As coronavirus took elderly lives, 30% of Delaware nursing homes failed to follow proper steps
In the first weeks of the coronavirus pandemic, when Delaware nursing home residents were dying at one of the highest rates in the country, 30% of those facilities were failing to follow protocols to curb the spread of the virus.
A Delaware Online/News Journal analysis of federal infection control inspections carried out by the state shows that even weeks after the coronavirus began taking lives, many of Delaware's nursing homes had not taken proper steps to keep residents safe.
“Early on, I think there was horrible chaos,” said Mary Ersek, a University of Pennsylvania nursing professor who specializes in end-of-life care. “Nursing homes said they had it under control, but they didn’t.”
These Centers for Medicare and Medicaid Services inspections, which were conducted between late March and early June, did not apply to assisted living communities.
Fourteen of 47 nursing homes failed their inspection, documents show. Many of these facilities didn’t isolate COVID-19-positive patients from residents who were not sick. Some did not follow federal COVID-19 guidelines.
Many staff members failed to wear or properly store personal protective equipment, if they were regularly provided with it at all.
At one nursing home, an employee felt obligated to wear the same N-95 mask for four weeks, while a colleague bought his own protective equipment and stored it in his car and shared it with co-workers.
WHAT'S GOING ON? Data on coronavirus' toll in Delaware nursing homes contains errors.
Eight of the 14 nursing homes had been previously cited for issues related to infection control.
As of July 17, there have been 1,160 COVID-19 cases in nursing homes and assisted living communities in the state. Of these, 333 died, about 64% of the total coronavirus-related deaths in Delaware.
The 14 nursing homes that failed their inspections fixed the errors, and most developed a plan to prevent a relapse.
Yet these the inspection reports show how some Delaware nursing homes struggled to combat the virus. In the early weeks of the pandemic, it was hard for facilities to obtain protective equipment for employees. And many facilities have been historically understaffed.
Because of limited testing in Delaware at the time, only residents with symptoms could receive a COVID-19 test.
Some administrators said they were not aware they were not following the latest federal guidelines.
But that may not account for all of the issues at the facilities.
Milford Center — which has had 34 residents die of the virus — had one of the more troubling inspection reports.
On April 17, a state inspector deemed residents to be in “immediate jeopardy,” one of the more serious designations. For five hours, the official had closely watched the nursing home staff, which cares for less than 100 people. The inspector studied records and interviewed employees.
Eleven residents, who were considered presumptive positive or confirmed to have COVID-19, were sharing rooms with asymptomatic residents, the official wrote in a report.
In this context, the state defines asymptomatic residents as people who had no symptoms and had not been tested for COVID-19.
Staff members also wore the same personal protective equipment when caring for those who were sick with the virus and those who were not.
“These failures,” the state official wrote, “put residents at risk for contracting COVID-19.”
Milford Center abated its “immediate jeopardy” designation in about four hours by making necessary changes and was found to be in compliance during an inspection in June.
Just the day before Milford Center’s April inspection, Michele Parks-Cale’s father died at the facility. Though his death certificate confirmed he died of COVID-19, Owen “Bud” Parks, 80, was not tested when he was alive, Michele said.
Parks-Cale said she received little information about the care her father received in his final days.
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She knew nursing homes across the country were struggling and that coronavirus was deadly. But Parks-Cale thought Milford Center had everything under control.
Now she questions it.
From the beginning of the pandemic, family members have not been allowed into long-term care facilities — meaning those who serve as advocates and power of attorney have a difficult time obtaining information about their loved ones.
"It’s like being in the dark,” Parks-Cale said of the virus. “It’s like being in a cave with bats. You know they’re there, but you can’t see them.
“I didn’t realize it was so bad.”
'A deficiency is a deficiency'
In a time before coronavirus, infection control was the most commonly cited deficiency in nursing homes.
Delaware has a history of failing to control the spread of infection.
Of the state's nursing homes rated on Medicare's Nursing Home Compare website, about 80% have had one or more violations in the past three years, according to an analysis by Delaware Online/The News Journal.
The issues mostly related to infection control.
Sixty percent of these nursing homes had more than one violation, according to the analysis.
Ersek, the Penn professor, said nursing homes are often the “stepchildren” in health care.
Long-term care facilities also don’t have the same type of equipment that health systems do, she said. In nursing homes, patients are cared for in their bedrooms, not hospital rooms.
These facilities are also chronically understaffed – and often caring for a very sick population. When it comes to resources, like protective equipment, they are among the last to receive it, she said.
These inspection reports, Eserk said, do offer insight into how the virus has devastated some Delaware nursing homes.
“A deficiency is a deficiency,” Eserk said. “And they clearly weren’t following the rules, and we need to take that seriously. But when we seek the remedy to fix the deficiency, we have to look at the shared responsibility.”
Since February, nursing homes have had to monitor guidance from both state and federal governments. And, in the past four months, these regulations have changed dramatically, said Adam Balick, a lawyer who represents several Delaware nursing homes.
Typically, nursing homes are evaluated on regulations that are “published, and largely static,” he said. This allowed long-term care facilities to establish policies, properly train staff and perform audits to make sure the nursing home is in compliance.
But coronavirus changed everything.
Balick said he believes that the COVID-19 inspection reports should show “some acknowledgement that the guidance was not static.”
“There was not always consensus from regulators about what was expected from nursing homes,” he wrote in an email.
Separated only by a privacy curtain
At Hillside Center, a nursing home in Wilmington, the facility failed to follow federal guidelines in regards to separating symptomatic residents.
