Those living in nursing homes or other long-term care facilities are the people most susceptible to infectious diseases. So, it is no surprise that nursing home residents make up a huge part of the U.S.’s COVID-19 deaths. At the end of April 2020, COVID-19 deaths in nursing home reached nearly 12,000.1 According to The Washington Post, almost 1 out of 10 U.S. nursing homes has COVID-19 cases.2

There are clear reasons for the high number of COVID-19 deaths in nursing homes and other long-term care settings like assisted-living facilities, group homes and rehabilitation and psychiatric centers. The residents often have poor overall health and weakened immune systems and they live in close quarters. Moreover, such facilities have frequent visitors and shared staff, both of which can introduce pathogens.

Still, the lack of transparency of COVID-19 cases and deaths among nursing home residents and staff is shocking. Many states release no or only partial information about nursing home outbreaks.3 Some suggest the data embargo is an attempt to hide substandard infection control and medical oversight. Patients’ families, patient advocates, staff and, increasingly, lawmakers are demanding change.4

Nursing Homes Are Loosely Regulated

There are 15,600 nursing homes in the U.S, housing 1.3 million people.5 Nearly 70% of the facilities are operated by for-profit companies with 57% run by chains.6 Genesis Healthcare, whose Milford, Delaware, location reported 12 resident deaths and 61 presumed COVID-19 cases in April 2020,7 runs 426 nursing homes.8

Life Care Centers Of America Inc., whose Kirkland, Washington, facility experienced 37 deaths when the U.S. COVID-19 outbreak first began,9 operates 214 nursing homes.10

Nursing homes are lightly regulated by the federal government with most oversight falling to the states,11 including disclosure of COVID-19 cases and deaths.12 Family and staff members have been kept in the dark about COVID-19 infections, and risks and outbreaks have been deliberately downplayed.13

When USA Today probed why there was not greater federal oversight of nursing homes, especially during the COVID-19 crisis, the answers they received were not satisfying.14

“A spokeswoman for the Centers for Medicare and Medicaid Services said nursing homes are required to follow their local and state reporting requirements, but she did not respond to questions about why the agency is not tracking the number nationally.

CDC spokesman Scott Pauley said the agency used “informal outreach” to state health departments late last month to estimate that 400 nursing homes had positive cases.”

In April 2020, federal lawmakers pressed the federal government to release COVID-19 cases in nursing homes. In a letter to the director and administrator of the CDC, Sen. Ron Wyden, D-Ore., ranking member of the Senate Finance Committee, and Sen. Bob Casey, D-Pa., ranking member of the Senate Special Committee on Aging, wrote:15

“As we work to track and mitigate the spread of this virus … we are alarmed by reports that the Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) are maintaining a list of facilities that have had one or more cases of COVID-19, and yet, have declined to make this information public.

As our nation faces a crisis unlike we have ever experienced, we write to urge you to release this list of facilities immediately and request information on what you are doing to keep nursing home residents, their families and health professionals informed.”

Rep. Jan Schakowsky, D-Ill., and 77 House Democrats wrote Health and Human Services (HHS) Secretary Alex Azar and CMS Administrator Seema Verma asking them to collect and publicly report COVID-19 cases and deaths in nursing homes.16

Nursing Home Problems Existed Even Before COVID-19

Problems at U.S. nursing homes preceded the COVID-19 outbreak. According to City Journal, almost 51,000 of the 61,099 total deaths from the 2017-2018 flu season occurred in those of nursing home age.17 Moreover, the facilities often flunk their inspections, writes the newspaper:18

“Seventy-five percent of U.S. nursing homes have been cited for failing to properly monitor and control infections in the past three years, according to a USA TODAY analysis of federal inspection data …

Those citations have been as mild as a paperwork problem and as serious as failing to inform state officials that unmonitored workers had spread disease to patients in an outbreak.”

Up to 40% of U.S. nursing homes are cited for deficient infection-control procedures, City Journal reported, including the Kirkland, Washington, Life Care Centers of America facility where COVID-19 was first recognized in the U.S.19

Nursing homes are supposed to have an infection-control staffer, but 60% lacked specialized training, according to a 2018 survey, reports the journal.20 According to The Washington Post:21

“Nearly 45 percent of the nursing homes with known coronavirus cases nationwide were repeatedly cited in recent years for violating federal rules meant to protect residents from the spread of infections …

In Oregon … [a] facility failed to screen staffers before they entered the building or ensure that caregivers washed their hands or wear personal protective equipment, inspectors found.

In New Mexico, the state attorney general is investigating a nursing home with at least 13 deaths, saying managers did not require staff members to wear gloves or enforce social distancing.”

CMS inspections conducted post-COVID-19 discovered that over a third of facilities were not observing proper hand-washing and one-fourth were not using protective gear correctly.22 In an opinion piece in The Wall Street Journal, Dr. Michael Segal expresses shock that scrubs are now commonly worn on the street, defeating the whole purpose of them being sterile:23

“When I was being trained as a doctor in the 1980s, we were forbidden to leave the hospital in scrubs. You changed clothes in the hospital to avoid bringing in infections out on scrubs or bringing dirt in. At some point that changed and health care workers started removing scrubs at home and washing them there.”

