|
 On another night in another room of the New Jersey home, Barbara
Grimes noticed her roommate sitting in a puddle of urine, which
seeped into a wound on her tailbone. No one checked on the roommate
for three hours. The woman, Grimes said, had given up on calling for
help.
That same month, Hammonton staffers moved David Paul and another man
into a room last occupied by two residents infected with the
coronavirus, one of whom later died of COVID-19. The floors were
still dirty, the bathroom littered with trash, Paul said. Paul and
the other man, he said, soon tested positive themselves, and his
roommate died. In all, the Hammonton outbreak resulted in 238
infections and 39 deaths, state data shows.
"You cannot live here and really believe that these people care
about you," said Esaw, 70, who has lived in the home for nine years
and knows Grimes and Paul well.
Nursing homes worldwide, filled with elderly residents who are
particularly vulnerable to COVID-19, have suffered a harrowing toll
in the pandemic. (For a special report on Britain's care homes,
click https://reut.rs/2Us337c )
In the United States, longstanding problems with staffing shortages
and chronic turnover have left nursing homes especially exposed. An
estimated 40% of the country's more than 100,000 COVID-19 deaths are
connected to long-term care facilities such as nursing homes or
assisted-living centers, according to a Kaiser Family Foundation
tally.
About a quarter of nursing homes responding to a recent federal
survey reported shortages of direct-care staff during at least one
of the last two weeks in May, according to a Reuters analysis of
survey data from the Centers for Medicare and Medicaid Services.
A separate Reuters analysis of federal nursing home data shows that,
before the virus hit, about four in 10 homes nationwide would not
have met the minimum staffing regulations in California, which has
among the highest standards in a nation where some states have few
or no requirements for nursing staff levels. About 70% of U.S.
nursing homes would fail to meet a stricter staffing standard
advocated by some experts, the analysis showed.
The coronavirus pandemic has laid bare and deepened these historical
staffing problems, according to interviews with nearly two dozen
nursing home workers and residents nationwide. Nursing home staffers
are quitting in large numbers, these workers said, because of
illness fears and what they described as a slipshod emergency
response by management.
As outbreaks hit homes nationwide, administrators often sought to
downplay the danger, 17 workers at eight homes run by eight
different companies told Reuters. Managers hid the severity of
outbreaks, the workers said, in part because they were desperate to
retain staff who were scared and disillusioned with poor working
conditions and pay as low as $11 per hour. Some managers pressured
sick or infected workers to show up, said five workers at four
facilities.
At Hammonton Center, overworked nursing assistants have regularly
had to bathe, clean and feed as many as 30 residents by themselves,
far more than usual. Staffing on two occasions was so thin that
nursing assistants found residents who had been dead for several
hours in rooms no one had time to check, two Hammonton employees
said.
Centers Health Care, which runs the facility, declined to comment on
most accounts of residents and workers cited in this report. It
denied any lapse of care at the home. The company disputed the
contention that residents were not discovered for hours after they
died.
Reports of overwhelmed staff extend far beyond Hammonton. At Life
Care Center of Nashoba Valley in Littleton, Massachusetts, so many
staff had quit or called in sick that managers left a teenage
nursing-assistant trainee on a shift caring for nearly 30 dementia
patients, said a current worker and a former worker. Part way
through the shift, one more nursing assistant was assigned to help
her in response to staff complaints, the workers said.
The vast majority of more than 40 nurses and nursing assistants at
the Life Care home have quit since April, six current and former
workers told Reuters. Twenty-six people died, according to federal
data, including a nursing assistant. The outbreak caused 87
confirmed infections, the data show.
The rapid staff exodus left residents without the most basic care,
the workers said. "These are people who all need to be changed.
They're incontinent. A lot of them need help eating," said Lisa
Harmon, a nurse who supervises weekend shifts. "There's only so much
one person can do."
Tim Killian, a spokesman for the home's owner, Life Care Centers of
America Inc - one of the nation's largest operators - acknowledged
that a large portion of the Massachusetts home's staff quit under
"extremely challenging" conditions. He said facility leaders could
not recall a teenager being assigned to care for dementia patients
alone.
Echoing other industry advocates, Killian said nursing homes have
generally reacted well to an unprecedented challenge, despite little
government help. The U.S. government has taken heavy criticism for
being slow to react to nationwide shortages of protective gear and
testing kits.
"It's just ridiculous to think that nursing homes, absent direct and
substantial government support, could manage a global pandemic,"
Killian said.
'HIDING IT FROM US'
Staffing had long been a problem at the Massachusetts Life Care
home, with nursing assistants often caring for too many residents,
workers said. The shortages became a crisis in the outbreak, they
said, as management failed to provide protective gear or to
communicate how the virus was spreading.
In March, veteran nursing assistant Patti Galvan noticed residents
getting fevers and coughing. She brought her own mask, but a manager
told her not to wear it, saying it wouldn't prevent infection. Other
workers said management told them to remove masks they brought from
home because they would cause other workers to ask for protective
equipment the facility could not provide.
