By Peter Whoriskey, Maria Sacchetti and Richard A. Webster Washington Post March 21, 2020
At least 55 coronavirus deaths, one quarter of all fatalities, have occurred in elder care facilities, a Washington Post review finds
Judie Shape, left, who tested positive for the coronavirus, waves to her daughter, Lori Spencer, on March 11 at the Life Care Center in Kirkland, Wash., near Seattle. (Ted S. Warren/AP)
As senior care centers across the country scrambled this week to bolster their defenses against the coronavirus, dozens discovered it already was inside.
Across the United States, the numbers of reported cases of coronavirus at nursing homes, assisted living facilities and other elder care centers have spiked, with at least 73 facilities in 22 states reporting infections, according to a review by The Washington Post of reports from states, local media and nursing homes.
As of Friday evening, at least 55 coronavirus deaths had occurred among people living in elder care facilities, though the number is probably higher because official counts often omit a description of the person’s last place of residence. That figure represented more than a quarter of U.S. deaths then attributed to the pandemic, even though fewer than 1 percent of Americans live in care facilities.
The dangers the coronavirus poses to older people have been well documented, and in a nursing home, the virus can move quickly from person to person and be particularly lethal.
Indeed, in late February, an outbreak at the Life Care Center in Kirkland, Wash., showed just how deadly the virus could be in such settings: At least 129 cases have been reported, and 35 people have died. After that outbreak, at another home in New Orleans, five people died this week.
As coronavirus quietly spread, a nondescript nursing home became the deadliest hot spot
The Kirkland deaths, government and nursing home officials say, spurred their preparations. But as the recent surge in infections shows, some of the defenses may have been deployed too late to slow the virus, while others have been undermined by the same shortages that have constrained the U.S. response to the coronavirus.
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Some nursing homes are not requiring workers to use “personal protective equipment” — disposable masks, gloves and gowns — because of potential shortages, the inconvenience and costs, The Post found. Nationally, some health officials are worried about running out of the protective gear that, among other things, is supposed to prevent the virus from sidelining nursing home workers, firefighters, EMTs and other emergency responders.
Moreover, there are few signs that state health departments are thoroughly testing residents and staff at nursing homes even after an outbreak. At several homes where residents have tested positive, officials are testing only those already showing symptoms, even though some carrying the coronavirus show no symptoms at all.
The federal response to the crisis appears to have been a step behind the virus as well. The government agency that regulates most nursing homes, the Centers for Medicare and Medicaid Services, offered guidance on March 9 limiting nursing home visitors. Four days later, it offered stricter rules, effectively prohibiting visitors unless a resident was about to die, and shutting down communal activities and dining.
The agency regulates more than 15,000 nursing homes across the country that receive federal Medicaid funding.
“America’s patients and providers should rest secure knowing that we are taking aggressive precautions to safeguard your health,” CMS Administrator Seema Verma said in a statement announcing the rules March 9.
Despite assurances, nursing home residents and their loved ones often feel adrift, unable to decide where a person would be best protected from the virus.
“Should I pull him out of there? What should I do?” Elizabeth Penner, a Seattle lawyer whose 71-year-old father is in a retirement home, said earlier this week.
Her father’s facility, the Lakeshore, has had two positive coronavirus cases, one on March 14 and another on March 18.
She worried officials seemed unable to test quickly enough to separate the healthy from the sick.
“There’s completely insufficient resources to deal with what they know is coming,” said Penner, 32, her voice cracking.
She also has a husband, 3-year-old son and two stepchildren who shuttle between homes and could infect her father if he stayed with her.
Her father was not tested until Wednesday and on Friday learned his results were negative. She felt he was safest staying put.
‘This could happen anywhere’
Approximately 1.3 million people resided in federally certified nursing facilities in 2017, the most recent data available, and another nearly 1 million were in assisted living or retirement communities, according to the Kaiser Family Foundation (KFF), a health policy research organization.
Nursing facilities have accounted for a significant number of deaths because they can turn into breeding grounds for illnesses, the foundation said in a policy brief released after the outbreak in Washington state. Facilities often are densely packed with elderly or sick residents sharing a room. Infection and respiratory issues are common.
