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The Eldercare Advocate: Ten Questions to Ask a NH in COVID-19

April 23, 2020|advocacy, aging, Aging Parents, anxiety, caregivers, Cognition, confinement, coronavirus, COVID-19, distance, Eldercare, elders, Isolation, Loneliness, long term care, nursing homes, Skilled Nursing Facilities, 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. 

An April 14 Article by Maggie Flynn In Skilled Nursing News entitled “PPE Shortages to Play Central Role in Future Nursing Home Lawsuits” as a result of widespread shortages of masks and gowns as well as quick and effective tests. The article continues saying that 6 months from now as the virus is either in the throes of dwindling or has hopefully become extinct, is when the lawsuits will begin to emerge. According to Christy Tosh Crider, chair of the healthcare litigation group at the law firm Baker Donelson as advertisements for lawsuits related to COVID-19 are already underway. It encourages facilities to know the rate at which they use PPEs, knowing how to calculate it, and how that could change if a patient is suspected to be positive, is returned after a hospitalization with a positive diagnosis, or if they admit a new patient with a positive diagnosis. 

An April 15, 2020 article in the NY Times speaks to the unspeakable tragedies occurring in our nations Nursing Homes. Based on an anonymous tip, 17 bodies were found in a small morgue intended only for 4 bodies at Andover Subacute and Rehabilitation Center in Andover, NJ. According to Eric C. Danielson, the police chief in Andover, “they were just overwhelmed by the number of people that were expiring” The 17 deaths were among 68 recently linked to the long-term care facility.

According to an April 16, 2020 NY Times article, there were 29 or possibly more deaths linked to the virus at a Queens. relatives complained there was a disturbing lack of information about what was going on inside the home. The home finally reported 29 deaths to a local state assemblyman, but according to Assemblyman Kim, that number did not coincide with reports from healthcare workers inside the home. Two workers at the home estimate the actual deaths from the virus closer to 60. In Suffolk County, Long Island, nearly half of all the COVID-19 deaths involved nursing homes or assisted-living facilities.

Now that families are banned from visitation, they are at a distinct disadvantage. They can only rely on the veracity of what they are being told when they call.  According to Governor Chris Cuomo, in a news conference on Sunday, April 19, nursing homes continue to be  (paraphrasing) a number one concern as they are a number one feeding ground because residents are confined in a congregate setting. The virus spreads like fire in dried grass. However, On April 15, only under duress from vocal families did Governor Cuomo promise to issue an executive order requiring nursing homes to inform relatives of COVID-19 infections and deaths in facilities and to release the numbers for each nursing home, albeit with the caveat “to the best we have”.  He had previously been unwilling to provide that information.

According to the California Department of Public Health, as of April 17, 2020, of the 1224 Skilled Nursing Facilities in that state, 258 are reported to have one or more residents or healthcare worker diagnosed with a case of COVID-19. As of April 16, 2020, for over a week The Ohio Columbus Dispatch and other media organizations has been asking for the number or people who died in each of the state’s nursing homes as a result of the coronavirus. The state health department and many country health departments have repeatedly refused to provide that number. On April 15, the Ohio Health Director finally released the overall number of cases in long-term care facilities but did not release the number of health care workers who have tested positive nor the overall number of death or the number of deaths attributed to the virus at each facility. Of the more than 100 nursing homes and ALF in Ohio, it’s reported that 826 residents have been diagnosed as being positive for the virus. That accounts for more than 10% of the cases in the state. In an effort for more transparency, and as a result of pressure from advocacy groups and families alike, as of Sunday evening, April 19, 2020, CMS released New Reporting Guidelines for Nursing Homes. According to an article by Alex Spanko in Skilled Nursing News, a USA Today investigation found more than 3,000 COVID-19 deaths associated with nursing homes. However, a NY Times article of April 19, 2020 there have been 7,000 deaths across the country that can be attributed to the coronavirus. Spanko goes on in his article to report that according to USA Today, “Six states did not respond, including Florida, a retirement haven,” “Another six states said they were compiling numbers but declined to provide some or all of them. Thirteen states could only provide partial data, citing various reasons including that they were not tracking deaths specifically in nursing homes or couldn’t separate staff and residents who have tested positive.” [1] CMS lagged behind the American Health Care Association, an organization representing a variety of non-profit and for-profit health care providers- including SNFs, that urged all of its members to report their COVID-19 cases to the state department agencies that oversee and conduct annual inspections at SNFs. 

Sens. Bob Casey and Ron Wyden, wrote a letter to the Centers for Disease Control & Prevention, the CDC, in early April urging them to issue a list of all public facilities with COVID-19 cases by April 16. 

This crucial information is not only of vital importance to the American Public, the families and loved ones of residents in the over 15,000 nursing homes in this country, but it will go a long way in reliably determining the numbers of personal protective equipment (PPEs) and testing kits needed in these facilities so they may provide residents and healthcare workers the environment for receiving and providing a safe level of care.

What are some questions families can ask to determine if the needs of their loved ones, and the workers who care for them, are being met?

Ten Questions to Guide You

1.  First and foremost: Has anyone in the nursing home tested positive for COVID-19? This would be someone who has been a long-term resident in the facility as opposed to a new patient admitted from the hospital after being tested positive for the virus. This would include any outside personnel who have recently come into the facility, although there are severe restrictions in most buildings on those who can enter the building, including pharmacy personnel who are relegated to dropping off medications at the front desk.

a.  Is the facility admitting any new residents from the hospital with a new positive diagnosis of the virus?

2.  What is the nursing home doing to prevent infections? What screening techniques is the facility using on a daily basis to screen staff for COVID-19?

3.  What precautions have been put into place for residents in rooms with more than one bed?

4.  Does the nursing home staff have sufficient Personal Protective Equipment and what does that equipment consist of? (i.e., masks, face shield, gowns, gloves) How often are masks, shields, gowns and gloves reused? If the staff does not have sufficient protective equipment, what is being done to secure such equipment and what is being provided to the staff in the interim?

5.  How is the nursing home helping residents stay connected with families or loved ones? Will they provide a regular schedule for you to connect with your loved one? 

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 tomeet the social and emotional needs of residents, such  as video calls. An April 7th article in McKnight’s Long-Term Care News “Seniors who use video chat are less likely to report symptoms of depression”.[2]

6.  What creative approaches are being used to engage residents who are isolated in their rooms? 

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. Are the doors of resident’s rooms 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 are out of ear shot and 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.

7.  What methods of exercise or movement are being provided for residents who are isolated? 

It is commonly known that reduced mobility has psychological, physical and social consequences for older adults. Lack of mobility results in weakness, can increase the risk of falls, and contributes to sadness, loneliness, and hastens cognitive decline. 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. 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.

8.  What is the facility doing to keep residents socially connected with their fellow residents?

9.  What steps is the facility taking to keep families and residents abreast of important information. 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. 

10.  Has the nursing home’s staffing been affected by the virus? If so, in what way? What is the facility doing to address these issues? What is the facility doing to meet the routine care needs of residents in terms of bathing, feeding, medication management in the light of a staffing shortage. [1] [2]

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