By national standards, the nursing home at the center of the U.S. outbreak of a new coronavirus ranked far better than most.
Life Care Center of Kirkland earned five stars from a federal regulator, which means it is “much above average” in measures such as staffing and the quality of care it provides. While inspectors found lapses in infection control at the Seattle-area home during an April survey, these caused minimal harm, they determined.
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This strong track record did not spare at least seven Life Care residents from dying from the new coronavirus in recent weeks, raising concerns that such an outbreak could happen at long-term care centers in Georgia and elsewhere. Early evidence suggests that older people — especially those with existing health problems — are more vulnerable to the new coronavirus and more likely to die from it, much like the flu.
Public health officials went on alert.
The Centers for Disease Control and Prevention (CDC) issued guidance for long-term care homes, while the federal agency that regulates nursing homes advised them to watch visitors and staff for signs of sickness. The agency overseeing Medicare and Medicaid said it had directed local agencies responsible for inspecting nursing homes to focus their inspections solely on infection control, a directive covering 15,000 nursing homes across the country.
In Georgia, Gov. Brian Kemp acknowledged the heightened risk at these facilities at his news conference Thursday, even as he sought to reassure the public that the risk to most Americans was low.
“I know that this is something that everyone has been concerned about,” Kemp said.
But records show that the vulnerability of the elderly is not the only reason Georgia long-term care residents and their loved ones should pay close attention to the outbreak, an Atlanta Journal-Constitution review found. Well before the emergence of COVID-19, the disease caused by the new coronavirus, these homes have struggled to protect their residents from far more routine infection threats, such as the flu and gastroenteritis.
Nationally, one to three million serious infections occur every year in nursing homes and assisted living facilities, according to the CDC. As many as 388,000 residents die each year due to infections.
Some 43% of Georgia nursing homes had been cited for infection-related problems in the four years prior, according to a late 2017 Kaiser Health News analysis of federal inspection reports. In 2019, the Georgia Department of Public Health confirmed 109 outbreaks in long-term care homes across the state.
State records show that some facilities fall short on matters as basic as training staff to keep their hands clean.
These chronic lapses signal that steep challenges lie ahead for the state’s nursing and long-term care homes, which provide nearly 83,000 beds across the state. Even in ideal conditions, residents are especially susceptible to infections because of their advanced age or other health problems.
"All those things combined make it a powder keg," said New York University School of Global Public Health epidemiology professor Robyn Gershon. "It's a sad indictment of how we take care of our elderly people in this country."
Facility staff move room to room to bathe, feed or change diapers for the sickest of patients, making it easier to spread disease. At larger centers, hundreds of staffers, visitors, volunteers and medical personnel enter their doors every week.
Add these risk factors to inadequate staffing, high staff turnover, and other well-known problems that have troubled long-term care facilities for seniors in Georgia, and it’s clear more work needs to be done to strengthen them against infectious outbreaks, including coronavirus, experts said.
Education and outbreaks
Since the Life Care outbreak, industry leaders have given thousands of homes nationwide guidance on infection prevention strategies, and administrators are eager to learn more, said Tony Marshall, president and CEO of the Georgia Health Care Association, a trade group that represents nursing homes and assisted living facilities.
A Tuesday training webinar brought more than 13,000 viewers, Marshall said. Washington state long-term care homes are sharing how they’re coping with staffing shortages and other issues during the deadly coronavirus outbreak.
“It’s very much an issue that providers are trying to make sure they are prepared for and responsive to,” Marshall said.
At Lenbrook in Atlanta’s Buckhead neighborhood, some 200 residents, family members and staffers attended a special town hall meeting Thursday to learn about coronavirus procedures and express concerns. The facility is also putting into place more stations with hand sanitizer and facial tissue.
"What we're doing most is more communication, more education and probably a bolder approach," said Chris Keysor, Lenbrook's CEO and chair of the board of directors at LeadingAge Georgia, a group that represents not-for-profit senior care services.
Nursing homes, which are federally regulated, must have protocols in place to prevent and control infections, as well as emergency plans that can address an outbreak. For now, they must also employ an infection preventionist, a nurse or other staffer who is in charge of preventing and tracking infections. A proposed Trump administration regulation, however, would roll back this requirement.
Assisted living facilities and personal care homes, which are mostly regulated on the state level, are required to have infection control plans and an adequate supply of cleaning and first aid materials.
Inspections find lapses
All of these centers also must report outbreaks to the state Department of Public Health.
