Why are some nursing homes hit harder by COVID-19? Data offers clues
Several weeks into the COVID-19 pandemic, government inspectors found infection control problems in one out of every four Connecticut nursing homes they examined. The problems ranged from staff not using protective equipment to commingling residents infected with the virus with those who were not.
Data from the Centers for Medicare and Medicaid Services (CMS) shows that nursing homes where the virus has hit particularly hard were more likely to have infection control issues than those with fewer cases. Those lapses were also more likely to occur in facilities where more of the residents are people of color.
There have been, to date, a total of 8,322 documented infections among residents in Connecticut nursing homes – and 57% of them lived in homes where inspectors found infection control lapses. Comparatively, about half that number – 27% – were in homes where no shortfalls were identified. Likewise, 58% of the nearly 2,400 residents who died from COVID-19 were in the nursing homes with inspection lapses compared to 28% in the homes with none. Not all facilities were accounted for in the state breakdown.
Experts say it is too early to know exactly why some nursing homes suffered more than others, but pulling reasons from data is a top priority to shield them all from a potential second wave.
“What we’ve been trying to figure out is, ‘Why are some of these facilities at higher risk for serious illness and death than others?'” Dr. Matthew Cartter, the top epidemiologist at the state Department of Public Health, said. “Were all nursing homes equally at risk, or were some at greater risk than others? We don’t know the answers, but data suggest that not all nursing homes were equally likely to be impacted by the COVID-19 virus.”
The Department of Public Health is exploring explanations from whether the harder-hit homes had more residents with underlying health conditions, more minority residents, or more lapses in following infection control guidelines.
“There will be a lot of work that’s done both during the pandemic and afterwards looking at what happened in long-term care facilities. It’s also important to point out for COVID-19 for nursing homes in the United States, it’s like a Category Five hurricane,” said Cartter, who has investigated hundreds of outbreaks during his career. “The level of infection control prevention in those facilities was sufficient to handle normal outbreaks, but they were never built to withstand a pandemic.”
For COVID-19 for nursing homes in the United States, it’s like a Category Five hurricane. The level of infection control prevention in those facilities was sufficient to handle normal outbreaks, but they were never built to withstand a pandemic.”
Figuring out how to shield nursing homes from another viral outbreak is particularly important in Connecticut, since facilities here have some of the highest COVID-19 infection and death rates in the U.S., according to preliminary data released Monday by the federal government.
Death counts higher in facilities with more people of color
The Connecticut Department of Public Health has not been able to produce a breakdown of the race and ethnicity of COVID-19 nursing home deaths, but it did for the first time last week release a rundown of the characteristics of who is living in each of the state’s 213 nursing homes.
Facilities where more of the residents are black or Latino have higher numbers of residents who have been infected with or died from COVID-19, the data shows.
For example, at Riverside in East Hartford – where more nursing home residents have died than any other facility in the state – 43% of the residents were black or Latino. Statewide, that figure is only 18%. At Abbott Terrace Health Center in Waterbury, which has the second highest number of COVID-19 deaths, 39% of the residents were black or Latino.
This racial disparity of nursing home fatalities is particularly large in Connecticut. Researchers at the University of Chicago reviewed nursing home data in nine states, and found Connecticut had the second largest disparity in the numbers of nursing homes that have had at least one resident infected or die from COVID-19. Only Illinois had more.
“We found a strong and consistent relationship between race and the probability of COVID-19 cases and deaths. Nursing homes with the lowest percent white residents were more than twice as likely to have COVID-19 cases or deaths as those with the highest percent white residents,” Tamara Konetzka, a professor in the university’s Departments of Public Health Sciences and Medicine, testified before the U.S. Senate Special Committee on Aging two weeks ago.
A May 21 New York Times analysis on the racial infection rate disparities in nursing homes in 17 states puts Connecticut in sixth place for having the largest gaps between homes where at least one-quarter of the residents are black or Latino and facilities with fewer than 5% of these populations.
The state has noticed the reports on these disparities and is doing its own analysis now, Cartter said. That study will also look at whether minority residents were more likely to have other underlying health conditions that made them more vulnerable to the virus.
