Nursing Homes and COVID-19
The environment, the staff, and the residents
Author: Yasmeen Makboul
Nursing homes and other long term care facilities have been deemed hot spots for the deadly, novel coronavirus.
As of October 2020, “More than 84,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19”.4 But why? The page will focus on how nursing homes have been devastated during the COVID-19 pandemic: from their residents, the staff, to the environment in which they must operate.
Voiceover summary (2:57m) and transcript
Transcript:
Hello and welcome. My name is Yasmeen Makboul. I am a graduate student at the OHSU-PSU School of Public Health. Today, I will briefly explain how and why nursing homes and other long term care facilities have been deemed hot spots for the deadly, novel coronavirus.
Nursing homes have become hot spots for a number of reasons: they house a mostly elderly population with underlying health conditions, they often operate with inadequate staffing and an inadequate supply of PPE, they have long struggled following infection control procedures, and without proper precautions congregate living conditions can cause infection rates to skyrocket.
Nursing homes have long struggled with infection control. Studies show that understaffed nursing homes have higher rates of infection. The busier the staff, the less time they have for hand washing and following other infection control protocols.9
Nursing home staff are often paid far below a living wage. Specifically, CNAs and caregivers, deemed essential and heroic, are being paid a median salary below $30,000 a year, with little to no sick leave.5,8 This can push nursing home staff to work multiple jobs at different facilities.5 The CDC stated that this movement of staff from facility to facility, along with a shortage of PPE, was likely the culprit of coronavirus infection transmission in nursing homes.5 With significant community spread, staff members are at increased risk for contracting the virus and bringing it into the nursing home with them.3,10
Nursing home residents are being infected and dying at high rates. Their older age combined with other underlying health issues makes them more susceptible to a severe case of COVID-19 with more complications. “By July 30, 2020, 362,000 people in virtually every U.S. nursing home were infected with the virus, representing about 8% of all cases in the country”.8 As of October 2020, “More than 84,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19”.4
Without proper PPE and infection control training and compliance, combined with chronically low staffing levels and increased risk in residents because of age and underlying conditions, it was inevitable that COVID-19 would devastate these facilities, the staff, and their residents.
In order to begin to combat this crisis within nursing homes, staff and residents must be able to receive testing regularly and adequate PPE must be provided and used correctly. Facilities also need to take better care of their staff by creating better work environments, including having adequate staffing, providing hazard pay, sick time, and other benefits. To accomplish this, and to further enhance care and safety for staff and residents in nursing homes, the government needs to pay attention to what is happening within them and assure they are funded well, operating effectively, and continuously monitored.2
New Recording.m4aThe Environment
The Many Risk Factors for Nursing Homes as Hot Spots2
Mostly elderly population with underlying health conditions
Inadequate staffing
Inadequate PPE supply
Poor infection control
Congregate living
Nursing Homes Struggle with Infection Control
Nursing homes are notorious for struggling to follow infection prevention protocols, suffering high infection rates long before COVID-19. One study reported that 9,697 nursing homes in the U.S., or 63%, were cited for one or more infection control issues.9 Unsurprisingly, more citations were found at facilities that were understaffed compared to those with higher levels of nurses and nursing aides.9
Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, stated, “'So many times, when there aren’t enough staff, the aides and nurses are literally trying to do 50 things at once, running from person to person. That’s when things fall through the cracks, like hand washing, which is the most useful thing to do to prevent infections’”.9
Astonishingly, 4 in 10 facilities in the U.S. have been cited for infection control errors and deficiencies, even in nursing homes with high government ratings in overall quality.9
Government inspection reports from across the U.S. show that many infection control errors are basic. Errors included skipping handwashing between patients, or failing to wear personal protective equipment (PPE) in rooms with contagious patients in isolation.9
"It’s all these little things that are part of infection-control practices that when they are added up can create an environment for an infection outbreak".9
-Patricia Hunter, Washington State Long-Term Care Ombuds
The Staff
Nursing Home Staff: Underpaid, Under-Appreciated, and Overworked
Nursing homes are often understaffed, and workers are likely to be underpaid and overworked.
Certified Nursing Assistants (CNAs) and aides make an average of $14.25 per hour. Earning a living wage can require being employed at multiple facilities.5
These workers, deemed essential and heroic, are being paid a median salary below $30,000 a year, with little to no sick leave.5,8
Further, many nursing homes rely on staffing services to provide them with workers on an as-needed basis rather than hiring, effectively training, and paying full time staff.
Nursing Homes Can't Adequately Pay Their Staff
In a report about nursing home staff in California, facilities say that they, "can't pay [staff] more because [the state of] California doesn't pay them enough through Medicaid".4
Mike Dark, an attorney that works on nursing home reform, says that, "the state already tried paying nursing homes more in 2006... That money tends to go into the pockets of the executives and the administrators who run these places”.4
Instead of paying staff more per hour, or hiring more full-time workers, administration is pocketing these profits.