Killian acknowledged protective-gear shortages, which created
"tension" between management and workers, but said administrators
were powerless to solve nationwide supply problems.
Staffers started getting sick and staying home, but managers
"weren't taking it seriously," said Galvan.
"They were just hiding it from us," said Galvan, who left more than
two months ago after getting flu-like symptoms and has no plans to
return. "If they were honest with us, and were more caring and more
responsible, they wouldn't have lost us all."
Galvan had worked at the facility for three decades.
Amy Lamontagne, the facility's executive director, said management
never withheld information. "There was no secret-keeping," she said.
Killian said management couldn't inform staff about coronavirus
infections until it had confirmed test results or, when testing
wasn't available, a formal diagnosis from a nearby hospital.
Colleen Lelievre, a nurse who still works at the facility, said
testing wasn't needed to recognize the unusual number of residents
with COVID-19 symptoms in March. But management, she said, never
leveled with the staff about why so many residents were being
hospitalized.
As more workers quit or called in sick, those who remained regularly
worked 80- to 90-hour weeks, said Harmon, the weekend nursing
supervisor. Physical- and occupational-therapy assistants filled in
for nursing assistants.
The depleted staff couldn't bathe and feed every resident, workers
said. In a dementia unit, workers were unable to keep residents from
wandering into hallways and other patients' rooms, potentially
spreading infection. Staff had no time to sit with dying residents,
said Harmon, who sometimes left her phone with them so they could
call relatives in their final hours.
Despite these conditions, the facility reported no staff shortages
in response to the government's nursing-home survey. Killian said
the facility had no shortages in late May because the number of
residents had declined to the point where the home was "fully
staffed" with many fewer workers. Lamontagne said the 120-bed
facility now has 65 residents.
Overall, 192 of Life Care's more than 200 nursing homes responded to
the federal survey, and about 29% of those reported staff shortages,
according to the Reuters analysis.
Harmon and Lelievre said the Massachusetts home still has far fewer
staff than it needs. The facility has very few nursing assistants,
Lelievre said on Saturday, making it nearly impossible for staff to
safely move some residents out of their beds, which often requires
two people.
Lamontagne, the executive director, had a different take: "We're
doing fine with our staffing," she said.
Several workers questioned why the facility wasn't more prepared,
since its owner had, weeks before, managed the site of one of the
first major U.S. outbreaks, at the Life Care facility in Kirkland,
Washington – with 45 deaths linked to the home, according to local
public health authorities.
"They didn't have any plan," said John De Mesa, a nursing assistant
who said he contracted the virus in March.
Killian said the gap between the Washington and Massachusetts
outbreaks gave the company little time to act on lessons learned.
[to top of second column] |
In late March and early April - as many Life Care residents were hospitalized -
the Massachusetts National Guard came to the home to administer tests.
Administrators brought in corporate staff and workers from a nearby Life Care
facility to give the appearance of a fully staffed home around the time of the
Guard visit, Harmon and Lelievre said. Most of the added staff left within a
week, they said.
Killian dismissed the contention that the extra staff were deployed for
appearances, saying all staffing decisions aim to improve care.
The home told workers they could not get tested along with residents, staffers
said. The state at the time, in early April, was restricting testing in nursing
homes to residents only.
After workers complained about the lack of testing, management sent a text
message to the staff on April 5.
"We encourage you to direct any questions or concerns about your health to your
personal physician," read the message, which was reviewed by Reuters.
Some workers sought out their own testing. Life Care did not test workers until
mid-May, Harmon and Lelievre said. Staff had to bill their insurers for the
tests, they said. Those with no insurance had to pay upfront and seek
reimbursement from Life Care.
Thirty-four workers at the facility had tested positive by the end of May,
according to federal data. Those who became ill with COVID-19 were not paid for
their time away, Harmon and Lelievre said. Killian said sick workers could use
accrued paid time off.
HISTORY OF STAFFING PROBLEMS
Insufficient staffing and frequent turnover have caused quality-of-care problems
at nursing homes for decades, studies and government inquiries have shown.
Most nursing-home revenue comes from Medicaid and Medicare, the federal health
programs for the poor and elderly. The fixed payments, some researchers say,
incentivize companies operating on thin margins to cut staffing to the bone.
Industry lobbyists have long sought higher reimbursements, which they argue
haven’t kept pace with costs.
The American Health Care Association, an industry trade group, testified before
Congress twice last year and requested help in attracting workers. Since the
pandemic hit, the group has asked state officials for help recruiting nurses
from less-impacted regions, as New York City hospitals did. "Just like
hospitals, we called for help," the group said in a statement.
"In our case, nobody listened for months."
The federal government conducted its nursing home survey last month to seek data
on staff and equipment shortages during the pandemic. At least 3,200 nursing
homes - 23% of the 13,600 facilities that submitted data - reported staffing
shortages in late May, according to the Reuters analysis. About 2,000 facilities
did not respond to the survey.
U.S. regulators set few standards for nursing-home staffing, requiring only the
presence of a registered nurse for one eight-hour shift and a licensed nurse,
with a lower-level credential, in the building at all times.
