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The Eldercare Advocate: Nursing Home Challenges during COVID-19

April 9, 2020|Aging Parents, anxiety, caregivers, confinement, coronavirus, COVID19, Depression, distance, Eldercare, elders, empathy, health care workers, Isolation, Loneliness, long term care, masks, nursing homes, protective equipment, Quality of Life, Sadness, Skilled Nursing Facilities, stress, Well-Being, wellbeing

The TV’s are blaring in almost every room whether or not someone is in them!!!! Not an unfamiliar site if you’ve ever been in a nursing home. A practice that I always thought should be frowned upon. 

But now more than ever, it has resulted in being inundated with constant information on the coronavirus. Number of cases, deaths, vulnerable populations, lockdowns, state after state, country after country, families being separated from loved ones, talk of fines if you leave your house or you are not appropriately practicing social distancing…..the list goes on and on. The residents and staff members alike, are affected by the news. Staff members concerned for the safety and well-being of the residents, themselves and their families; residents wondering about their fate as well as their families and loved ones with whom they are no longer in contact.

The stress and fear are palpable as soon as you enter the building. As a staff member, your temperature is taken at the front desk each day when you arrive. While 98.6 is considered the average normal temperature, 99 degrees has been determined as the upper limit allowable for a health care worker in many nursing homes. Anything above and you will be sent home even your baseline may be slightly higher. Each staff member is also assigned one mask/week. If inadvertently it drops on the floor, or something undesirable splashes onto the mask, there may not be an available replacement, clearly placing you at risk. Some staff members have felt sick from breathing in their own droplets and carbon dioxide for hours on end. As a result, some have elected to stay home on “intermittent” days to “recover”, all the while feeling guilty about leaving their coworkers unsupported and the residents for whom they feel responsible.

NYS state guidelines indicate that when a health care professional (HCP) enters a resident’s room to deliver care, both the HCP and resident must be wearing a mask. “Residents must wear facemasks when HCP (healthcare professionals) or other direct care providers enter their rooms, unless such is not tolerable”. Because of equipment shortages, many facilities are not adhering to these guidelines ultimately placing both residents and staff members at risk. 

Residents are confined and languishing in their rooms. CMS guidelines as of 3/25/2020 stated that residents who test positive must be quarantined in their rooms. However, The Department of Health of each state may issue guidelines which are more stringent and may supersede CMS guidelines. It appears that sometimes these guidelines have been misinterpreted. On a unit in which a positive case of coronavirus has been identified, residents are required to remain in their rooms. However, despite the fact that this does not apply to residents on other units, in some facilities all residents throughout a facility are now being confined to their rooms despite lack of an identified case on that unit or floor. 

Now on a unit where there has been a positive case, and a death which could possibly have been related but testing was not done, doors to all resident rooms are closed. The halls are silent. There is no longer the blare of TV sets with constant barrage of coronavirus news bellowing into the hallways. But the potential repercussions are just as devastating. Residents behind closed doors, out of ear shot, out of eyesight. At least when doors were open residents could be quickly eyeballed as staff members rushed down the halls, not that the eyeballs always paid attention, but there certainly was a greater chance that this would occur. I entered the room of a trach patient whose door was closed and found the call bell on the floor. Other residents may have the call bell nearby but are unable or sufficiently aware to ring for help.  Now in the hallways you hear nothing. No one calling out for help as you sometimes hear in nursing homes. No one crying they want to go home. Nothing. Silence. What is happening behind those closed doors? Has anyone fallen? Do they need anything?  Are they hungry, thirsty, or need to use the bathroom? 

This is creating a more dangerous situation for the resident and the facility alike.  Because of fear associated with spreading the disease and the possible disastrous effects in a nursing home facility, family members are now being deprived of crucial time together in the final moments of life. The guidelines state that visitors are allowed in the case of comfort and end of life care. “Effective immediately, suspend all visitation except when medically necessary (i.e., visitor is essential to the care of the patient or is providing support in imminent end-of-life situation) or for family members of residents in imminent end-of-life situations.” Despite this allowance spelled out in the guidelines, I learned of a a son who was not allowed into a facility to spend the last moments with his father. This was a heartbreaking tragedy. 

Residents confined to their rooms are experiencing decline in function. A colleague reported that her mother is now extremely weak because she has been “cooped” up in her small room without any means of exercise for almost 2 weeks. Lack of mobility results in weakness, can increase the risk of falls, certainly contributes to sadness and loneliness and hastens cognitive decline. In addition, routine is important for residents with dementia. Disruption to the routine is more likely to result in persons with dementia becoming more agitated, confused and scared, ultimately resulting in more behavioral outbursts. This can be more traumatic for roommates, staff and the environment in general.