On the other hand, facilities may not be getting enough money from the state or Medicaid to make significant increases in their staffs' salaries and benefits.3
Spread by Staff Shown to be Catastrophic
Staff working at multiple facilities is likely to be the culprit of coronavirus infection transmission in nursing homes, said a report from the Centers for Disease Control.5
A study done in New York State estimated that about 25% of nursing home workers tested positive for the virus.5
"By July 30, 2020, 362,000 people in virtually every U.S. nursing home were infected with the virus, representing about 8% of all cases in the country".8
Sadly, this movement of staff between facilities and high infection rate has shown to be incredibly disastrous to the health of staff and residents.
A recent report showed that the average nursing home has staff connected to about 15 other facilities.3 Research estimates that if nursing home workers had the pay incentive to work at only one facility, outbreaks could be reduced by 44%.5
Nursing Home Staff Aren't Being Protected During COVID-19 Pandemic
Nursing home staff were not being protected early enough to aid in stopping the spread of the virus. Facilities were often unable to provide staff with proper PPE to protect themselves and their residents.
With significant community spread, staff members are at increased risk for contracting the virus and bringing it into the nursing home with them.3,10
Without proper PPE and infection control training and compliance, combined with chronically low staffing levels and increased risk in residents because of age and underlying conditions, it was inevitable that COVID-19 would devastate these facilities, the staff, and their residents.
"Unfortunately, staff have been the largest vector towards bringing COVID into nursing homes around the country".3
-David Grabowski, a professor of health care policy at Harvard Medical School
More about PPE and Worker Protections:
What has been happening around the U.S.?
"Across the country, nearly 15 percent of nursing home providers say they have less than one week of supply of at least one type of key personal protective equipment, such as gloves or masks".10
[A nursing home staff member] said, "administrators told her that they were going to order medical-grade eye protection, but that suppliers were out. Instead, she said, she was given orange plastic swimming goggles”.6
"In Baltimore County, at the Forest Haven Nursing and Rehabilitation Center, workers said they were given rain ponchos and nylon hair bonnets in early April, after Maryland required all nursing homes to provide the staff with protective equipment".6
"In East Los Angeles, at the Buena Ventura Post Acute Care Center, a five-star facility, a certified nursing assistant, said workers were not given masks until April, well into the outbreak in the United States".6
Let’s be clear here: the spread of COVID-19 is not at the fault of nursing home staff. The real enemy here is the system. The system that nursing homes operate under often forces people to work at multiple facilities to make ends meet, increasing risk of transmission and exposure to COVID-19.3,5,8 Further, nursing home management and administration and the U.S. government have failed during this pandemic to provide workers with an adequate supply of PPE.6,10 This has caused the spread of COVID-19 from staff member to staff member, staff member to resident, and vise versa.
The Residents
Nursing Homes Residents are at High Risk for Contracting COVID-19
Nursing home residents are being infected and dying at high rates. Their older age combined with other underlying health issues make them more susceptible to a severe case of COVID-19 with more complications.
"By July 30, 2020, 62,000 nursing home residents died of COVID-19, accounting for 41% of all nation COVID-19 deaths".8
“She said her strongest concern was for the residents... 'It’s so unfair to them. They contracted this through no fault of their own’".6
-Donna Johnson,
a cook at Forest Haven Nursing and Rehabilitation Center in Maryland
a cook at Forest Haven Nursing and Rehabilitation Center in Maryland
“If the virus doesn’t kill me the loneliness will.”
The quote11 above is from one nursing home resident as they reflect on being isolated from their loved ones during the COVID-19 lockdown.
Not only is the pandemic a threat to their physical health, but their mental health is also at risk.11 The restrictions put in place for visitors and social gatherings have virtually shut residents into their rooms for months.
"'No visitors, no going out, no nothing,'” commented one resident surveyed".11
"According to the CDC, social isolation significantly increases the risk of premature death from all causes... Social isolation is also associated with a 50% percent increased risk of dementia".11
Many residents, family members, and advocates feel that family visits should be a priority and that facility management need to get creative on how this can become possible and still be safe.11
Minority Residents at Higher Risk for COVID-19 Compared to Their White Counterparts
COVID-19 has been infecting and killing people of color at disproportionately higher rates, and minority nursing home residents are no exception.
