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| Karen Kingston stands on her front porch for a portrait at her home Friday, Sept. 18, 2020, in Old Lyme. Kingston's 98-year-old mother lives at Three Rivers Healthcare nursing home in Norwich, which the state Department of Public Health moved to close this past Wednesday, Sept. 16, 2020, after several residents have died from COVID-19 and over two dozen others became infected with the virus. Kingston, whose mother tested negative for the virus, said all the residents have to be moved out in two weeks. (Kassi Jackson/The Hartford Courant) |
The moment she learned about the first COVID-19 case in the Norwich nursing home where her mother lives, Karen Montanaro Kingston had been frantically trying to get the 98-year-old out of there.
But word of the outbreak at the Three Rivers Healthcare Center got out. Other homes shied away, she said, saying her mother was a “high risk” patient — even as Three Rivers staff assured her that her mother, Irene Montanaro, didn’t have the coronavirus.
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| Karen Kingston's mother, Irene Montanaro is 98 years old and lives at Three Rivers Healthcare in Norwich, Conn. She has tested negative for COVID-19. (Provided by Karen Kingston) |
Kingston watched as the situation at Three Rivers worsened, an outbreak that would infect more than two dozen patients and staff and claim at least four lives. Montanaro’s former roommate at the facility died on Sept. 10 as the number of cases kept climbing.
“We would get these robocalls every Tuesday or Thursday and one time it said there were 10 new cases and that’s when I knew it was out of control and we needed to get her out of there,” Kingston said.
Now, with the state taking the dramatic step of ordering all patients out of the nursing home, Kingston and the family members of the other residents at Three Rivers are dealing with another disruption. The evacuation is the latest blow to families who had little contact with their loved ones because of the coronavirus lockdown and dealt with ongoing reports about the outbreak spreading and residents' dying. Now, their loved ones are being abruptly uprooted.
“We are kind of in limbo right now and don’t know what’s going to happen,” Kingston said. “Who is going to move my 98-year-old mother? We can’t go in there and help her pack. We can’t help her settle into a new place. She is going to have to go through this alone at 98-years-old.”
One tragedy after another
The decision to relocate all 53 residents was made quickly by state officials as they came to realize the depth of problems inside the Norwich facility.
Two inspections at the facility identified a range of infection control issues — many preventable errors in areas that received widespread attention as COVID-19 tore through nursing homes across the state, killing upwards of 2,500.
The problems cited by the health department included staff shortages, failure to properly cohort COVID positive and negative residents, having staff work with both COVID positive and negative residents on the same shift and lack of proper PPE. Among the issues that has generated widespread attention is the decision to work by a nurse who had vacationed with family members concerned they might be infected.
Now, in wake of the decision to move the residents out, state officials are scrambling to contact all of the families of residents to assure them their loved ones are OK and to get a sense of where they might want to go next. Some families haven’t been contacted, while other residents don’t have families to contact and are under the care of a conservator.
“We have not heard anything from anyone as to what is happening in there. We are completely in the dark,” Katelynn Gosselin said.
Gosselins’ 82-year-old grandmother, Maryjane Jackson, has been at Three Rivers since February. Jackson fell at home and was injured. She went to Three Rivers for rehabilitation, but needs 24-hour supervision now.
“I would like to get her out of there and home but that’s not possible,” Gosselin said. “I would hope they will move her somewhere close.”
Some families were told Friday by DPH officials that they plan to have everyone out of Three Rivers within two weeks. They will be moving four or five residents a day, starting with the COVID positive cases. Many of those, officials have said, are going to the Riverside Health and Rehabilitation Center in East Hartford.
Long-term Care Ombudswoman Mairead Painter said her office has been swamped with calls from family members since the announcement. She said the fast moving situation has left everyone with questions and family members worried about their loved ones.
“For some of them this has been their home for years and now they have to move somewhere new,” Painter said. “It’s been one tragedy after another for these families.”
“Mom was OK there”
When the first COVID case was announced in mid-August, Gosselin started a petition seeking to have any residents who were positive transferred out of Three Rivers before the virus spread. About 200 people signed it.
“We thought she was in a safe facility where they would take good care of her — and that didn’t happen,” Gosselin said.
Gosselin said she has no problem with the state moving patients out of Three Rivers.
“I have to say I see it as a good thing that they’re closing it because I don’t think the staff did a very good job of protecting people,” Gosselin said. “The fact a nurse was able to go to work while she was sick and not wear a mask and no one said anything to her is more than enough to close it down.”
Gosselin is referring to the actions of a supervising nurse who worked a double shift on July 24 after going on vacation in Rhode Island. She told several of her fellow employees that she wasn’t feeling well and that at least two members of her family had gotten COVID-19 tests, according to DPH investigators.
