How Many of These 68,000 Deaths Could Have Been Avoided?

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By The New York Times Editorial Board, September 5 2020

Nursing home residents and staff members account for around 40 percent of coronavirus-related deaths in the U.S. There’s no justifiable reason for that.

Jose Velasquez, a 79-year-old father from Bexar County, Texas, tested positive for the coronavirus on March 26 and died on April 17. During those weeks, the staff at the nursing home where he lived assured his family that he showed no symptoms of Covid-19 and, according to a lawsuit filed by his children, failed to ensure that he received proper medical care. The staff did not transfer him to a hospital as he deteriorated or even warn his family that he was sick, according to the suit. Mr. Velasquez’s family says that just hours before he died, the staff at the home reported he was “doing fine.”

The facility had a bad safety record, according to the lawsuit, was chronically understaffed, had received citations for failing to carry out basic infection-control programs and, in the months after the coronavirus erupted, its operators did not heed state guidelines for keeping the virus in check. At least 18 residents and one staff member have died from the virus at the nursing home — more than at any other nursing home in San Antonio, according to an analysis by The New York Times; other homes owned by the same company have lost at least 43 more people.

That’s not surprising. Around 40 percent of all coronavirus-related deaths in the United States have been among the staff and residents of nursing homes and other long-term care facilities — totaling some 68,000 people.

Those deaths were not inevitable. The novel coronavirus is adept at spreading in congregant living facilities, and older people face an increased risk of contracting and dying from it. But most of the nation’s nursing homes had months of warning about the coming threat: One of the first coronavirus outbreaks in the country was in a nursing home near Seattle, making it clear that such facilities ought to prepare.

It’s no mystery how. Nursing homes that have managed to contain the virus have done so by employing basic measures such as using personal protective equipment, routinely testing employees and residents and bringing on extra workers. Those successes make clear that many, if not most, of those 68,000 lives could have been spared with careful planning and effective leadership.

To be clear, responsibility for the nation’s disastrous coronavirus response rests largely with the federal government — which left states, cities and institutions scrambling to set social distancing policies, secure equipment and effectively test and trace enough people to stop the virus from spreading. But in nursing homes, those broader failures have been compounded by several long-brewing problems of the industry’s own making.

Some 70 percent of America’s long-term care facilities are run by for-profit companies, including private investment firms. Those companies have squeezed profits out of these facilities by forcing them to skimp on care. As a result, per-patient staffing hours have fallen and staff quality has suffered. A recent report from the Government Accountability Office found that almost half of American nursing homes routinely violate infection-control standards, including those involving the isolation of sick residents, and a ProPublica investigation found that roughly 43 percent of such facilities did not have a legally mandated emergency response plan at the start of this pandemic.

Rather than check these practices with a strong hand or a watchful eye, the Trump administration has granted the long-term care industry several concessions in recent years: smaller fines, potentially lower tax bills and relaxed training requirements for nursing home workers. It has also proposed rolling back infection-control rules meant to keep pathogens like the coronavirus under control.

Since the start of the pandemic, the industry has received billions of dollars in emergency aid — hundreds of thousands of which has gone to companies with terrible safety records. Rather than focus on improving those records, operators of private nursing homes have deployed an army of lobbyists to press for even more funding and favorable policies.

Among the most alarming of those policies is total immunity from wrongful death and other malpractice lawsuits — including those pertaining to the coronavirus — from 2019 through at least 2024. Republican lawmakers and industry trade groups have argued that such protections are necessary to prevent struggling homes from collapsing under the weight of litigation. But there’s a much better way to protect nursing homes from wrongful death lawsuits: help them protect patients from dying needlessly.

In a just world, the long-term care industry would right now face more accountability, not less. Eric Dreiband, an assistant U.S. attorney general, was correct when he spoke of the government’s duty to ensure that nursing home residents “are adequately cared for with dignity and respect and not unnecessarily put at risk.” But the Justice Department’s investigation into whether states violated nursing home residents’ rights by admitting Covid-19 patients into state-run homes from hospitals is not the best way to fulfill that duty. Such transfers were almost certainly unwise, but research continues to show that asymptomatic staff members — not incoming patients — were the driving force behind nursing home outbreaks.

Instead, federal officials ought to increase financial oversight of the industry, in which many businesses have been known to run afoul of the law — for instance, by bilking Medicare, soliciting kickbacks and illegally shielding assets from bankruptcy filings. Investigations by ProPublica and other news outlets have found that some facilities that struck lucrative deals to take on residents who tested positive for the coronavirus did not in turn ramp up their services accordingly.

Every effort should be made to ensure that the bulk of the money that the government puts into this industry goes to patient care, not providers’ pockets. An investigation started by the House of Representatives into the nation’s largest for-profit homes is a meaningful step in this direction. The Justice Department should follow suit.

For another thing, testing mandates and rules about personal protective equipment need to be backed up with financial and logistical support.Facilities and municipalities are still bidding against one another for personal protective equipment, and for most of the past six months long-term care facilities have had no higher prioritization for testing than an average person.

A medic in Austin, Tex., putting on personal protective equipment before entering a nursing home. John Moore/Getty Images

The federal government’s attempts to address these problems have been belated and clumsy: unusable gloves and gowns, a testing initiative that didn’t begin until midsummer and that remains far too meager, and unenforceable mandates. “Before you can hold facilities to testing requirements or mandate the use of personal protective equipment, you have to ensure that they can actually access those things,” said David Grabowski, a health care policy expert at Harvard Medical School.

The only way to prevent the coronavirus from racing through nursing homes is to nationalize the supply chain for these essential tools, and then ensure that they are readily available to the institutions that need them most.

Nursing home staffing shortages also need to be addressed. As Mr. Grabowski and others have noted, certified nursing assistants, who make up the bulk of nursing home workers, have one of the most dangerous jobs in America right now. Their work is more deadly than logging or deep sea fishing — more than 700 nursing home workers have died from the coronavirus so far — and most earn minimum wage or close to it. As certified nursing assistants get sick or quit, staff shortages are approaching crisis levels.

In the near term, lawmakers should provide for hazard pay for nursing home workers in the next relief package and should require all nursing homes to enact non-punitive sick-leave policies so that workers don’t infect colleagues or residents.

In the longer term, federal officials need to consider revising Medicaid reimbursement rates for long-term care so they support higher than minimum-wage salaries, and shifting reimbursement policies so at least some long-term care can be reimbursed with Medicare dollars.

Lawmakers and nursing home operators also would do well to consider a national initiative, perhaps involving student volunteers and internship programs, to recruit future workers to nursing home care. That work, which can be deeply rewarding, will remain urgently needed long after this crisis passes.