Nursing homes whose residents are majority Latino and Black are twice as likely to have a coronavirus outbreak in their facility compared to those homes where the resident population is majority white.6
In another analysis of more than two dozen states, researchers found that "the death rate was more than 20% higher in majority-Black facilities compared with majority-White facilities".7
"Typically, what occurs in the general population is mirrored in long-term care facilities".6
In communities of color with little resources, low socioeconomic status, and high rates of chronic disease, there are higher rates of COVID-19 and poorer outcomes.8
Again, let's be clear here: this inequity between majority-Black facilities and majority-White facilities is a product of racism. Any disparity in terms of race during the pandemic "is socially and politically constructed. These disparities are due to racism”.7 Higher proportion minority facilities don't have access to the same resources as majority-white facilities, or, more specifically, they aren't able to obtain resources to better help and care for their residents.8
Higher proportion minority facilities typically are "larger for-profit facilities affiliated with a chain, [have] more Medicaid residents and lower RN [registered nurse] and total nurse staffing hours, and [are] located in counties with more COVID-19 cases and deaths".8
Again, with significant community spread, staff members are at increased risk for contracting the virus and bringing it into the nursing home with them, ultimately infecting their residents.3,10 Communities of color are suffering from COVID-19 at a much higher rates compared to their white counterparts.
Further, "a lack of access to quality health care, educational opportunities and a stable income"7 and other "long-term imbalances"7 have caused minorities to suffer from numerous chronic and communicable diseases.7 COVID-19 is no exception.
So, what do we do to combat this crisis?
Provide regular testing for nursing home staff members and residents
Provide effective and adequate PPE for staff
Provide nursing home staff with sick leave, increased salaries, benefits, hazard pay, etc.
Provide nursing homes with more staff to effectively care for residents, so they follow infection control protocols, etc.
To accomplish this, and to further enhance care and safety for staff and residents in nursing homes, the government needs to pay attention to what is happening within them and assure they are funded well, operating effectively, and continuously monitored.2
ABC News Nightline video
This ABC News Nightline1 video clip provides a comprehensive overview of how COVID-19 has overloaded and devastated nursing homes.
Video (10:38m): How COVID-19 turned US nursing homes into devastating hotspots
Click on the link above or on the video to the right to view.
References
2 Bion, X. S. (2020, August 12). Why Nursing Homes Become COVID-19 Hot Spots. Retrieved November 23, 2020, from https://www.chcf.org/blog/why-nursing-homes-become-covid-19-hot-spots/
3 De Freytas-Tamura, K. (2020, September 10). 'They Call Me a Criminal': Nursing Home Workers Who May Spread the Virus. Retrieved November 23, 2020, from https://www.google.com/amp/s/www.nytimes.com/2020/09/10/us/virus-florida-nursing-homes-contract-workers.amp.html
4 Fortier, J. (2020, October 24). Employees Who Work At Multiple Nursing Homes May Have Helped Spread The Coronavirus. Retrieved November 22, 2020, from https://www.npr.org/2020/10/24/927384339/employees-who-work-at-multiple-nursing-homes-may-have-helped-spread-the-coronavi
5 Fried, C. (2020, November 17). Employees Work at Multiple Nursing Homes and Spread COVID-19. Retrieved November 22, 2020, from https://www.anderson.ucla.edu/faculty-and-research/anderson-review/nursing-networks-covid
6 Gebeloff, R., Ivory, D., Richtel, M., Smith, M., Yourish, K., Dance, S., . . . Parker, M. (2020, September 10). The Striking Racial Divide in How Covid-19 Has Hit Nursing Homes. Retrieved November 23, 2020, from https://www.nytimes.com/article/coronavirus-nursing-homes-racial-disparity.html
7 King, S., & Jacobs, J. (2020, October 29). Near birthplace of Martin Luther King Jr., a predominantly Black nursing home tries to heal after outbreak. Retrieved November 29, 2020, from https://www.washingtonpost.com/business/2020/09/09/black-nursing-homes-coronavirus/
8 Marcotte, B. (2020, September 25). Underrepresented Populations Suffer Most from COVID-19 in Nursing Homes, Assisted Living Communities. Retrieved November 23, 2020, from https://www.urmc.rochester.edu/news/story/minorities-suffer-most-from-covid-19-in-nursing-homes-assisted-living-communities
9 Rau, J. (2020, March 15). Coronavirus Stress Test: Many 5-Star Nursing Homes Have Infection-Control Lapses. Retrieved November 22, 2020, from https://khn.org/news/coronavirus-preparedness-infection-control-lapses-at-top-rated-nursing-homes/
10 Roubein, R. (2020, November 11). Pandemic invades nursing homes again. Retrieved November 23, 2020, from https://www.politico.com/news/2020/11/11/pandemic-nursing-homes-435851
11 Seegert, L. (2020, October 20). COVID-19 is taking a huge emotional toll on nursing home residents. Retrieved December 10, 2020, from https://www.pbs.org/newshour/health/covid-19-is-taking-a-huge-emotional-toll-on-nursing-home-residents