At least two-thirds of states, including California, set minimum-staffing
standards for nursing care, though the requirements vary widely and often
contain loopholes. Some, including Indiana and Virginia, have no minimum
standards for direct-care nursing staff.
California requires its 1,200 nursing homes to provide 3.5 hours of daily direct
care, part of a 2017 law setting some of the highest standards nationally. If
applied nationwide, about 37% of nursing homes would fail to meet that
requirement, according to the Reuters analysis, which examined federal data on
staffing during the last quarter of 2019 for nearly 15,000 nursing homes.
About a third of California homes don't meet the state's own staffing standards
because regulators last year granted them exemptions from requirements for
overall staffing or for certain positions. The state said it granted some
waivers because of workforce shortages.
Annual turnover of nursing staff at homes in California - among the few states
that track that data - has increased from 44% in 2014 to 53% in 2018.
Some researchers believe California's requirements don't go far enough. Charlene
Harrington - a nursing professor emerita at University of California, San
Francisco, who has studied nursing-home staffing shortages - advocates for 4.1
hours of per-patient direct care. She cites a 2001 federal study that concluded
quality of care can decline below that level. At least 70% of nursing homes
nationwide would fail to meet that higher bar, the Reuters analysis shows.
Some scholars and industry advocates blame staffing problems on systemic
weaknesses in U.S. nursing-home funding.
"No one wants to pay the taxes for them, even though they're all of our
grannies, or mothers," said Vincent Mor, a professor at Brown University's
school of public health, who has studied nursing home quality and staffing.
Some experts blame nursing home owners, mostly for-profit companies, for
skimping on staff to make more money. Harrington, the UCSF nursing professor,
called industry complaints about government funding "nonsense," arguing that
major companies would leave the business if it were unprofitable.
IN THE DARK
When outbreaks hit, some nursing home managers pressured sick workers to show up
unless they had a positive coronavirus test, or to return to work before the
recommended self-quarantine period, five workers at four facilities said.
Nursing assistant Gabby Niziolek, 20, said she started feeling sick in late
March during a shift at Plaza Healthcare and Rehabilitation Center in Elizabeth,
New Jersey. Some co-workers had started feeling ill, she said, and she noticed
residents losing their appetite and turning a pallid color.
When she asked to leave, her manager told her to finish her shift, Niziolek
said. The next day, after she got tested, she said she was told to return to
work while awaiting results. When the results came back positive, Niziolek's
boss asked if she was showing symptoms. She said she was, and stayed home.
"If you're positive and you don't have symptoms, they still want you to work,"
Niziolek said.
Plaza Healthcare and Rehabilitation Center did not respond to requests for
comment.
Residents and staff at New Jersey's Hammonton Center were kept in the dark for
weeks about the extent of the facility's outbreak, said three residents and six
staffers.
As illness spread in late March, managers told workers that the sudden jump in
residents with fevers, appetite loss and shortness of breath stemmed from cases
of "aspiration pneumonia," a condition that usually isn't caused by an
infectious disease. Weeks later, managers said that residents who had been
hospitalized tested positive for the coronavirus.
Workers weren't informed at the start of shifts that they would be working on
hallways filled with residents believed to be infected, staffers said.
Home operator Centers Health Care said it couldn't be sure that symptomatic
residents had the virus until testing became more widely available in April.
A nursing assistant who was among the first to test positive for the virus said
she reported the diagnosis to her supervisor and told several co-workers, as her
doctor had advised. Five days later, when she was at home sick, a manager called
to chastise her for telling co-workers, she said.
Centers Health Care said in a statement that its staff are "working tirelessly
around the clock." The company said staffing shortages are an industry-wide
issue, but that it has ensured it meets state minimum staffing requirements
during the pandemic by redeploying staff as needed within its network of
facilities. The company declined to detail its staffing levels.
Hammonton nurses and aides said that about half of the facility's direct-care
staff have left, and that the facility replaced some with workers from temporary
staffing agencies.
Hammonton Center reported some staff shortages to the government, as did about
half of the 38 Centers Health Care homes that responded to the survey, according
to the Reuters analysis of the data.
Grimes, who has lived at Hammonton for six years, said she started noticing that
her roommate had a "horrible cough" that kept getting worse. She told nurses
about the condition, and her roommate was hospitalized in April. The woman later
died, but Grimes said staff never told her the cause.
Grimes said she got moved to a separate wing for those who had not contracted
the virus - but staff never explained, she said, whether her roommate had tested
positive. Last month, after getting a second test, Grimes learned she was
positive, though she said she only had a slight fever.
"We don't know when somebody gets sick; we have to sniff it out like a
bloodhound," she said. "You can only guess what happened when that person is
getting carried out on a gurney."
(Reporting by Chris Kirkham and Benjamin Lesser; Editing by Janet Roberts and
Brian Thevenot)
[© 2020 Thomson Reuters. All rights
reserved.] Copyright 2020 Reuters. All rights reserved. This material may not be published,
broadcast, rewritten or redistributed.
Thompson Reuters is solely responsible for this content. |