Widespread infection control lapses
Long-term care facilities have struggled for years to follow best practices to control the spread of infections.
In Connecticut, federal watchdogs at the Government Accountability Office recently reported that half of the state’s nursing homes had infection-control problems for multiple years leading up to the pandemic — compared to 33% in New York, 24% in Massachusetts, 22% in New Hampshire, 39% in New Jersey, and 8% in Rhode Island. Connecticut’s performance, however, was slightly better than the 55% national average.
The researchers from the University of Chicago found no correlation between the inspection ratings given before the pandemic and nursing homes having a single case of COVID-19. A CT Mirror report in early May, found otherwise for homes where a large number of residents have the virus, and the inspections released last week show that inspectors are more likely to find lapses in facilities with higher coronavirus infections and death rates.
Five homes among the 39 in Connecticut where problems have been found since the pandemic began have been cited and fined, officials said. One nursing home has been issued two of those citations. The department declined to disclose the homes where fines have been issued, or their amounts.
Matthew Barrett, president of the association that represents for-profit nursing homes in the state, said home operators made the necessary improvements whenever inspectors found deficiencies.
“Nursing home operators and their employees want the same thing that state public health regulators want – and they want it even more – which is to beat back this highly contagious and insidious virus threatening the health of nursing home residents it is their mission to serve,” said Barrett, executive director of the Connecticut Association of Health Care Facilities. “In every case,” he continued, “operators have made immediate corrective actions and the public can be assured that practices are in place that will lead to the quality outcomes everyone wants.”
“Caregivers deserve recognition for the extraordinary work they are doing battling a virus that has confused and challenged medical and academic experts and public health officials across the nation, especially in how the virus transmits from individuals who are carriers but show no symptoms,” Barrett said. “COVID-19 is a historic virus in this regard. It challenges normal infection control concepts. The inspection reports must be viewed from this context and perspective.”
Dr. Patrick Coll, associate director for clinical geriatrics at UConn Health’s Center on Aging, said there are many unknowns as to why certain facilities and people are impacted more harshly. He suspects that lapses in following infection-control guidelines played a small role, while lack of testing, and therefore quarantining, of staff and residents was the chief reason the virus spread so quickly.
“My feeling is that the occurrence of COVID-19 in a nursing home doesn’t mean that the facility did not follow standards with regards to infection control. They have been very, very serious with regards to their infection control measures, and they still saw significant numbers,” said Coll, who consults for a handful of the facilities. “Most likely, it was asymptomatic staff. So staff who didn’t know they had COVID were coming into work and they may have been exposing some of the residents to the virus.”
Officials at DPH said they believe nursing homes here have been hit particularly hard because New York City and the region has been the nation’s epicenter for COVID-19 infections. Barbara Cass, the agency’s branch chief for health care and quality safety, said that “it could be a host of things.” It could be that some nursing homes have older residents, or have more severe health issues or are located in urban centers where there are heavier concentrations of the disease, she said.
Causes for the spread of infection could also be things that would show up on inspections; inspectors found lapses ranging from improper use or no use of protective equipment, failure to document residents’ conditions, failure to appropriately cohort residents, a lack of signage outside rooms where residents with coronavirus were staying, insufficient hand sanitizing procedures, and failure to enforce social distancing.
The inspections are performed to help nursing homes improve, said Donna Ortelle the agency’s chief for facilities, licensing and investigations.
“Our surveyors need to have assurances that when they identify an issue, remediation, or coaching, or training or in-servicing is started right away,” said Ortelle. Measures are validated while the surveyors are still at the facility, she said.
The most citations
Of the five nursing homes with the most COVID-19 deaths, inspectors found problems at four. Riverside in East Hartford was the only one to have no lapses during either of its two inspections. The inspections turned up deficiencies at Kimberly Hall North in Windsor, Abbott Terrace in Waterbury, Shady Knoll in Seymour and Regency House & Rehabilitation Center in Wallingford.
Inspectors found issues during all three visits to RegalCare in New Haven. There have been 54 infections and seven deaths there.
