Exclusive: Under pressure from relatives, SF allows outdoor nursing home visits

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By Sarah Ravani, San Francisco Chronicle, September 4 2020

Theresa Palmer has a Zoom meeting with her 103-year-old mother and other family members. Photo by Yalonda M. James / The Chronicle

The San Francisco Public Health Department has issued a new health order letting nursing home residents receive visitors outdoors — a victory for hundreds of people like Teresa Palmer, who hasn’t seen her 103-year-old mother since March and feared she would never see her in person again.

The city changed its policy Friday, a day after The Chronicle contacted the health department with questions about its months-long ban on such visits, one of the strictest visitation orders in the state. Palmer and other relatives have complained to the city for months about its restrictions, which barred even authorized decision makers from the premises despite state guidance that has allowed outdoor visits at nursing homes since June 26. San Francisco even prohibited window visits.

The city’s new rules took effect Saturday and allow nursing homes that have been free of new coronavirus infections for 14 days to offer supervised one-hour visits outdoors or from cars or through windows, or all three.

“It’s about time,” said Tony Chicotel, a staff attorney with California Advocates for Nursing Home Reform. “Countless visits were lost while they fiddled with this, but ultimately going forward, I’m happy for the residents and their families, and we will see how it plays out in practice.”

San Francisco has at least 19 nursing homes. The new rules cover all but two of them, Laguna Honda and the facility at San Francisco General Hospital, where outdoor visits will also be allowed but under separate policies, a department representative said.

Hugging, hand-shaking and touching are prohibited under the new rules. Nursing homes will have to screen visitors for coronavirus symptoms and ensure that masks are worn and social distancing is followed. Indoor visits are still not allowed. Four people from one household or two people from different households can visit.

Palmer’s mother, who lives at the Jewish Home skilled nursing facility, has a difficult time understanding her daughter on Zoom. Talking on the phone is even harder. That’s because she’s deaf. And 103 years old.

Palmer hasn’t seen her mother for nearly six months since San Francisco issued its ban on nursing home visits March 10 and extended it July 30 to protect residents and staff from the coronavirus.

“You can’t keep people in prison,” said Palmer, a retired geriatrician. “It’s ridiculous. We can get our hair cut outside, but we cannot see our elders outside. It’s crazy.”

She and other families say their relatives in these homes are suffering, and the isolation is having a negative impact on their health. For residents with disabilities or dementia, family members are often their eyes, ears and voice in demanding proper care. Some families were so frustrated with the policy that they removed their relatives from skilled care.

Brian Etemad’s mother, a nursing home resident in San Francisco, stopped eating when he was barred from seeing her in person. Two months ago, he brought her to his home in San Mateo County. “She was thrilled,” Etemad said.

Without access, families said they couldn’t ensure their relatives were receiving the care they needed.

Palmer is among several families that for months had urged the city’s Public Health Department to permit outdoor visits. Their unanswered demands prompted Chicotel to file a civil rights complaint against the department on behalf of nursing home residents on Aug. 18.

Palmer welcomed the new health order, but said it didn’t go far enough.

Residents participate in an exercise activity while socially distanced at Gordon Manor assisted-care facility in Redwood City, Calif. Tuesday, June 30, 2020. Photo: Jessica Christian, The Chronicle

“It’s an important start,” she said. “That is the absolute minimum. There are people who are losing weight, who are distressed … who are too cognitively impaired to understand why their families can’t be there.”

Palmer said the city needs to allow a designated family member to take “all the precautions that staff take” to enter the premises. It’s a guideline that is permitted by the state if a city meets certain requirements.

Not all counties regulate nursing homes, as San Francisco does. In many counties, nursing home administrators can decide the rules, as long as they are within state guidelines.

But Alameda County, which has high coronavirus case rates, also prohibits outdoor visits at nursing homes.

In San Francisco, public health officials defended their previous policy, saying it may have saved lives.

“San Francisco has been extremely cautious regarding its most vulnerable populations,” said a spokeswoman from the city’s COVID Command Center, which is run by the health department. “We took aggressive action early, and one of the most effective actions was restricting” nursing home visits.

“We are aware of the sacrifices that restricted visitation has required of both families and residents,” she added.

Throughout the spring, coronavirus infections and deaths at nursing homes drove the pandemic. Deaths there and at assisted-living facilities still account for nearly 39% of all COVID-19 deaths in California.

But new cases in nursing homes are falling. Across California new coronavirus cases in nursing homes have plunged. The seven-day average was 99 on Sept. 4, down from 481 on July 4. The average number of deaths over seven days on the same dates also dropped by nearly half: to 22 from 41.

Under state guidance for nursing home visits, updated on Aug. 25, nursing homes can facilitate outdoor visits and require masks and physical distance. While the state only recommends that staff screen visitors and ask whether they’ve had symptoms of COVID-19, it requires them to make space available for such visits.

Heidi Steinecker, a deputy director at the state’s Public Health Department, said the state is “requiring that all skilled nursing facilities offer outdoor visitation or visitation in a large communal space.”

The state also allows indoor visits only at nursing homes in communities where there is a decline in new coronavirus cases, hospitalizations or deaths. Also, there must be no new infections among residents or staff of a facility for 14 days, and no staffing shortages. Finally, the nursing home must provide adequate testing and have an approved COVID-19 mitigation plan.

The state keeps a list of facilities that are eligible for indoor visits. As of Sept. 1, three San Francisco nursing homes qualified: Central Gardens Post Acute, San Francisco Health Care and Pacific Heights Transitional Care Center. But under the city’s new policy, even these homes may not invite guests inside.

“We recently discovered the issue with the (San Francisco) county public health order and are in discussions,” Steinecker said, although counties are permitted to impose restricts that are exceed state minimums.

Before the new health order, San Francisco allowed family members or a legal representative to request an exemption to the ban. The city health order said that unless an answer was provided in two business days, the request was considered rejected. The health department did not respond when asked how many exemptions it granted.

Chicotel said he filed an objection on July 22 on behalf of a daughter who wanted to see her mother. Eight days later, Chicotel received an email from the city attorney’s office that the health department was working on updated guidance for visitation and would release it by the end of the next week.

That guidance wasn’t released until more than a month later.

Frustrated, Chicotel filed his civil rights complaint demanding an investigation into the “blatant discriminatory nature” of the health department’s policy.” He has yet to receive a response from the state.

The Chronicle interviewed the woman who sought an exemption from city rules so she could visit her mother.

“You’re trying to do what is best for them and you’re trying to advocate for them, and you’re locked out. You try to get help, and there isn’t any out there,” she said, identifying herself only as Sue, saying she feared the nursing home would retaliate against her mother, a resident.

On Friday, Sue expressed skepticism about the city’s new health order, indicating she will believe it when she is able to visit her mother.

“I’m a little gun-shy and suspicious,” she said.

Sarah Ravani is a San Francisco Chronicle staff writer. Email: sravani@sfchronicle.com Twitter: @SarRavani