Nursing homes failing to fix well-known infection-control fundamentals

cmsseemav-150x150Nursing homes and other long-term care facilities now account for around 62,000 coronavirus deaths, 42% of the country’s total. So how is it possible that, months into the pandemic, owners and operators keep failing to fix well-known infection-control basics, like mixing healthy and infected residents and allowing poorly paid staffers to work at multiple facilities, carrying the disease from each to each?

On a side note, is it any comfort to frightened nursing home residents and outraged loved ones that Seema Verma, the nation’s chief regulator of long-term facilities, has obsessed, with taxpayer money, of course, on her image and public relations — spending on girls’ night bashes and face time with well-heeled patrons in her own party?

The independent, nonpartisan Kaiser Health News service deserves credit for piecing together various information sources to raise significant questions about not only nursing homes and long term care facilities but also hospitals and the care giving institutions’ infection-control procedures — notably whether, with all medical science knows now about Covid-19, facilities appropriately separate and isolate individuals with coronavirus diagnoses from others uninfected.

Reporter Christina Jewett said she not only interviewed key parties but also examined government workplace safety complaints and health facility inspection reports:

“A KHN investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate Covid patients from those without the coronavirus, in some places fueling its spread and leaving staff unprepared and infected or, in some cases, dead. As recently as July, a National Nurses United survey of more than 21,000 nurses found that 32% work in a facility that does not have a dedicated Covid unit. At that time, the coronavirus had reached all but 17 U.S. counties, data collected by Johns Hopkins University shows. KHN discovered that Covid victims have been commingled with uninfected patients in health care facilities in states including California, Florida, New Jersey, Iowa, Ohio, Maryland, and New York.”

What in tarnation are medical personnel thinking in commingling the sick and well? KHN reported this:

“Covid patients have been mixed in with others for a variety of reasons. Some hospitals report having limited tests, so patients carrying the virus are identified only after they had already exposed others. In other cases, they had false-negative test results, or their facility was dismissive of federal guidelines, which carry no force of law. And while federal Medicare officials have inspected nearly every U.S. nursing home in recent months and states have occasionally levied fines and cut off new admissions for isolation lapses, hospitals have seen less scrutiny.”

Staff travel and spread disease

With long-term care facilities, experts keep drilling down for causes of deaths and infections among residents and staff. The New York Times said that a key driver appears to be the institutions’ own, poorly paid health workers. They may need to piece together multiple jobs at different facilities to make a living. The testing they receive has been a variable, and, especially until recently, sketchy at best. They have complained that they lack desperately needed personal protective equipment and training in dealing with a medical calamity of global dimension.

Day to day, what has occurred is that health workers go from one long term care center to another, not only caring for the old, sick, and injured, but also infecting them and others with the coronavirus.

As the New York Times reported:

“A recent report by the National Bureau of Economic Research that looked at geolocation data found that 7% of smartphones appearing in a U.S. nursing home also appeared in at least one other elder facility, even after visits by patients’ friends and family members were restricted. The typical nursing home has, on average, staff connections with 15 other facilities, said the report, which concluded that ‘eliminating staff linkages between nursing homes could reduce coronavirus infections in nursing homes by 44%. In Florida, the researchers found a web of interconnected nursing homes and assisted living facilities, particularly in Miami-Dade County, which has one of the highest concentrations of them in the country …

“’What our research is suggesting is that the real culprit here, epidemiologically, appears to be shared staff,’ said Keith Chen, professor of behavioral economics at the UCLA Anderson School of Management and a lead author of the report. Nursing homes generally struggle with finding enough staff and, faced with laws that require a certain number of staff hours per resident, ‘there’s a tremendous number of staffing agencies that spring up to spread workers across nursing homes,’ he said. ‘But that’s exactly what you don’t want in the middle of a respiratory pandemic.’”

The newspaper interviewed health workers who described their economic plight and toil — often for vulnerable individuals who the care givers emphasized are in dire need of their help:

“Sheryl Carlos, 56, works three jobs seven days a week in Port St. Lucie, north of West Palm Beach. One is at a nursing home and another at a retirement community; she earns extra income caring for a couple of people in private homes. She makes about $13 an hour. ‘Let me tell you something, I don’t have a life,’ she said recently as she drove back home in the early morning after finishing a nine-hour shift. “If some jobs were paying you enough, you wouldn’t have to be working like that.’”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them and their loved ones by abuse and neglect in nursing homes and other long-term care facilities. The pandemic has taken a terrible toll on the aged, sick, and injured in long-term care. It is unacceptable and has been unrelenting, popping into public view early in Washington state, saving the Northeast, and then spreading across the South, West, and Midwest.

If health workers themselves, journalists, behavioral economists, and safety advocates can drill down on and spotlight persistent injurious practices (of a common sense variety) at nursing homes and other care facilities, it might be the immodest query for bureaucrats, regulators, politicians, and maybe even prosecutors and law enforcement: Why are obvious and fundamental infection control issues getting taken care of? What kind of willfulness allows negligent practices to recur and recur?

Yes, states and the federal government share the oversight of these facilities, notably with more local teams inspecting sites.

Reputation building on the public buck

That said, the buck rises upward fast, with regulatory responsibility for nursing homes and long-term care falling under the Centers for Medicaid and Medicare Services (CMS), headed by Verma. She has taken a much-earned shellacking from congressional Democrats, who say they have investigated and affirmed her inappropriate spending of millions in taxpayer dollars for PR consultants and flacks. They have gotten insider information and have thrown public money at private events to fete Verma, get her on magazine covers, and to arrange for her to cozy up with powerful people — in her own political party.

The New York Times, in what might be an embarrassing framing of its skewed views of capital politics these days, described the investigation of Verma’s skeevy spending and pursuit of the political spotlight as having “exposed not only a shadow operation to polish Ms. Verma’s personal brand but also the underside of life in Washington, where the personal and the professional often blend into a mélange of questionable interactions. Democrats said the report expanded on the findings of an audit in July by the inspector general of the Department of Health and Human Services that criticized Ms. Verma’s use of outside consultants to perform ‘inherently governmental functions,’ including strategic communications. Ms. Verma runs an agency with a $1 trillion budget and 4,000 federal employees, overseeing federal health care programs used by 145 million poor and older Americans…”

Fie on apple polishing and politicking while the vulnerable get sick and die. If Verma aspires to grander attention and maybe a posher political post or fat cat corporate gig, she and the folks who report to her could better deserve and earn it by digging in and doing job no. 1 — safeguarding the institutionalized elderly, ill, and injured. Facility owners and operators need to step up much more, too. They could do what they have promised residents and their loved ones, providing appropriate care, notably with infection controls to safeguard people at high risk. The owners and operators could do right by their own people, too, providing them with the testing, PPE, and training they need. And paying them in fairer fashion for the hard, difficult work they do.

With the average cost of a private room in a nursing home soaring to near $100,000 a year, it is tough for residents and loved ones to hear owners and operators — now, many of them equity investors aka profit-hungry hedge funds — cry, “poor me.”

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