Most people who contract the coronavirus have mild symptoms, but the elderly and those with diabetes or heart or lung disease are at higher risk of falling severely ill, or dying. Approximately 16 percent of all nursing home residents nationwide underwent treatment for a respiratory illness in 2017, according to the analysis.
“The grim reality is that, for the elderly, covid-19 is an almost perfect killing machine,” said Mark Parkinson, president and CEO of the American Health Care Association (AHCA), during a recent CNN interview.
Jeffrey Duchin, the public health officer in Seattle’s King County, warned that the tragedy at Life Care was not a fluke, noting conditions there are no different from “any long-term care facility, anywhere in the country.”
“This could happen anywhere,” Duchin said.
While nobody has pinpointed how the virus entered the home, the Centers for Disease Control and Prevention found that staff members working in multiple facilities and “limitations” in infection control helped propel the virus through the home and others in the area. Almost 40 percent of nursing homes nationwide had at least one infection control “deficiency” in 2017, which could include staff failing to wash hands, according to the Kaiser analysis.
Infection control is complicated and requires robust staffing and sustained monitoring often found in hospitals but less so in short-staffed nursing facilities, Duchin said.
“The unfortunate truth is that long-term care facilities do not have the same infection control resources on a daily basis that acute care hospitals have,” he said. “They’re not required to have the same amount of infection control, oversight of their work or training. And they don’t have funding to bring on people to do that routinely.”
At Life Care, county health officials said, a typical night shift had nine people for 120 residents.
“It’s difficult for staff who are working very hard and sometimes understaffed at these facilities to take on that responsibility,” Duchin said. “So for all those reasons, I think you’ll see around the country that these facilities are going to be hit very hard by covid-19, just like they’re hit very hard every year when we have an H3N2 influenza season.”
Indeed, Kirkland is hardly alone. On Wednesday, officials in Florida reported that residents or workers at 19 elder care facilities had tested positive. In Oregon, possible cases were being monitored at 97 long-term care facilities. In Washington, at least a dozen elder care facilities have reported cases.
Outbreaks at several facilities raised alarm because of how quickly they spread to other residents: At one nursing home near Chicago, 46 residents tested positive, state officials reported this week. At another in Lander, Wyo., eight tested positive, and one in New Orleans has 23 cases, including five dead.
Protective gear shortage ‘a money thing’
The nation’s nursing homes have taken important steps to address the threat. Many have followed federal guidance and essentially banned visitors. Many facilities have suspended group classes for exercise or crafts and do not allow residents to gather for meals. They also have set up extra hand-washing stations and take residents’ temperatures more frequently.
Lisa Sweet, chief clinical officer of the National Association of Health Care Assistants, a group that represents nursing aides, says some nursing homes are not ready.
One critical issue is a shortage of basic supplies, such as alcohol-based hand sanitizer or the personal protective equipment that helps prevent workers from contracting the virus and spreading it from one patient to another as they make the rounds.
Among challenges at nursing homes, aside from the vulnerability of residents, is that one worker, if infected, can become a “super-spreader,” said Lauren Ancel Meyers, a professor at the University of Texas at Austin who has studied infectious-disease surveillance.
While several nursing assistants interviewed say they have not been ordered to use the personal protective equipment at their nursing homes, Sweet said they probably should be. While nursing home aides are required to use gloves when carrying out some tasks, the presence of the coronavirus means such workers also could be wearing masks and face shields to prevent spreading the highly contagious virus.
“If a resident is not symptomatic, they could still be infectious,” she said. “Nursing assistants work so closely with people — to feed them, to brush their teeth — that they’re vulnerable.”
“Most nursing homes don’t have an overabundance of supplies — they don’t have the budget or space,” Sweet said.
Sherry Perry, a nursing assistant from Lebanon, Tenn., said staff at her workplace are not using personal protective equipment with residents.
The nursing home has not yet had any cases, she said, and “if they turn on their light 20 times for help, we would have to suit up 20 times.”
But she said she agrees with those who say personal protective equipment beyond gloves ought to be used even before an outbreak is discovered.
