An outbreak in a single Seattle nursing home has led to at least 18 deaths from COVID-19, pointing to the vulnerability of such facilities as places where the coronavirus can take hold.
The elderly, especially those with underlying health issues, are more likely to contract severe cases of the illness. The Chinese Center for Disease Control and Prevention found that the death rate more than tripled among patients over 70 there.
Plus, on top of housing high-risk patients in close quarters, nursing homes are particularly challenging places to contain outbreaks of disease because aides go from patient to patient, increasing the chances for a virus to spread quickly.
What are the nearly 700 nursing homes overseen by the Pennsylvania Department of Health doing to defend against an outbreak?
So far, these facilities are mostly taking preventative measures surrounding visitor protocol.
On Tuesday, the American Health Care Association issued guidance that nursing homes only allow essential visitors into their buildings.
All Department of Veterans Affairs nursing homes, of which there are eight in Pennsylvania, will adopt a “No Visitor” stance, with exceptions for when veterans are in their last stages of life in hospice units. The VA also announced Tuesday that it would suspend all new admissions, but will continue to allow transfers from other VA facilities once medical personnel have determined patients are not at risk of having or transmitting COVID-19. Nursing home staff will continue to be screened regularly.
Philadelphia Nursing Home, which has the capacity for 402 residents, is also restricting all visitors, except in extreme circumstances.
At Liberty Lutheran, which runs five senior living communities from Philadelphia to State College, a spokesperson wrote in a statement that the facility has increased frequency of sanitizing measures and availability of hand sanitizer. The company is adding security to offer more extensive screening at the entrances and limiting visitor times. Children under 14 and large groups will be banned from those facilities for now.
ManorCare, which runs 10 facilities across the state, will begin taking the temperature of all visitors upon entry, all employees at the start of each shift, and all patients throughout the day.
But limiting visitors may not be enough, according to researchers. And, in fact, it can be very hard to tell from information available to the public whether a nursing home is adequately prepared for an emergency.
“When we look at what patients or caregivers are looking for when they’re trying to decide what kind of nursing home might be best fit to their needs, typically people focus on the physical environment, how it looks, how nice the staff are or how professional they are,” said Kirstin Manges, a nurse and Ph.D. with the University of Pennsylvania who studies quality control in nursing homes. “However, there is very little out there to allow patients or caregivers to identify how well prepared a nursing home is for a disaster or an outbreak, whether it be the flu or a pandemic.”
In 2017, the Centers for Medicare and Medicaid Services began to inspect facilities for emergency preparedness. But Manges said the required pandemic plans are loose, difficult to interpret and hard to access.
“It’s challenging to know how to capture or measure preparedness in a way that we can accurately describe it to consumers,” she said.
The Pennsylvania Health Department contracts with the Hospital and Healthsystem Association of Pennsylvania to implement emergency preparedness plans on a state level.
Mark Ross, the association’s vice president of emergency management, said facilities plan for flu outbreaks, which can also be deadly at nursing homes, and so they have lots of experience practicing their emergency plans.
“We consistently review those plans, educate and train on them, exercise on them, and then go back and review them again,” said Ross.
For example, in a drill, facilities might be asked to come up with a plan for how staff would continue to provide services even if the facility was under-resourced or understaffed.
Ross said those pandemic plans have been adjusted to accommodate the particulars of COVID-19, but he would not provide any details or specifics of the adjustments. The state-level pandemic plans are not available to the public — Ross said there are also pandemic plans on the regional and facility level, but declined to share them.
Manges, from Penn, said it hasn’t really occurred to people to even ask about emergency preparedness until recently. With an increase in floods, hurricanes and other natural disasters, caregivers are starting to want to know what emergency plans facilities have in place.
One critical element to a strong emergency plan is adequate staffing and pay. Research has shown that 4 out of 10 health care professionals show up to work even when they’re sick with flu-like illnesses. In hospital settings, there is evidence to show that those workers keep coming in just because they’re not feeling that sick. But in long-term care facilities, staff are showing up to work because they’re unable to afford the lost wages. Nursing assistants and aides make an average of $13 an hour.
A spokesperson for ManorCare said the company does offer paid sick leave, but the amount varies by employee, depending on full- or part-time status and how long the employee has been with the company. ManorCare is not offering additional sick leave in light of the COVID-19 outbreak; the spokesperson said the company works with a third-party staffing agency to fill gaps when necessary.
Sheri Gifford, executive director of Philadelphia Nursing Home, also confirmed that her employees have paid sick time, but that the company hasn’t considered adding more in light of the epidemic. She said they’ve discussed a surge staffing plan, but don’t have one in place at the moment.
“We have one presumptive positive case in Philadelphia,” said Gifford. “I think the risk is still considered very low.” As of Tuesday afternoon, the Pennsylvania Health Department had reported 12 cases of COVID-19, with about half of them in the Philadelphia region.
Jule Beckert, the ManorCare spokesperson, said that if a patient tests positive for the disease, he or she will be isolated, as will any employee who had contact with the patient. Depending on whether the patient is considered “end of life,” the person would be transferred out and family visitation would be arranged with the appropriate protective gear.
Fair Acres in Lima, Delaware County, is the largest nursing home in the Philadelphia area, with 874 beds. Administrators there did not immediately respond to a request for comment, but on the automated voicemail at the facility, the operator reminds callers that there are no stipulated visiting hours, and visitors are encouraged to visit their loved ones whenever it’s convenient for them.