Patients and Families Not Told of Outbreaks

Nursing homes and long-term care facilities that do not report their COVID-19 cases publicly also likely do not inform residents and their families. According to KUSA TV in Colorado, a woman who went through rehabilitation at the Orchard Park Health Care Center in Greenwood Village after a fall and her son were not told of a COVID-19 outbreak she was exposed to.24

After discharge, she was admitted to a hospital where she tested positive for COVID-19 and died a week later. According to KUSA TV, her son, Jim Wilson:25

“… said he was never told about the outbreak, even after his mother died. ‘I think we should have been told when she was in there. She should have been tested when she was in there, said Wilson. ‘They should inform all future, current and past residents of what’s going on.'”

Jan Ransom, a reporter for The New York Times, was also not told that a nursing home in the Bronx where her father lived had cases of COVID-19, which he had caught. Ransom writes in Pro Publica:26

“What I did not know was that he already had the virus. Shortly after being admitted to the hospital, he tested positive for COVID-19. Hours later, I called the nursing home to alert the staff. A nursing home staffer told me that my father was not the first resident to test positive. He was the fourth. I was stunned …

After realizing my dad’s nursing home had left me in the dark, I started to make some calls. I thought about my father’s roommate and the families of other residents at the facility who were unaware of the storm brewing inside. I was certain I should have been alerted that the virus had been detected in the home they shared. I was wrong.

When I called the state Department of Health to complain on my family’s behalf, I was informed that nursing homes in New York — the epicenter of the crisis in the United States — were not obligated to tell families when the virus is detected in other residents.”

According to National Public Radio, nursing home residents who are poor or of color are also more likely to be exposed to COVID-19.27

“Seven of the 11 nursing homes with the highest number of deaths report that 46 percent or more of their residents are ‘non-white.’ Most of these ‘non-white’ residents are black and latinx. At one facility, the Franklin Center for Rehabilitation and Nursing in Queens, which reported 45 deaths, 80 percent of the residents are minority, including 47 percent who are Asian.”28

Nursing Home Workers Endure COVID-19 Abuses

A nursing home or long-term care facility that does not report COVID-19 outbreaks to authorities or families is unlikely to let staff know the virus risks, either. This puts both residents and staff at risk. Just as heart-breaking as the COVID-19 patients are the deaths of heroic health care workers.29 According to USA Today:30

“Francine Rico, who has worked at Villa at Windsor Park [Illinois] for nearly 23 years, said she found out that a resident she had worked with had tested positive for COVID-19 from a co-worker who happened to take the call from the hospital where the resident was tested. She said her facility’s administrators were not upfront.

‘I’m mad because we are frontline workers but we have been lied to,’ she said. ‘They put our lives on the line. They have put our residents’ lives on the line.'”

Another employee, Tainika Somerville, working at Bridgeview Health Care Center in Illinois, was also kept in the dark. According to USA Today:31

“… she, too, worked directly with a resident who tested positive for COVID-19 and later died. She said no one at the Bridgeview Health Care Center in Illinois told her she’d been in contact with someone who had it. Instead, she learned about it through news articles and social media.”

Nursing home workers, among the lowest paid of all health care workers, have expressed their plans to strike over the lack of protection against COVID-19.32

Nursing Home Risks Starting To Be Acknowledged

There are signs that the great risks nursing home residents and employees face from COVID-19 are being acknowledged. In Pennsylvania, nursing home administrators outside of Pittsburgh announced they would no longer just test for symptoms, but presume all residents to be positive.33

A study in the New England Journal of Medicine confirms that testing only symptomatic residents for COVID-19 is dangerously inadequate and that asymptomatic residents must be included.34

“The data presented here suggest that sole reliance on symptom-based strategies may not be effective to prevent introduction of SARS-CoV-2 and further transmission in skilled nursing facilities.

Impaired immune responses associated with aging and the high prevalence of underlying conditions, such as cognitive impairment and chronic cough, make it difficult to recognize early signs and symptoms of respiratory viral infections in this population.”

With increasing reports of underreported nursing home COVID-19 cases and deaths, CMS issued new guidelines. According to City Journal:35

“In the wake of coronavirus’s emergence, the Centers for Disease Control advised nursing homes to initiate strict controls, including restricting outside visitors, examining all residents for early signs of respiratory distress, and isolating where possible those who test positive for Covid-19.

The CMS followed up with more instructions, including beginning symptom screenings such as temperature checks for all residents. And the federal government instructed states to make nursing homes a priority for receiving medical supplies.”

A few days later, on April 19, 2020, the CMS mandated that nursing homes inform residents, their families and the federal government about cases of COVID-19, which the agency will collect.36 CMS also admitted that nursing homes have become “an accelerator” for the virus.37

But the growing awareness does not assure the transparency and containment of COVID-19 infections. According to NBC News, the nursing home industry is fighting back and seeking to get states to provide immunity from lawsuits to the owners and employees of U.S. nursing homes.38

“So far at least six states have provided explicit immunity from coronavirus lawsuits for nursing homes, and six more have granted some form of immunity to health care providers, which legal experts say could likely be interpreted to include nursing homes …

Of the states that have addressed nursing home liability as a response to the outbreak, two — Massachusetts and New York — have passed laws that explicitly immunize the facilities. Governors in Connecticut, Georgia, Michigan and New Jersey have issued executive orders that immunize facilities.”

While nursing home risks have rarely been clearer, the reaction of too many nursing homes is to circle the wagons rather than improve their conditions. If immunity is granted to nursing homes, it is safe to say the risks from COVID-19 will only get worse.

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