On March 29, as Pennsylvania, New York and other states began ordering nursing homes to admit medically stable residents infected with the coronavirus, national trade groups warned it could unnecessarily cost more lives.
The health directives put “frail and older adults who reside in nursing homes at risk” and would “result in more people going to the hospital and more deaths,” the American Health Care Association and affiliates said at the time.
A month later, it appears government officials should have heeded the dire call to pursue different pandemic emergency plans.
The deadly virus has spread like wildfire through many nursing homes across the Northeast, and state officials are scrambling to better protect those most vulnerable to COVID-19, the disease caused by the virus.
The death toll is devastating, according to interviews with nursing-home officials, patients’ families, health-care advocates, government officials and from an examination of state records by the USA Today Network Atlantic Group, a consortium of 37 Gannett-owned daily newspapers across the Northeast.
At least 3,043 people have died inside New York nursing homes due to COVID-19 complications, or about 17% of the state’s 18,015 deaths as of Wednesday.
In Pennsylvania, about 65% of coronavirus deaths were nursing-home residents, and in counties in the hardest hit southeastern part of the state, long-term care residents account for as much as 80% of county deaths.
New Jersey had 3,200 residents of long-term care homes die due to complications from the virus, about 40% of the statewide total.
About 58% of the deaths in Delaware lived in nursing homes, and 46% of the fatalities in Maryland were at nursing homes, prompting Gov. Larry Hogan to order residents and staff members at nursing homes be tested for coronavirus.
Meanwhile, advocates and residents’ relatives have criticized state and federal officials, as well as some nursing homes, for failing to address the crisis as deaths mounted.
“To have a mandate that nursing homes accept COVID-19 patients has put many people in grave danger,” said Richard Mollot, executive director of the Long Term Care Community Coalition in New York.
“We know facilities have a lot of infection-control problems, we know that facilities have low staff, so what do you think was going to happen when the staff were further strained in caring for these patients?”
Amid the pushback, New York Health Commissioner Dr. Howard Zucker on Wednesday issued an advisory warning nursing homes they could face fines or lose their license if they didn’t properly isolate COVID-19-infected residents, citing state health law.
The letter noted nursing homes incapable of isolating contagious residents should transfer them to other medical facilities and stop admitting additional residents.
New Jersey’s Health Commissioner Judith Persichilli took a similar step on April 13, clarifying how the state’s nursing homes could deny admitting infected patients.
“People just can’t go back until the spread in the nursing homes slows down and until they can take care of their residents appropriately,” Persichilli said the day the revised guidelines were distributed.
Pennsylvania’s Department of Health has not updated its guidance regarding nursing home admission.
A grieving daughter’s COVID-19 nursing home story
Yet efforts have come too late for some family members, many of whom complained of being kept in the dark about risks at nursing homes since visitors were banned in March to combat the virus.
One is Kathleen Cole, who said her 89-year-old mother, Dolores McGoldrick, died April 17 after contracting COVID-19 at Ferncliff Nursing Home in Rhinebeck, New York.
McGoldrick, a former teacher, was infected shortly after a fellow nursing home resident was re-admitted from a hospital in late March, Cole said.
The nursing home staff said the other resident didn’t have COVID-19 when re-admitted but didn’t provide many other details about the case, she added.
Cole, who is a nurse, cast blame for her mother’s death on the entire nursing home system. It spanned from Ferncliff’s inability to contain the virus to state officials’ refusal to release many details about infections and deaths at the facility and others.
“The whole thing has just been handled awfully … by everybody in regard to nursing homes,” she said. “It’s like a slaughterhouse at these places.”
Cole recounted calling nursing home staff about her mother and being told repeatedly that she was stable since testing positive on April 2. But at one point, several phone calls went unanswered, which Cole chalked up to understaffing over the holiday weekend in mid-April.
Cole said she only learned of the true situation after her mother was transferred to a local hospital’s emergency room on April 14.
“My mother’s hands were blue — it wasn’t like a dusky shade blue, her nail beds were blue, her feet were blue, she was ice cold,” Cole said, recalling the scene at the hospital.
“She never opened her eyes for anybody to speak with, and she was just in a horrible, horrible state,” she said. “I know that didn’t occur over the course of several hours; that was something that was accumulating over time.”
Cole has countless unanswered questions, including how her mother contracted the virus. She was in a private room, and staff said there was an isolation unit set up for COVID-19-positive residents, suggesting lapses in containment efforts, Cole said.
“I just felt that she wasn’t being evaluated appropriately, and that actions should have been taken sooner and maybe my mother would have made it through,” she said.
Jon Goldberg, a spokesman for Ferncliff, which had reported six deaths as of Thursday, declined to discuss a specific resident’s case, citing health privacy laws.
In general, Goldberg disputed that staffing shortages existed. He noted the facility was providing sufficient protective gear and COVID-19 testing for its residents and staff despite supply challenges caused by state and federal issues.