Residents in the nursing home environment experience isolation and lack of stimulation in the best of circumstances. The restrictions as a result of these trying times is worsening an already dire situation for many residents of the over 15,000 in our country. Social workers, psychologists, recreational staff are especially crucial during this time. Resident fears and anxiety, are not being regularly addressed. Nursing homes are most assuredly dealing with a stressful situation. Administrators are experiencing their own personal anxiety and stress. They are walking a tightrope between trying to avert the frightening possibility of having a positive case of COVD-19 in their building juxtaposed with concerns for their personal safety and the safety of their family. There may also be staff shortages at this time.  But we must ensure that resident rights and needs continue to be a priority. I have personally seen residents who had previously been up in a chair and out in a dining room for meals and activities several times now remaining in their beds, day after day, in their hospital gowns or sleeping apparel. The importance of adhering to a daily routine is an important ingredient for mental and psychological well-being for us all. Getting out of bed, bathing, getting dressed, improves mental outlook and prepares one for the day ahead. Residents care needs must continue to be addressed. They should be washed and dressed and out of bed whether or not they remain sheltered in their rooms. Let us not choose or use expedience in the name of safety. Resident emotional and psychological well-being is of critical importance. Family members and loved ones should understand the guidelines for their state and press the issues of importance to their loved ones with facility administrators. 

CMS has encouraged nursing homes to establish virtual communication between residents and families. In NYS, the Department of Health guidelines state that facilities must provide other methods to meet the social andemotional needs of residents, such as video calls. Whether in the facility in which I’m presently associated, or through conversation with colleagues in other facilities, I have not seen or heard of regular attempts to address this issue. An April 7th article in McKnight’s Long-Term Care News “Seniors who use video chat are less likely to report symptoms of depression”.[1]

CMS has also encouraged nursing homes to keep the loved ones of residents appraised of their care by suggesting that facilities assign a staff member as a primary contact for family members both for responding to queries as well as to initiate contact to inform them of their status. This is a particularly anxious time for them; not knowing what is going on in the facility when they know their physical presence is vital to advocacy and ensuring quality care. It is my sincere hope that facilities are taking steps in this area. Through colleagues at a variety of facilities, I do not know that this is being pursued as common practice during this time.

More than ever, recreational department staff are crucial. Rather than continuing a recent cooking activity in a central location when no one can attend because it’s on the calendar, in order to deliver a hot pancake or cookie to a resident’s room, this is the time for creativity and more in-room visits and programs. (i.e., music, games, conversation, facilitating phone calls, etc.) I recently encountered a resident who said he loved music but who didn’t regularly listen to his radio because he feared the batteries would die. No one had addressed this issue.I purchased some batteries for his radio. His face lit up like a Christmas tree. We can all reach out with small gestures which can go a long way. 

I heard of this recent disturbing situation in a facility. A staff member, because of the position could clearly work remotely. The position was related to census building and reimbursement. This individual and their spouse have a pre-teenage child. One of the parents no longer had sick days available from work. The parent who could work remotely requested permission to work from home as the child through billowing tears expressed fear that the parent would get the virus if they went to work in the nursing home. The employee’s request was denied and was told the option was to bring the child to work. The employee felt trapped. In fear of losing his/her job, they came to work leaving the child at home alone for several hours, placing themselves and their child at risk. Especially in this time of crisis, care for the bottom line cannot supersede the care for the employee, especially for a business with the express purpose of caring for people. Person-centered care starts with caring for the people in your employ. I hope this is an isolated situation and that providers realize the safety and well-being of their employees greatly impacts the safety and well-being of the people in their facilities for whom they are responsible. 

The hallmark of the nursing home resident prior to the restrictions resulting from the coronavirus has been lack of sunshine, loneliness, isolation and lack of engagement. The situation as it is presently is more dire and cause for more concern.  All of us are challenged at this time. Kindness is an inner desire makes us want to do things even if we don’t get anything in return. It is the joy of our life to do them. When we do good things from this inner desire, there is kindness in everything we think, way, want and do.” Emanuel Swedenborg

It is particularly important for all of us to remember this at these times. Please reach out to friends, families, neighbors and loved ones. Browse through your contact list and reconnect with someone you haven’t been in touch with for a while. Say hello to let someone know you are thinking of them, share a story, tell a joke, reminisce, bring a smile, warm a heart. On a personal level, being the recipient and the person reaching out has helped me tremendously. We all need this at this time. Some are struggling more than others. Social distancing does not have to mean disconnected. The digital age has allowed us to remain connected in a way we have never been before. Maybe the lemonade we can create from this situation is to understand we are truly interconnected; it is forcing us to slow down; to reach outside of ourselves enough to care for each other in ways we were too busy to previously think about in our all too busy lives. [1]

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