Vulnerable, especially in nursing homes, unsafe in covid’s community spread

andbehome-300x191Audiences laugh when Sancho Panza, a sage but servile character in the musical “Man of La Mancha,” observes that “whether the pitcher hits the stone or the stone hits the pitcher, it’s bad for the pitcher.” A paraphrase of that aphorism — regarding community spread of the coronavirus and the elderly, particularly those in nursing homes — might be sadly apt these days.

From Norton, Kansas, to La Crosse, Wis., public health officials and owners and operators of long-term care facilities are watching with dread the predicted Covid-19 surge occurring in communities across the country and surrounding the aged, sick, and injured in institutions.

And while some extreme theorists — including in the White House — argue for a pandemic response that claims the vulnerable can be protected (say, in nursing homes) while the healthy should, doggone it, just get sick with the coronavirus and get it over with, common sense and evidence are laying waste to the risky “let’s let Covid-19 blaze so herd immunity takes effect” theory.

The Washington Post reported that Wisconsin is providing a tragic and real-life petri dish that already is showing, for example, that illnesses among a sizable party hearty student population can have deadly consequence for seniors in long-term care in their shared community. As the newspaper reported:

“Mayor Tim Kabat was already on edge as thousands of students returned to La Crosse, Wis., to resume classes this fall at the city’s three colleges. When he saw young people packing downtown bars and restaurants in September, crowded closely and often unmasked, the longtime mayor’s worry turned to dread. Now, more than a month later, La Crosse has endured a devastating spike in coronavirus cases — a wildfire of infection that first appeared predominantly in the student-age population, spread throughout the community and ultimately ravaged elderly residents who had previously managed to avoid the worst of the pandemic. For most of 2020, La Crosse’s nursing homes had lost no one to Covid-19. In recent weeks, the county has recorded 19 deaths, most of them in long-term care facilities. Everyone who died was over 60. Fifteen of the victims were 80 or older. The spike offers a vivid illustration of the perils of pushing a herd-immunity strategy, as infections among younger people can fuel broader community outbreaks that ultimately kill some of the most vulnerable residents.”

The newspaper noted that rigorous research needs to be done to firmly fix the link between young peoples’ behaviors, infections, and the deadly consequences for the infirm elderly. But preliminary genetic studies show matches of the viral strain that makes the college students sick and their elders seriously ill and worse.

Partisan bickering between a Democratic governor (who wants stringent coronavirus public health measures) and lawmaker state Republicans (who want to open as much as they can to boost the economy) has not helped as coronavirus cases have skyrocketed in Wisconsin.

Failures in infection-control basics

With nursing homes, some fundamental infection-control issues may be in big play, specifically whether over stressed, under trained, and under paid nursing home staff may be central to issues about safeguarding residents from Covid-19 — especially if there aren’t enough care givers and they lack the testing and personal protective equipment they need to protect themselves and those they’re attending.

Yet another research study shows the glaring need for PPE and adequate facility staffing, with Harvard and University of Rochester experts reporting that:

“Using the most comprehensive survey of nursing homes during the Covid-19 pandemic to date, we found that roughly one in five facilities faced a staff shortage or a severe shortage of PPE in early July 2020. Despite a slight decrease in facilities with any PPE shortage driven by the higher availability of gowns, overall PPE and staff shortages had not meaningfully improved since late May 2020 … Staff shortages were greater in facilities with Covid-19 cases, particularly among staff members; in those serving a high proportion of disadvantaged patients on Medicaid; and in those with lower quality scores, including pre-pandemic staffing scores. Given the disproportionate burden of morbidity and mortality faced by nursing home residents, the magnitude of these shortfalls poses a major threat to public health, especially in areas with the highest proportions of nursing homes with severe shortages, many of which experienced surges in Covid-19 activity in July and August 2020.”

The researchers found this, too:

“It is also notable that the most prominent staff shortages were for nurses and nurse aides, as opposed to clinicians or other staff. Shortages in these staffing categories were common before Covid-19, but the pandemic is straining an overstretched workforce that is already contending with low pay and demanding work environments. This point is supported by the finding that nursing homes with lower staffing quality scores before the pandemic were more likely to report current shortages. Nurses and nurse aides are on the front lines of care delivery, with daily or even hourly contact with residents. These shortages could have a major impact not just on nursing homes’ ability to adhere to standard infection control protocols but also on their capacity to provide necessary ongoing care not directly related to Covid-19.”

A rural home hits an awful mark: 100% infection

For anyone tempted to think that the menace of the coronavirus to nursing home residents has subsided after seeming long and lethal months, the town of Norton (pop. 3,000) in northern Kansas near the Nebraska border offers contrarian evidence.

As reported by AARP, the nation’s largest advocacy group for older Americans, the Andbe Home in Norton has been pounded by the pandemic, with all 62 residents infected with the coronavirus. Ten have died and one is hospitalized. The facility has been locked down and residents have been isolated. The local health department reported that 35 staff at the facility also have tested positive. Locals have posted on Facebook, defending the home and its staff. They note that in a small town, everyone knows everyone and the staff has taken care of the home’s residents for a long time.

AARP, however, says that the home’s owners and operators were warned by state officials to step up their coronavirus safeguards but ignored the cautions, possibly with the erroneous idea that the tiny town is so isolated it would not be touched by the pandemic. The seniors’ group reported this, too:

“’What did the nursing home facility do to protect residents?’ asks Elaine Ryan, vice president for state advocacy and strategy at AARP. ‘We cannot resign ourselves to the idea that infections and deaths are inevitable.’ The outbreak is a worst-case scenario for any nursing home, as facilities across the country have at times suspended visits and limited group activities during the pandemic to protect vulnerable residents. More than 252,000 nursing home residents have contracted Covid-19 nationally, according to the latest data from the Centers for Medicare and Medicaid Services. More than 59,000 have died.
An exclusive AARP analysis of federal nursing home data found that 51% of Kansas nursing facilities reported a staff shortage between Aug. 24 and Sept. 20. That’s the second-highest mark nationally, barely trailing South Dakota’s 51.1%. Separately, AARP’s analysis found that nearly a third of the state’s nursing homes reported having insufficient personal protective equipment (13th highest). Kansas also reported 3.3 nursing home staff infections per 100 residents, ranking 15th nationally.”

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 at nursing homes and other long-term care facilities. In these pandemic times, major questions have been raised about nursing home staffing, testing, isolating, and other measures to protect their elderly, ill, and injured residents. Some of those in long-term care who are sickened may find remedy and justice for themselves and their loved ones through lawsuits in the civil system.

But, really, we are past the time for politicians, officials, regulators, and communities to step up and do much more effective battle against the coronavirus and the sickness and death with which it is slamming nursing homes and other long-term facilities. We may need, individually and as families, to redouble our commitment to the highest hygiene, with aggressive hand washing. We can stop arguing and cover our faces. We can maintain distances from each other and avoid contact (now even for relatively short periods) in confined spaces with poor ventilation. We can get vaccinated for the flu and other infections.

We may see youngsters’ opportunities increase for in-person classes, with lesser risk. But we may wish to exercise abundant caution about older kids, their activities, and their contact with older family members and friends, especially those who are frail enough to be in nursing homes. This will be a tough conversation for the holidays, notably as colleges and universities that have welcomed students back to campus send young people home for seasonal breaks. We’ve got a lot of work to do to defeat Covid-19 and to ensure that it stops its relentless preying on the old, sick, injured, communities of color, and the poor.

Photo credit: Andbe Home, Norton, Kansas, as captured by Google Earth street view
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