Nursing homes are a perfect environment for coronavirus, pairing residents at higher risk of serious illness with facilities that may be poorly equipped to prevent the spread of infection within their walls and beyond.
Seventy-five percent of nursing homes in the United States have been cited for failing to properly monitor and control infections in the past three years – a higher proportion than previously known, according to a USA TODAY analysis of federal inspection data. These quotes were as light as a paperwork problem, and as serious as a nursing home that failed to notify state officials of an epidemic while unattended workers were transmitting the disease to patients .
In each case, the citation is a warning sign for practices and shortcomings that could become crucial factors in an epidemic inside and outside the establishment. The governor of North Carolina said that the state’s first case of coronavirus had passed through Washington State, where the virus had devastated the Kirkland Life Care Center.
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Failed infection control means nursing homes can spread the new coronavirus, also known as COVID-19, far beyond their walls, said Charlene Harrington, professor emeritus of nursing at University of California, San Francisco.
“Nursing homes are only seen as a problem for residents and perhaps staff, but in this case, you can see that it can affect the whole community,” she said. “Poor care in a nursing home is becoming an epicenter for the whole community.”
Highlighting the link between infection control and the spread of the coronavirus, the Centers for Medicare & Medicaid Services announced Wednesday that its inspections would focus only on issues related to infection control and other serious threats to health and safety, such as as allegations of abuse – start with nursing homes and hospitals.
The agency made this change effective immediately, allowing inspectors to focus on controlling the spread of COVID-19.
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Dr. David Gifford, who represents nursing homes across the country as chief medical officer of the American Health Care Association, warned that the vast majority of quotes do not relate to situations that have caused significant harm. He said inspectors detect most problems early enough that facilities can resolve them before anyone is injured.
“It is always helpful for federal investigators to step in and identify areas that could be better for infection control,” said Gifford. “What the public needs to know is … if it is not corrected, the regulations require (the government) to close the nursing home within six months.”
“An environment rich in infections”
The Life Care Center, which U.S. authorities believe is the site of the first outbreak in a long-term facility, has received an overall five-star rating from federal regulators, but has previously been criticized for its infection control procedures.
Federal regulators award points for violations – no points for the most benign offenses that affect few people, many points for violations that threaten or are widespread. Nursing homes in the United States have averaged about 10 points over three years, according to USA TODAY analysis. Last year, the only Life Care Center offense was 16 points. He had received no infection control records in the previous two years.
The 2019 inspection report described the daughter of a resident saying that her mother’s open heel injury often hit the ground while nurses were working. Inspectors found other basic problems at Life Care, such as kitchen staff not washing their hands properly or changing gloves, according to federal records.
After the recent COVID-19 epidemic, the Life Care Center said it had implemented infection control recommendations from the Centers for Disease Control and Prevention and local and state health services. The facility also said that it restricted visitors, monitored residents and employees, and asked staff to stay home if they were sick.
“The coronavirus in long-term care facilities is a horrible example of a perfect storm,” said attorney Steven Levin, of Levin & Perconti in Chicago, a practice focused on representing residents of nursing homes. and their families. “In my opinion, the nursing homes we deal with have extreme difficulty managing everyday infections, and it’s an environment rich in infections.”
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About 26.8% of nursing homes have received at least as many violation points as the Life Care Center in the past three years, according to analysis by USA TODAY. And thousands of nursing homes – more than 15% of them – have been cited for individual problems at least as serious as those of Life Care. About 1% had problems that were worse.
The worst during the three-year period analyzed was The Westbury Place in Houston, cited for two 8-point violations and two 150-point violations. Among the failures cited: not using sterile equipment for tracheostomy care; do not keep patients isolated while suffering from the difficult-to-cure infection known as MRSA; and not properly cleaning a catheterized patient for five days.
The types of errors at Wheat State Manor in Whitewater, Kansas, which accumulated 64 points from federal inspectors, were more common. During an inspection, an employee checked a patient’s incontinence, cleaned up another patient’s incontinence, helped the two patients settle into chairs, and then left – all without wash hands between patients or after work. Regulators said this type of infection control problem affected many residents, but caused little real damage.
Wheat State Manor was one of more than 300 nursing homes that have accumulated four citations for infection control problems in the past three years. Six nursing homes each had seven offenses: Lakeview Terrace, York Healthcare & Wellness Center and Country Villa Rehabilitation Center, all in Los Angeles; Champaign Urbana Nursing and Rehab in Savoy, Illinois; Aperion Care Forest Park in Forest Park, Illinois; and the Enclave of San Antonio.