In an email, Goldberg wrote that Ferncliff “has no higher priority than the health and lives of our residents and care members.
“We will continue to do everything in our power to protect, care and advocate for them, and to communicate truthfully and candidly with the people who love them and the communities we serve,” he added.
What states are doing about COVID-19 in nursing homes
Central to the nursing home crisis was the early focus on preventing coronavirus patients from overwhelming hospitals.
Massive convention centers and college buildings were converted into temporary hospitals in New York and New Jersey as infections mounted, and hospitals in other states braced to handle surges in COVID-19 patients.
On March 18, Pennsylvania Health Secretary Dr. Rachel Levine directed licensed long-term care facilities to continue admitting new patients, including those discharged from hospitals but unable to go home, and to readmit current patients after hospital stays.
“This may include stable patients who have had the COVID-19 virus,” according to a copy of the guidelines.
Continued admissions was ordered “to alleviate the increasing burden in the acute care settings,” according to the directive. But hospitals in most counties were never overwhelmed with coronavirus patients.
State health officials also directed long-term care centers to employ “normal discharge-to-home” criteria to assist in long-term care bed availability, and to take “appropriate quarantine measures” for positive cases.
On Friday, a state health spokeswoman said the department is reviewing its guidance for long-term care facilities to see if it needed to be updated
As of Thursday, 468 — one quarter of Pennsylvania’s roughly 1,900 long-term care centers — had at least one COVID-19 case, according to state health data.
Those residents and staff testing positive combined account for 17% of the state’s 45,763 residents testing positive for the coronavirus since March 6. They also account for roughly 65% of the 2,292 deaths in the state.
Pennsylvania Health Department spokesman Nate Wardle said the department is aware of the “significance” of COVID-19 in long-term care facilities and is working to assist them as individuals are discharged from hospitals.
Pennsylvania is among six states reporting long-term care infection data where deaths in long-term care facilities account for more than half of overall coronavirus deaths, according to the Kaiser Family Foundation, a national nonprofit that focuses on health care issues.
On March 31, the New Jersey Department of Health told the state’s long-term care facilities that they could not deny admission or re-admission based on a confirmed diagnosis of COVID-19.
The state needed to make room in its hospitals for the growing number of COVID-19 cases and turned to nursing homes to take over the care of some patients.
At the time, Persichilli said there were restrictions in place to prevent the spread of the virus, such as placing asymptomatic residents on their own wings or floors.
“What we were encountering was that a resident would go to the hospital, be treated, recover, and (the nursing home) would not accept the resident back,” Persichilli said at the time.
“Part of the directive is that this is that resident’s home. We keep forgetting that. They should be accepted back with the appropriate precautions,” she added.
At the time, there were fewer than 1,000 known cases in long-term care facilities, which includes nursing homes, assisted living facilities and other care homes.
Not even two weeks later, the number of cases had climbed to more than 5,200, prompting the state to provide additional guidance.
Persichilli on April 13 clarified that the state allowed for re-admission of suspected COVID-19 patients only if they could be placed in isolation.
The order required nursing homes to separate residents in groups and designate staff for each, preventing employees from moving between patients who could spread the virus.
The separate groups are residents who have tested positive for or show symptoms of COVID-19; residents who might have been exposed to the virus; and residents who are not ill and have not been exposed.
On Wednesday, New York’s health commissioner outlined similar guidelines for separating nursing home residents and staff. The advisory also reinforced prior measures taken to protect nursing homes, such as banning visitors and requiring temperature checks of staff.
New York Gov. Andrew Cuomo has said the coronavirus has proven an efficient predator that preys upon nursing homes staff and residents, despite the precautions. He has also urged some nursing homes to reach out to the Health Department to help relocate patients.
“If a nursing home has a patient that they can’t handle, COVID, or whatever the reason, they must refer that patient out of that facility,” he said during a press briefing Monday.
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But New York state Assemblyman Ron Kim, D-Queens, on Wednesday asserted the virus has exposed the poor state of many nursing homes after decades of governmental funding cuts and harmful regulatory changes.
“These tragedies in nursing homes are not accidents, they’re the outcome of bad policy decisions,” he said during a press briefing to announce new legislation seeking to improve care and transparency at nursing homes.
What nursing homes say about COVID-19 crisis
Nursing home leaders contend state and federal officials have failed to provide adequate resources and guidance during the pandemic.
From insufficient coronavirus testing and personal protective equipment shortages, they said the dereliction of duty helped ignite and fuel the outbreak in nursing homes.
“Frankly, I think we’ve been neglected, and we’re still neglected,” said Dr. Elaine Healy, vice president of the New York Medical Directors Association.
“When the focus started being put on us through the efforts of the press, the response has been to sort of look at us in a negative way,” she said, citing New York authorities launching investigations into COVID-19 deaths at nursing homes.