Findings included three residents sharing a room, one of whom had COVID-19. While the infected resident was waiting to be transferred to the secluded section of the nursing home, staff was observed having significant contact with each of the residents to help dress or use the toilet without changing their protective equipment.
Amitai Dagan, the vice president for marketing at RegalCare, said their strategy has evolved as they learn more about the virus and receive additional guidance.
“The guidelines from DPH and the CDC to our industry have been fluid and constantly being changed and revised, so our plan to protect our staff and residents has been that as well, always with the intention to keep everyone safe,” she said. “Since the initial deficiency findings, the team at RegalCare at New Haven have been continuously educating the staff on the appropriate usage of PPE. Competencies and weekly audits are being done to ensure accuracy of the implemented Plan of Correction.”
She added that staff has ample protective equipment and are now only reusing it in line with federal guidelines. Inspectors visited the home again Tuesday. She expects a clear record from that visit, she said.
During a May inspection of Windsor Health and Rehabilitation, a licensed practical nurse was seen pouring medications without wearing a mask or other protective gear. The nurse said she had recovered from COVID-19 and “did not need to wear a mask.”
Supervisors said that no residents or staff became sick as a result of the violation, and that the facility would ensure all employees wore masks. There have been 48 residents infected and 22 deaths there.
“Our priority and focus are the commitment to providing our patients and residents with the utmost care and to continue to deliver our services in a safe and dignified manner to our residents,” said Lara Alatise, owner and administrator of Windsor Health. “All of our staff have been educated, and reeducated, to take a number of steps to ensure our that our patients and residents receive the safest care during this pandemic and at all times.”
At Touchpoints at Farmington, inspectors in April noted that the facility failed to store clean jumpsuits worn by staff in a separate area from soiled jumpsuits. There have been 84 residents infected and 19 deaths there.
David Skoczulek, vice president of business development for iCare Health Network, which owns the nursing home, said the company disagrees with the findings.
“We have appealed this allegation and fully expect that it will be reversed upon review,” he said. “During this unprecedented pandemic, we have taken a leadership role in establishing prudent practices for nursing homes in Connecticut. The fact that a single DPH surveyor erroneously characterized this practice as deficient should not detract from the ongoing and heroic efforts of our frontline caregivers.”
At Harbor Village North Health and Rehabilitation Center in New London, where five residents have been infected and one has died, inspectors found in April that several staff members were entering through a back door where there was no wall-mounted hand sanitizer dispenser and “inadequate” paper towel supplies in the sink area. Workers also failed to practice social distancing, the inspectors noted.
“The staff stood shoulder-to-shoulder at the counter of the central nurses’ station filling out the health screening questionnaire while waiting for use of the temporal scanner thermometer,” they wrote. “Staff who could not stand at the counter stood in a line down the hallway near one another. The temporal scanner thermometer was observed being passed from staff to staff without the benefit of sanitation between use.”
The facility quickly installed a new hand sanitizing station and an additional paper towel dispenser. The floor was marked at six-foot intervals to promote social distancing, and staff were re-educated on sanitizing and distancing procedures, officials said.
“Our residents and families who rely on the quality care we provide can be assured that our facility administration took immediate action to address the identified issues, and we have immediately implemented procedures to prevent any further occurrences,” said Troy Guntulis, executive director of Harbor Village.
Inspectors touring the Groton Regency Center in May saw 13 residents sitting “elbow to elbow” in a common television area. Four others were walking in the hallway without masks, the inspectors noted.
My feeling is that the occurrence of COVID-19 in nursing home doesn’t mean that the facility did not follow standards with regards to infection control. They have been very, very serious with regards to their infection control measures, and they still saw significant numbers.”
Chairs were subsequently arranged to maintain an appropriate social distance and residents were encouraged to wear masks.
“Infection control is an absolute top priority for us,” said Lori Mayer, a spokeswoman for Genesis Healthcare, which owns Groton Regency. “Facility staff at Groton Regency are working hard every day to care for the residents under extremely difficult circumstances and are doing their best to comply with constantly changing guidance and requirements issued by various regulatory bodies.”
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