "again and again to reinforce and share new guidance in small groups, in person and in writing (ex. posters with policies). The training has included education on PPE requirements, donning and doffing, handwashing, cleaning equipment, and using shields and goggles. COVID specific information books and resources are available on all units at all times. National and regional support services are on the floor regularly supervising and are present to offer additional guidance and to clarify protocols. We regularly audit each facility for compliance and provide one-to-one or small group re-education."
Village Health fared well on its May 2019 annual health inspection, with any deficiencies listed as posing minimal harm. The facility also passed two COVID-19 focused infection control audits the state conducted for CMS. But Village Health did not pass an infection control audit on Nov. 4, Rotenberg confirmed in an email.
Montana Department of Public Health and Human Services spokesperson Jon Ebelt said the state health department was issuing a Plan of Correction to Village Health citing any deficiencies, and said that document is not yet available to the public. Village Health confirmed in an email that it received the notice from the state.
"We are reviewing the findings now, which include some isolated incidents of employees not properly donning masks as instructed at the time of the survey and some missing documentation from a specific session of screening," Rotenberg said in an email. "... Any deviation from our rigorous protocols by any staff member is concerning to us and will promptly be addressed and corrections made that the dept of health has identified."
Prior to receiving the notice from the state, Village Health said that it was addressing COVID-19 with the "highest attention to staff safety and top-quality care for residents. Since the onset of the COVID-19 pandemic, state oversight bodies had found no violations of regulations and guidance, and independent sources provided Village Health with top ratings for safety and adherence to best practices in the industry."
Rotenberg said in an email Tuesday that the state conducted another infection control survey on Nov. 23 and Village Health was informed that it would be receiving zero citations. DPHHS has not issued any plans of corrections related to COVID-19 to the other three nursing homes in Missoula, according to the most recent information available on the state website.
Missoula City-County Health Department records show Village Health was the focus of 10 of 13 complaints pertaining to senior care facilities from the beginning of September to Nov. 5. The local health department issued no violation-based orders in response to the complaints.
Local health department officials have not issued any violation-based orders to long-term care facilities or nursing homes the two months prior to Nov. 5 when the Missoulian last requested any new complaints, according to Shannon Therriault, director of environmental health. The department ordered some businesses to close until they comply with COVID-19 restrictions, but it does not have authority to shutter federally regulated nursing homes.
Local health departments can prohibit new admissions and order other anti-contagion actions but "closing the doors and removing the residents falls under licensing authorities," according to Ellen Leahy, director and health officer for the Missoula City-County Health Department.
Appropriate staffing levels
Concerns about staffing shortages resulting in long and understaffed shifts appeared in interviews with the CNAs and in complaints to the local health department. CNAs told the Missoulian that as more staff had to quarantine, "8-hour shifts turned into 10- to 15-hour shifts" and said that upon showing up to a shift, it was not uncommon to find out that a coworker had called in sick. A CNA provided the Missoulian with text messages between her and a staff member who schedules shifts that stated on several days the facility was "desperate for coverage" and offered a bonus to work.
In response to complaints to the Missoula City-County Health Department citing staffing shortages, including one complaint that stated, "Staff are working with up to 24 residents at a time for one CNA and one nurse,” the department's infectious disease specialist Pam Whitney told the Missoulian the department explored finding more resources for staffing at long-term care facilities, including the National Guard.
In a statement to the Missoulian, Village Health denied "any report that there are severe staffing shortages" and said the facility has had "tremendous support from our staff, contractors and regional and corporate teams." Village Health added that staff regularly work 8- and 12- hour shifts, and are not scheduled to care for more than 20 residents without support. Village Health said in a statement that while "the total headcount of all care providers fluctuates daily based on census of residents," the facility averages 106% above the state minimum requirements for both licensed staff and aides.
Skilled nursing homes are not required to meet a specific staff-to-resident ratio, and are instead required to meet a minimum number of hours for registered nurses, licensed practical nurses and nursing aides, based on the time of day and the number of beds in the facility. According to state law, nursing homes in Montana with more than 100 beds will be given individual consideration, but a 100-bed facility would need to have at least 120 nursing aide hours in a 24-hour period, in addition to 32 registered nurse hours and 32 licensed practical nurse hours.
Whitney said in an email that short-handed facilities "eventually pulled other staff in." The health officials declined to name the facility with a severe shortage, but Leahy said it was "one of the larger ones." Village Health is the largest skilled nursing home in Missoula County. The second largest facility is Hillside Health & Rehabilitation, which has 95 beds and as of Nov. 15, reported its first resident COVID-19 case.
Work protocols
CNAs who tested positive for COVID-19 said they were asked to return to work at Village Health while still recovering, and a complaint to the Missoula City-County Health Department alleged an unsafe practice because an employee who tested positive was working with positive residents.
In an investigation of that complaint, the Missoula City-County Health Department found that Village Health had gotten approval from the state health department for two asymptomatic positive staff members to work with positive COVID patients.
Leahy had previously denied that request. The state was unaware that Leahy had denied that request and agreed the decision was within the jurisdiction of the local health office, according to Whitney.
Leahy also confirmed that some facilities have been hit so hard by quarantines and isolations that they have implemented new protocols from the Centers for Disease Control and Prevention for how asymptomatic quarantined workers can go back to work on a “case by case basis.”
The emergency protocols the CDC released allow health care workers who have tested positive for COVID-19 to continue working with suspected or confirmed COVID-19 patients, pending approval from the appropriate state, local, territorial, and/or tribal health authorities, as a measure to mitigate staffing shortages.
Village Health said in a statement that staff are not allowed to return to work until they obtain approval from the Missoula City-County Health Department; "Any suggestion that there is pressure to return to work before authorized by health protocol is untrue."
A separate complaint submitted to the local health department on Oct. 21 stated that “Staff is working in both COVID and non-COVID halls on the same shift often," and a CNA stated that she would work in the COVID unit one day, and another hall without positive cases the next day.
In response to the complaint, the local health department again contacted Village Health and was told that "staff worked on one or the other area, and were not working both areas in one shift," Whitney told the Missoulian.
Village Health reiterated in its statement that it does not float staff from a COVID unit to a non-COVID unit in the same shift, and that "proper infection control is practiced in all units with appropriate PPE, and enhanced protocols are added when the staff enter a COVID unit." It added it is testing all staff and residents per CMS guidelines and has sufficient PPE.
Safety, prevention
Through its spokesperson, Village Health stressed its attention to keeping residents safe and healthy: “We remain focused on prevention, as the safety and well-being of residents and team members is our top priority.”
The CNAs the Missoulian spoke with also corroborated some of the practices outlined by Village Health in statements, such as surveillance testing, the use of PPE in the designated COVID-19 hall (although CNAs cited varying supplies of PPE and use requirements at the onset of the outbreak) and the notification of cases to residents' families and staff, which is mandated by CMS.
Village Health concluded its original statement to the Missoulian saying: "Our commitment to our residents and valued staff is and always has been steadfast. We greatly appreciate the daily commitment and dedication of our staff who care for our residents with utmost skill and compassion during this especially challenging time."
Editor's note: Dee Strauss, executive director of Village Health, is married to Jim Strauss, publisher of the Missoulian.
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