“This is really a series of forest fires burning in different facilities that we didn’t start,” she added.
Strikingly, Italian officials issued similar orders for nursing homes to admit coronavirus patients on March 8, a move under investigation by authorities for contributing to potentially preventable deaths, according to the Associated Press.
Despite push back on state decisions to send infected patients into nursing homes, some administrators say there was no other option.
“Our facilities were ultimately the release valve” for overwhelmed hospitals, said Jordan Strohl, the administrator at The Actors Fund Home in Englewood in Bergen County, the epicenter of the outbreak in New Jersey.
“When we heard from them how bad it was and how bad things were there, I felt like it was our obligation to step up and do the right thing,” he added.
Strohl converted half of the 25-bed sub-acute care building to care for COVID-19 cases, hiring a contractor to install airlocks to prevent contamination. He offered hazard pay and incentives to keep his staff on the job and had nurses volunteering to work with residents on the COVID-19 wing, he said.
Strohl said The Actors Fund Home was likely better prepared than some other nursing homes in the state, and still residents’ relatives were concerned about the state’s order to admit patients with known cases.
One person suggested flying sick residents out to the U.S.N.S. Comfort, the U.S. Navy hospital ship docked in New York Harbor at the time, he said. But that was outside of Strohl’s authority, so he did what he could.
“I tried to write back to every single person,” he said. “I said, ‘I understand your concern, but I will tell you this is the best way to take care of them.’”
Nurse practitioner Lisa Kaplewicz at the Tarrytown Hall Care Center in Westchester County said an issue for residents is when they have to leave the nursing to go a medical appointment.
“That’s a concern because they have the exposure to other people in the community that might potentially be asymptomatic carriers, so we have to presume that there’s been an exposure,” she said.
“We have to isolate these residents within our facility to prevent transmission to the other residents that are here.”
Some nursing homes in New Jersey also adjusted to care only for COVID-19 patients, according to Theresa Edelstein, senior vice president of the New Jersey Hospital Association.
“Nursing homes that care for COVID-19 patients are playing a very important role in preserving access to care,” she said.
“Not every COVID patient discharged from the hospital can go directly home. For those who need additional skilled nursing care, our nursing homes have been there.”
Some experts have called on New York to pursue COVID-19 only facilities for infected nursing home residents, such as those in New Jersey, Massachusetts and Connecticut.
Cuomo this week said some hospitals are designated as COVID-19 only, but the state has not released any details on them.
And others want the state to at least test everyone in every nursing facility for coronavirus. Dutchess County in the Hudson Valley said it will look to test all residents at its 13 homes.
“We have seen the ravaging toll COVID-19 has taken on nursing homes throughout our nation, and we are taking proactive steps to ensure we save lives,” said Dutchess County Executive Marc Molinaro, whose father recently died from the virus.
How nursing homes are testing, staffing during COVID-19 pandemic
In Maryland, Gov. Larry Hogan enacted an executive order on Wednesday requiring universal testing of all residents and staff at Maryland nursing homes, regardless of whether they are symptomatic.
Nursing home outbreaks represent 19% of all total positive cases in Maryland and 46% of all deaths. There have been outbreaks or clusters of cases at 278 different facilities across the state, including 4,011 confirmed cases at 143 different Maryland nursing homes.
“Even when best practices and care is in place, this virus may still be transmitted by asymptomatic staff, meaning that every patient interaction comes with some risk,” Hogan said at a press briefing.
Impacted facilities are also required to provide regular updates to their residents, resident representatives and staff regarding COVID-19 infections, a measure that New York officials required this month amid calls for improved transparency.
Under the executive order, any nursing home staff who test positive will be immediately discharged into isolation. It will also be mandatory for facilities to cooperate with strike teams deployed by the state.
The strike teams will be supplemented with newly-created “bridge teams,” which will provide emergency clinical staffing to facilities in crisis.
Meanwhile, New York on Wednesday revised guidelines preventing COVID-19 positive nursing home employees who are asymptomatic from returning to work for 14 days from the first positive test date.
Previously, the workers could return in seven days based on Centers for Disease Control and Prevention guidance, according to a letter issued by the health commissioner.
Health experts asserted improved testing and clearer guidance on isolation will be key to limiting the death toll in nursing homes.
As the virus is spreading, it is very hard to know what the threshold for stopping admissions should be particularly if adequate COVID-19 testing is not available for residents and staff, said Summer Johnson McGee, the dean of the School of Health Sciences at the University of New Haven in West Haven, Conn.
But McGee believes if new admissions were stopped after the first positive case was identified, it may have given facilities better ability to contain its spread.
“Many facilities are at 100% capacity, which means there were no beds to create isolation units,” she said.
“Nursing homes should be working to create excess beds to be able to isolate healthy patients in local hotels or surge capacity venues.”
Tania Savayan of the Journal News in New York contributed to this report.
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