The inspection report describes the tragic scenario of two female residents who were roommates. The official refers to these two women as R3 and R4.
On April 10, R3 had a fever of 102.6 degrees, among other symptoms. Yet, the woman was kept in her room with her roommate. The next day, she underwent a COVID-19 test, which came back positive.
The woman continued to live with her roommate, who was not demonstrating any symptoms, the inspector wrote in the report.
They were separated only by a privacy curtain.
According to federal guidelines, these facilities “should separate patients and residents who have COVID-19 from patients and residents who do not, or have an unknown status.”
In Delaware’s state of emergency declaration, the state says facilities should “designate a room, unit or floor of the facility to care for residents with known or suspected COVID-19.”
In an interview with the inspector, the nursing home administrator and director of nursing “stated their understanding was that there was no need to isolate and separate R3 and R4 as there was a privacy curtain between them and the door was kept closed since R3 initially presented with symptoms on 4/10,” according to the report.
The day R3’s positive test results came back, on April 12, her roommate, R4, had a fever of 99.6 degrees and other symptoms, according to the report. On April 19, she underwent the COVID-19 test, and the next day results confirmed she too had the coronavirus.
She died on April 22.
On April 26, R3 died.
In the report, the inspector noted that the nursing home subsequently trained staff and is now separating residents who are confirmed or suspected to have COVID-19. During an inspection on June 2, the nursing home was found to be in compliance.
As of July 10, three Hillside Center residents have died from COVID-19.
Genesis HealthCare owns both Milford Center and Hillside Center. Dr. Richard Feifer, chief medical officer, said in a statement that the nursing homes are "currently in compliance with those regulations."
"The reality is the virus does not distinguish between five-star and one-star facilities or infection control history," Feifer said.
The cost of protection
As she described her access to personal protective equipment, the ManorCare Health Services-Pike Creek nurse was in tears.
She had reused the same N-95 mask for at least four weeks. She had worn the same coveralls for 10 to 14 days, the state inspector wrote in the report.
She described how, at the end of her shift, she “takes her coveralls home, sprays it with disinfectant, airs it out overnight, then brings it back to the facility to wear during the next shift she works,” according to the report.
This employee added that “the night shift did not know how to obtain clean PPE because it is locked in a room and night shift does not have the key to the room.”
The state discovered during a May inspection that the nursing home’s staff members were not wearing full personal protective equipment when providing direct care to residents and were not changing PPE between residents with different COVID-19 statuses.
ManorCare employees told the inspector in May that they wore gowns and eye protection only when they cared for a resident who was in isolation. A respiratory therapist, who was a consultant for the nursing home, said in the report that she was never told by the facility that full PPE was required when caring for all patients.
That’s because the then-nursing home administrator incorrectly interpreted this federal guideline. He was informed by a state official that because there are COVID-19-positive cases in the facility, the staff needs to wear full PPE for all patients — regardless of a COVID-19 diagnosis or symptoms.
The nursing home official “responded that he interpreted this as should, but that it was not required,” according to the report.
Another employee told the inspector that “PPE was not available to staff and he had to buy his own PPE online.” He said he keeps it in his car so he can give it to other “staff that need clean PPE to work in the COVID-19 positive units.”
Julie Beckert, a spokeswoman for ManorCare, said it has been a challenge for long-term care facilities to obtain PPE.
In a statement, she said the nursing home is in “the process of responding to our most recent survey and will ensure that our employees are aware of our procedures and review our training material about proper use of PPE including appropriate conservation, donning and doffing and infection control protocols.”
'It all happened so quickly'
When Michele Parks-Cale’s father got sick with COVID-19 in April, she felt like she had to become a detective to understand how Milford Center was handling her father’s care.
Every time a nurse or social worker called her with an update, she felt like she was receiving different information. It forced her to piece together details, making it difficult for her to decide how to handle her father’s care.
The nursing home had mailed letters with general updates about the pandemic and held regular Zoom calls with families. But during these updates, families couldn’t get specific information about their loved one, Parks-Cale said.
She debated moving him to a hospital but decided against it. To this day, she still thinks about this decision.
“I feel like I was led to believe that they had everything under control and that they were doing everything possible,” Parks-Cale said. “It all happened so quickly.
“One minute I heard there was one resident (with COVID-19), and then a week later it was wildfire.”
Transparency among nursing homes is more important than ever, said Eserk, the Penn nursing professor.
“I think what families want to know, and what’s been a challenge to nursing homes is … you care about their roommate but you really want to know: “What’s going on with my mom?”
“Without visitation, that’s a horrible, scary thing.”
While inspection reports are available on Medicare’s Nursing Home Compare website, it does not include any in the COVID-19 era.
Delaware nursing homes have asked Gov. John Carney to grant them immunity from lawsuits related to the coronavirus pandemic. If the governor signs an executive order, it could leave little legal recourse for families and patients who feel they have been wronged by these providers.
Parks-Cale said she now feels Milford Center officials were not forthcoming, though she believes her father’s nurses did their best.
A nurse stood by her father’s side for 14 hours, giving him a final dose of morphine at 2:30 a.m. on April 16. He died an hour later, becoming the 12th resident to die at the facility.
The next day, the nursing home was deemed to be in “immediate jeopardy.”
Weeks later, as she grieves her father’s death, Parks-Cole feels like she still doesn’t have the full picture of what happened.
“Helpless doesn’t even come close to describing it,” she said.
Contact Meredith Newman at (302) 324-2386 or at firstname.lastname@example.org. Follow her on Twitter at @merenewman.