But for some, following these rules has been difficult, an AJC review of recent Department of Community Health inspection reports show.
In November, when DCH inspected Brookside Commerce, it found the personal care home had failed to ensure that 5 of 12 staff members sampled had received training on general infection control practices in their first 60 days of employment.
In December, when DCH inspected Thrive at Green Island, an assisted living community in Columbus, it found that 6 of 7 staff members sampled had not been trained on general infection control principles, including the importance of hand hygiene, in their first 60 days of employment.
Brookside’s administrator said staff has since been trained properly and an infectious disease protocol is now in place. A Thrive spokeswoman did not comment on the specifics of its inspection, but said the home is monitoring the coronavirus outbreak.
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Inspectors found more serious problems at other homes. Brookdale Sweetwater Creek in Lithia Springs failed to report an apparent gastrointestinal illness outbreak that struck last year, and did not participate in an infection control investigation as required, according to DCH records. Out of 19 residents whose files were reviewed, 16 had nausea, vomiting and diarrhea for a nearly two-week period in 2019.
A Brookdale spokeswoman said the Lithia Springs home is no longer one of its locations, but did not provide specifics.
Other inspection reports for Georgia facilities show staffers unaware that they are supposed to report outbreaks. Some told investigators they did not know where to report them.
Manpower problems
For many of these lapses, the root cause is a simple problem of understaffing, experts said, a pre-existing deficit that could become worse if staff members themselves start testing positive for the coronavirus.
“When I read those citations — and I’ve read thousands over the years — what I most often see is workers didn’t have enough time,” said Richard Mollot, executive director of The Long Term Care Community Coalition, which advocates for older and disabled people who live in residential care settings.
Steps such as washing hands or changing gloves fall by the wayside as staff rush between patient rooms to complete their duties, Mollot and other experts said. Sometimes, nursing homes have no registered nurses on site to perform crucial medical assessments, according to the Centers for Medicare & Medicaid Services (CMS).
Conservative estimates show that turnover across the long-term care sector ranges from 45% to at least 66%, according to PHI, a group working to improve care for elderly and disabled people. This makes required training of new staff difficult.
In-service education requires that workers spend time away from caring for patients, said Dr. Lona Mody, a University of Michigan geriatrician who studies infection transmission and prevention in nursing homes.
"Sometimes organizations struggle finding stable staff to make that happen," said Mody. "I think that the industry has done better than in the past, but they do need to have more staging of good infection programs."
Sick leave policies can compound staffing problems. Most long-term care employees are not doctors or registered nurses, but lower-paid certified nursing assistants, dietary staff and janitors who lack job benefits.
The CDC recommends that staff stay home if they show signs of illness, but many low-wage workers go unpaid when they do, or risk getting written up if they take too many days off.
“A lot of these workers are on food stamps and they have to go to public emergency rooms when they’re sick,” New York University professor Gershon said.
Keeping infections out
With no coronavirus vaccine available and testing hard to get, long-term care homes need to focus on staying clear of the virus, said Dr. Swati Gaur, a Gainesville geriatrician who helped write guidance on preventing coronavirus spread for The Society for Post-Acute and Long-Term Care Medicine.
"The best thing we can do for our residents is to keep infections out," Gaur said.
The CDC is asking long-term care homes to use procedures designed to protect against other respiratory viruses such as the flu. Signs at the entrance should tell visitors to turn back if they have symptoms of illness. CMS recommends that visitors and new residents be screened for signs of the virus, while visitors who have traveled within the last 14 days to restricted countries should be barred.
If a flu test on a resident with signs of respiratory infection rules out that disease, care home staff should put that person in a specialized isolation room. In areas where there is evidence coronavirus is spreading among community members, care facilities should screen staff at the door for signs of sickness.
But the best of preparations by long term care homes cannot control all the possibilities posed by the new coronavirus. Homes with outbreaks may have to hire substitute health care workers quickly, and while local experts expect fewer staff shortages in Georgia than those in the Seattle area, the impact depends on the size and length of any local epidemic.
Medical supply shortages are possible. Distributors for some homes are are limiting the number of gloves, masks and other supplies that customers can buy, said Ginny Helms, president and CEO of LeadingAge Georgia. The Kemp administration said Thursday that ensuring adequate medical supplies is part of the state’s response to the epidemic.
Dr. Gaur, who is also medical director of New Horizons long term care centers, wondered whether an order she placed on Wednesday would arrive complete and on time.
All she could do was wait, Gaur said.
“Ask me tomorrow.”
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