By Sarah Ravani and Trisha Thadani, San Francisco Chronicle, May 10 2020
California is publicly sharing an incomplete picture of how far the potentially deadly coronavirus has spread throughout skilled nursing facilities for the elderly. Experts say the state’s decision to publish only point-in-time data for each facility rather than case totals over time creates confusion about the scope of infections.
Getting a handle on the true extent of the outbreaks at skilled nursing homes is crucial to containing the spread of the virus and saving lives. Data released Friday show that about 40% of all deaths from COVID-19 in California are among residents and staff at skilled nursing facilities.
But the state Department of Public Health publishes only a snapshot of “laboratory-positive” cases among staff and residents reported within 24 hours every day at 1,224 skilled nursing facilities throughout California. That means numbers only show how many people are currently sick, and do not account for the people who have recovered or have been transferred to a hospital.
While the state offers cumulative totals of all infections at all skilled nursing facilities combined, it doesn’t break out that information for each nursing home — making it difficult to know how far the virus has spread in one place, experts say.
“The state itself knows the data that they are getting from facilities is very unreliable,” said Michael Dark, a staff attorney at the California Advocates for Nursing Home Reform. “Many facilities don’t want to report for business reasons. These are for-profit businesses and reporting themselves as having the coronavirus spreading is going to hurt future revenues.”
When The Chronicle called and emailed 56 Bay Area facilities on the state list and asked for cumulative case and death counts, reporters got a more complete picture of outbreaks and deaths at facilities. In some cases — like at Canyon Springs Post Acute in San Jose and Central Gardens Convalescent in San Francisco — reporters found cumulative cases were nearly double what was reflected in the state’s point-in-time count.
Counties, for example, use cumulative — rather than point-in-time counts — for cases and deaths.
The state requires skilled nursing facilities to submit daily updates on staffing levels, the number of coronavirus patients and equipment availability through an online survey. The survey asks for cumulative data on residents and health care workers who have ever had a COVID-19 diagnosis. It also asks how many residents are suspected of having a coronavirus diagnosis.
If a resident has an active coronavirus diagnosis and is still at the nursing home, they are included in the daily count. But if that resident is no longer at the facility, meaning they’ve been transferred to a hospital, they are not counted in the daily count.
The state didn’t respond to requests for why it doesn’t publicly include cumulative data for each facility. The Department of Public Health said it is working “to provide additional data sets,” including cumulative data for each facility, but did not say when that information would be released.
Not having access to complete data makes it difficult to mitigate the risk, said Dr. Charlene Harrington, a UCSF professor in the School of Nursing.
The facilities are typically home to people who have complex health issues and may require around-the-clock care. Outbreaks at such facilities are particularly worrisome because their residents — often elderly with underlying heath conditions — are extremely vulnerable to dying from COVID-19.
“Everybody in the community needs to know where these hot spots are, and then the public health people need to get on top of it and get the testing out there and implement the prevention procedures to keep it from spreading,” Harrington said.
Relying on facilities to report their own data doesn’t guarantee accurate reporting. The state’s Public Health Department acknowledged that the “data was not fully validated” due to a new system of reporting reliant on facility cooperation.
As of May 6, the state’s cumulative numbers showed that 5,709 skilled nursing home residents and 3,545 facility staff members in California had been infected with the coronavirus, and 19 workers and 979 residents have died. After The Chronicle inquired about why death counts for each facility were not posted online, the state Department of Public Health released fatality information at each facility Friday.
Families are often left in the dark about their loved ones’ safety, and hospitals, which might transport a patient from acute care to a nursing home for recovery after a procedure, may not know if they are sending someone into a high-risk situation.
The state health department says it contacts the state’s skilled nursing facilities to update their cases every day. But in an email to The Chronicle, the state health department acknowledged flaws in its counting because it is facility-reported data and a brand new system, the data is not “fully validated.”
Trying to get accurate data from the facilities proved difficult. Some facilities transferred reporters to administrators who didn’t answer multiple requests for comment. Some also refused to answer.
“I do not care to participate at this time,” said an administrator at Redwood Convalescent Hospital in Castro Valley, before hanging up on a reporter. State data show that the facility has fewer than 11 positive cases among residents and fewer than 11 among staff.
“We are not accepting calls from media right now, thank you,” one person said at Redwood Healthcare Center in Oakland. State data show that the facility has fewer than 11 cases among its staff and 22 cases among residents.
The state’s Public Health Department told The Chronicle that failure to report resident or staff cases of communicable disease or infection and provide timely notification to residents and their representatives could result in enforcement by the department. The department did not specify if the enforcement would be a fine or another action.
The California Department of Public Health has not taken enforcement action during the pandemic because skilled nursing facilities have had “technical issues with the data system,” but “the Department will take enforcement action for non-reporting, especially for repeat occurrences.”
The state’s annual inspections of skilled nursing facilities are now shelved, Dark said. Some skilled nursing homes have a history of poor infection control, which results in violations and fines.
For example, Central Gardens in San Francisco has a history of complaints, including a 2019 citation for a lack of infection control guidelines. But such fines aren’t typically very high and there is no standardized process to issue a harsher citation if a facility has repeat offenses, said Louise Aronson, a professor of medicine and geriatrics at UCSF.
“Infection risk is high,” Aronson said. “If you’re a huge company, a thousand dollars is nothing. That is way cheaper than paying the salary of infection controllers.”
Health care industry representatives — including those representing nursing homes — sent a letter to Gov. Gavin Newsom asking him to sign an executive order protecting nursing homes, senior care facilities, doctors and hospitals from lawsuits and prosecutions during the pandemic.
Meanwhile, California Attorney General Xavier Becerra, along with a multistate coalition, sent a letter to Centers for Medicare and Medicaid Services Administrator Seema Verma to urge nursing homes to immediately increase transparency and outreach to the public and families on the spread of the coronavirus through the facilities.
Providing accurate data and releasing it in a timely manner is critical for nursing home staff, residents and their families. Not having reliable information on coronavirus cases puts people at risk, Harrington said.
“It is so important for the residents, the families,” Harrington said. “They are exposed and they are at risk. And if the nursing homes aren’t reporting accurately then the staff may not even know that they have cases in the facility and the families may not know.”
Sarah Ravani and Trisha Thadani are San Francisco Chronicle staff writers. Email: email@example.com, firstname.lastname@example.org Twitter: @SarRavani, @TrishaThadani