Abstract
Between February 2020 when the COVID-19 pandemic began and August 2020, the nation has watched over 5.2 million individuals become infected and over 167,000 deaths. Unfortunately, many of the infections and deaths have been nursing home residents and staff. To date, the Centers for Medicare and Medicaid Services (CMS) reported over 286,000 infected nursing home residents and almost 46,000 resident deaths as of August 2, 2020. Nursing home residents have a higher COVID death rate in the United States than non-nursing home residents; they are less than 0.5% of population but over 27% of total deaths (Centers for Disease Control and Prevention, 2020a; CMS, 2020).
The first outbreak of COVID-19 was at a nursing home in Kirkland, Washington in February 2020. Nursing home residents were known to be one of the most vulnerable populations in the country because of their advanced age, frailty, and multiple chronic conditions. Most live in large facilities with multiple individuals in one room and shared bathrooms (Centers for Disease Control and Prevention, 2020b). Many nursing home staff, especially Certified Nursing Assistants (CNAs) often work at multiple jobs to make sufficient income. Many do not have health insurance or sick leave.
Previously documented nursing home deficiencies likely contributed to nursing home outbreaks and the failure to contain outbreaks. Three fourths of U.S. nursing homes did not have adequate numbers of registered nurses before the pandemic and had inadequate infection control plans (Geng et al., 2019). Moreover, most nursing homes rely on CNAs, who have minimal training and earn very low wages, to provide the majority of care. After the pandemic began, nursing home owners failed to provide testing for their residents and staff and many homes did not have enough personal protective equipment (PPE) on hand to address the initial crises. Moreover, staff had not been trained in the proper use of PPE and how to isolate residents with suspected infections. Residents who became COVID-19 positive were sometimes left to share rooms with other residents who then became positive.
CMS made numerous federal nursing home policy decisions and directives to state agencies that made the nursing home COVID-19 situation worse. These included not making nursing homes a priority for testing and PPE. CMS urged nursing homes to accept COVID-19 residents and removed the 3-day hospital stay requirement to expedite the movement of older hospital residents to nursing homes. CMS did not require states to establish separate nursing home units or buildings for COVID-19 residents. CMS policy also failed to require testing of all nursing home staff and residents, so that testing generally occurred only after a major outbreak. Only in August did CMS require nursing homes to test staff weekly in states that had a 5% or greater COVID-19 testing positivity rate. The national and state shortage of testing and PPE has been disastrous for nursing home staff and residents. Even now, the results of testing can be delayed for a week or more.
To make matters worse, CMS removed all regular survey and complaint investigations of facilities in March so that nursing homes no longer had to comply with federal requirements for staffing and quality of care. Instead, CMS directed states to only focus on infection control surveys and investigations when serious abuse may be occurring. This sidelined the state nursing home surveyors at the same time that policies prohibited family and friends and ombudsman from visiting residents. Moreover, CMS did not require reporting nursing homes to report infections and deaths until May.
These are only a few of the federal policies that were adopted that made the COVID-19 situation worse. As federal, state, and local governments and public health officials plan for an expected resurgence of COVID-19 in the next few months, we need policy makers to take actions to improve nursing home staff and resident safety.
We salute the many dedicated nurses and nursing personnel who persisted through this crisis to take care of residents at the severe risk to their own health and that of their families and friends. Nurses remained on the job and did their best to provide care under extraordinarily adverse circumstances. What we need is more nurses in policy making positions within the health care system and in federal and state government so that reasonable policies can be made that save lives and prevent future outbreaks. Let’s aspire to this in the future.