All of them have accumulated more points than the Life Care Center.
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An inspection report for Lakeview Terrace was 28 pages long. Among the problems: a worker who may have been contagious distributed trays of food. The workers there did not wash their hands before helping someone with a drug-resistant infection, and then did not wash their hands before continuing to help other patients.
Some states have proven more problematic. In Washington State, where the nursing home epidemic began, about 85 percent of nursing homes have received infection control quotes, according to analysis by USA TODAY. But California and Michigan both did, with more than 90 percent cited. One of the Guam nursing homes was cited, as were the six in Puerto Rico.
In Rhode Island and North Carolina, however, only about a third of nursing homes have been cited for infection control violations.
Even among the nursing homes that received the highest overall ratings from federal regulators and the highest healthcare ratings, 41% still had infection control problems. This is of particular concern because, in a health care crisis, nursing homes often become a key exhaust valve.
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“Part of the resource crisis we face is ensuring that there is enough good care available in qualified nursing homes to ease some of the burden of acute care hospitals in a widespread epidemic “Said Mike Dark, attorney for California Advocates for Nursing Home. Reform.
He said that skilled nursing facilities in the United States already care for hundreds of thousands of patients a year when they leave acute care hospitals.
“A societal judgment that you must make”
Even before the coronavirus appeared, 380,000 people died of infections in long-term care facilities each year, according to the Centers for Disease Control and Prevention. Some studies cited by the CDC have suggested that 1.5 million Americans in long-term care, including nursing homes, could contract an infection every two years, possibly sending 150,000 of them to hospital.
According to some lawyers, part of this stems from the way nursing homes are run. Typically understaffed, nursing homes can be places where making money – or even just making it through a shift – depends on the corners cut.
Wendy Meltzer, executive director of the Illinois Citizens for Better Care, said that good infection control takes time.
“If you don’t have enough staff to start with, then the time you take to wash your hands and put on gloves and change gloves and make sure the sheets are changed appropriately and take people’s temperatures and what you need to do, “she said,” it all takes away from the daily pressures, minute by minute and hour by hour. “
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Often when people think of nursing homes, they focus on doctors and nurses, said Greg Kelley, president of SEIU Healthcare Illinois Indiana Missouri & Kansas, a union that represents more than 91,000 healthcare workers, child care, home care and nursing homes.
But Kelley said nursing homes rely on housekeepers, dieticians and others to keep their facilities up and running. These workers, on the front line of infection control, may earn miserable wages and may not receive enough sick days or paid leave.
And there is no one to replace them. This means sick employees often return to work.
A plan from the United States Department of Health and Human Services to control infections in nursing homes said that the flu can be easily spread among residents who live close to each other and frequently see health care professionals .
But health workers themselves, according to the plan, are contributing to the problem, with many not getting the annual flu vaccine.
Residents also often suffer from life-threatening illnesses like pneumonia and that of other residents.
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Few nursing homes have full-time infection control specialists. One study found that less than 10% of infection prevention specialists in nursing homes and qualified nursing facilities had specific training, such as certification, in infection control procedures. In acute care settings like hospitals, 95% had this training.
Gifford of the American Health Care Association said that nursing homes must have infection control and emergency preparedness plans that include how to cope with an epidemic or pandemic.
“I think even with all the planning you do, things get really difficult and complicated that need to be addressed in some sort of larger community,” said Gifford, “and I think that’s what we see in Washington. “
In Washington, he said that many workers were exposed to the virus and could not come to work. Part of the plan was initially to meet the nursing needs of other institutions. But the facility has learned that the state does not allow nurses to move quickly and easily across state borders. When they tried to mobilize federal workers, said Gifford, this created various challenges, including with wages.
Other problems have also arisen. Test results were not readily available, he said, and the establishment quickly ran out of essential supplies, such as masks. When he located supplies, he said, some suppliers were afraid to deliver them.
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Meltzer said there are simple ways to prevent coronavirus from spreading in nursing homes: take the temperature of visitors and employees when they enter buildings, require that each facility have someone working in infection control, and prescribes that assisted living facilities and other locations follow federal government regulations for nursing homes. All of this requires more staff, which means more money.
While these solutions may seem simple, they can be expensive.
“Ninety percent of nursing homes across the country would shout about how they couldn’t afford to do it,” said Meltzer. “And it’s just a societal judgment that you have to make, on who’s worth what. … For the most part, residents aren’t doing very well.”