Three days later the nurse tested positive as well. Several employees told the DPH that the woman didn’t wear a mask as she worked the double shift.
DPH hasn’t identified the supervising nurse, but the Courant has learned her name is Mary Ciezynski, who was working as a part-time employee at Three Rivers. Among those infected was her mother, a patient at the facility who has since died, though not of COVID.
All told, 21 residents have tested positive as well as six staff and at least four residents have died. The outbreak spread beyond the walls of Three Rivers to nearby Backus Hospital where at least nine employees were infected by a Three Rivers resident who spent several days in the hospital in mid-August.
The rapid outbreak was an abrupt turnaround. Up until the late July incident, Three Rivers had been relatively COVID-free with only a handful of cases and no deaths.
“My mom was OK there. It’s an old building but she liked the people taking care of her,” Kingston said.
While she didn’t like that she couldn’t visit her mother all of the time, Kingston was aware of how the virus was impacting other long-term care facilities across the state and knew the sacrifice was necessary.
Since Eastern Connecticut in general had very low case volumes she thought her mother was safe.
“They had done so well for so long but once they got one case it went down fast,” Kingston said.
Infection spread rapidly
The two DPH reports on Three Rivers revealed a litany of problems.
The facility, investigators found, was short-staffed. Eighteen of the 21 shifts that DPH reviewed between August 28-September 3 showed that one nurse worked alone in the A Wing, where patients with suspected COVID-19 were under observation.
Three Rivers also failed to properly test all of its employees as mandated by Gov. Lamont’s executive orders, the state found. A review of testing records showed that of the nursing homes' 55 employees, 16, or 29 percent, had missed weekly testing for COVID 19.
At least three patients were sent to the emergency room at William Backus Hospital without written documentation that the residents had COVID-19. DPH also cited Three Rivers for failing to cohort patients once the virus was detected and for having nurses working with both COVID positive and negative patients on the same shift.
Given the range of problems, the state late last week quietly appointed attorney Katharine Sacks as temporary manager of the facility, taking over all clinical decision-making from the owner, JACC Healthcare Inc.
But Sacks said it took her about 30 hours in the facility to realize that residents needed to be removed and that there was no way she could bring back into compliance by the state’s deadline of Sept. 30.
“I realized the building blocks of compliance weren’t here,” Sacks said, last week. She added she has been appointed a temporary manager of a long-term care facility about 30 times and had “never been in a facility she didn’t think could be brought up to compliance.”
Sacks said there was a severe staff shortage, lack of training for staff and no competent oversight of staff that was there.
In a statement, the nursing home owners, JACC Health Center of Norwich, said that it supported Gifford’s order to move all patients out of the facility. While Gifford’s executive order doesn’t actually close Three Rivers, it is unclear how it would operate without any residents.
“Since the initial COVID outbreak, we have been cooperating with the State Department of Public Health to bring our facility into full compliance with state and federal regulations, including the engagement of a Temporary Manager to oversee the facility,” the statement said. Following an initial assessment, the temporary manager concluded that bringing the facility back into substantial compliance within the timeframe mandated by regulatory bodies was not feasible due to a number of concerns, including the absence of critical staff."
Painter said given the depth of the issue at Three Rivers, she understands why DPH made such an unprecedented decision.
“It all comes down to poor management by a private, for-profit company,” Painter said. “This is opening people’s eyes about what no one sees inside a nursing home.”
The state’s plan is to first move the 17 residents identified as COVID positive and the seven residents under observation to the Riverside Health and Rehabilitation Center in East Hartford which still maintains a COVID-only wing. Riverside has had its own problems with COVID with more deaths than any facility in the state.
The 29 residents who have tested negative, including Irene Montanaro and Maryjane Jackson, will be placed in nursing homes within 15 miles of Norwich, if possible. While state officials have said there is capacity in nearby nursing homes to place Three Rivers residents, Painter believes it will not be easy or quick.
Just because a facility may have beds available doesn’t mean it’s the right fit for someone from Three Rivers. Painter said some people need 24-hour care, certain medications or a facility may not have the staff to handle more residents.
“Many families have been trying to get their loved ones out of there for weeks and can’t because other facilities don’t want people from a ‘high risk’ facility,” Painter said. “The state is going to have to make sure all the residents are tested and assure other facilities they aren’t exposing their residents to COVID.”
Kingston said she is hoping to get her mother moved closer to her Old Lyme home.
“I want to call somewhere and reserve a room but what if they can’t
move her right away and we lose our spot?” Kingston said. “A 98-year-old
woman shouldn’t have to go through this.”