“I agree with that, but companies don’t,” Perry said. “It’s a money thing.”
There is a federal stockpile of masks and other gear, and states can receive allocations from that. But supplies are grossly inadequate, and manufacturers warned as far back as 2009 that a pandemic could lead to significant shortages of masks.
Tamara McBride, chief of the Ohio Bureau of Health Preparedness, said the federal allocation is “not enough.”
The state is urging dentists and veterinarians to postpone elective surgeries to preserve hospital gear, and McBride said they also are asking the construction industry and the food service industry to conserve masks and gloves.
State health officials limit testing
While President Trump said two weeks ago that “anyone who wants a test can get a test,” several administrators and residents say state public health officials have refused to test all residents in facilities in which there has been an outbreak.
Despite the example of the Life Care Center, where an infection quickly spread to dozens of residents, state officials responding to some nursing home outbreaks are not testing all residents — that is, until they show symptoms. But by then, the disease may have spread.
At the Lambeth House in New Orleans, site of one of the deadliest nursing home outbreaks, testing did not begin until two days after a resident reported symptoms and checked into a hospital.
The facility immediately restricted interaction among residents, canceled all communal events, closed the cafe and wellness center, and prohibited any nonessential people from entering the property, Lambeth House spokesman Greg Beuerman said.
But testing has been limited to patients who have displayed symptoms. By Thursday, five residents, all men between ages 80 and 98, were dead. Eighteen others have tested positive.
“Hospitals have made it quite clear they don’t have the capacity to house everyone who comes down with the virus,” Beuerman said. “So, unless there are any other issues they are sent back [to Lambeth].”
Similarly, the Westchester Center for Rehabilitation and Nursing in Mount Vernon, N.Y., reported its first case March 14, after a resident had gone to the hospital with symptoms. Staff at the facility, which had already limited visitors, quarantined the section of the home where that resident lived, and workers began using personal protective equipment in treating residents there.
After two more residents tested positive Tuesday, state officials tested a “select group” of patients — people who had been roommates or lived adjacent to the residents who tested positive.
“We’re trying to get the [state Department of Health] to test more,” said Ari Zadeh, administrator of the facility. “We keep hearing there are millions of test kits coming. I haven’t seen them.”
Zadeh also predicted more nursing homes will be affected.
“Right now, this [New York] area is a hot spot,” Zadeh said. “But it’s going to hit every nursing home in the country at one point or another. There simply isn’t enough hospital beds to handle all that are or will be infected, at which point hospitals will be dependent on post-acute facilities like us to help. And it’s going to get worse before it gets better.”
Similarly, at the Atria in Burlingame, Calif., where five people have been affected by an outbreak in one facility, only some residents have been tested.
Julie Berk said her 85-year-old mother, Cari Parker, has yet to be tested.
“Of course we’re concerned — extremely concerned,” Berk said. But “they said only people who show symptoms will get tests.”
A grim reality inside homes
All the precautions have made life in the nation’s nursing homes and similar facilities gloomier.
In place of group activities and visitors, there are frequent instructions to wash hands and keep apart from one other by six feet or more.
Sheena Bumpas, a nursing assistant in Duncan, Okla., said no one on the Alzheimer’s wing understands the reasons for the precautions.
When they are walking toward someone, “we just go behind them, try to redirect.”
John Adams, 62, a U.S. Navy veteran and resident at a veterans home in Chula Vista, Calif., said he feels “really fortunate.”
He said residents are required to take their meals at a distance from one another in the dining room.
“The more that the social distancing things are enforced, the more they’re feeling it. We’re kind of joking about sending semaphore signals to each other across the dining room.”
All eight California veterans homes have restricted visitors and are screening residents and staff for symptoms, said Lindsey Sin, acting communications director for CalVet. They had not found any coronavirus infections as of Friday, she said.
Adams said he hopes the approach works, but he was unnerved in recent days when he saw staff taking one resident’s temperature. He spotted fingerprints on the washers and dryers, so he wiped them clean.
“I’m doing the best I can,” said Adams, who has a compromised immune system due to multiple sclerosis. “I wash my hands like a maniac.”
Jacqueline Dupree contributed to this report.