Written by: Kacey Sycamore

Published: 10 May 2020

When Jorge Newbery finally got through to his 95-year-old mother, Jennifer, on a video call April 18, she could barely talk or move and her eyes couldn’t focus.

It was the first time he had seen her since California nursing homes shut their doors to visitors a month earlier. Immediately after the video chat, Newbery called the front desk in a panic.

“I said, ‘You gotta get her out, you gotta call 911,’” he recalled. “She’s looking like she’s about to die.”

Newbery’s mother was living at the Rehabilitation Center of Santa Monica, one of 198 nursing homes in California where at least one patient had contracted the coronavirus as of April 28, public health records show. The outbreak at the Rehabilitation Center has been worse than most, with 12 employees and 24 patients infected, including nine fatalities, according to the Los Angeles County health department.

(Image: Sgt. Nicholas Shepherd, a practical nursing specialist, and Maj. Rahul Vedprakash, assigned to Urban Augmentation Medical Task Force 352-2, walk down a hallway to the next patient at the Royal Suites Healthcare & Rehabilitation Center in Galloway Township, N.J., May 5, 2020. U.S. Army photo by Spc. Miguel Pena)

The Rehabilitation Center shares several other worrisome characteristics with many other homes beset by coronavirus infections: Historically, it has had lower-than-average staffing levels and a record of not always following basic staffing and infection control rules, a Kaiser Health News analysis shows.

Compared with homes reporting no patient infections, California facilities with one or more patients with a COVID-19 case had on average a 25% fewer registered nurses per resident in the final three months of 2019, the last period for which the federal government has published data.

In addition, 91% of nursing homes reporting at least one case of the virus had a previous health violation for not following infection control rules, while 81% of homes without reported cases had such violations. Typical violations included nurses or aides not washing their hands or wearing protective clothing around potentially contagious patients.

“With low RN staffing, it is not surprising that these facilities have had previous violations for infection control and poorer overall quality as measured by having more deficiencies,” said Charlene Harrington, a professor emerita of the School of Nursing at the University of California-San Francisco. “It is a classic situation that reaffirms what researchers have found previously, only the situation with the COVID-19 virus is far more serious than anything the nursing homes have experienced before.”

In an email, Jeffrey Huang, the administrator of the Rehabilitation Center of Santa Monica, said “we respectfully and strongly disagree” that Medicare assessments of the home’s quality predict or reflect the nursing home’s efforts to protect residents from the coronavirus. The staff was “continuing to do everything possible for keeping our residents and staff safe in these uncertain times,” Huang wrote. He declined to discuss Newbery, citing patient confidentiality.

Nursing homes have emerged as one of the places the coronavirus spreads most aggressively. In California, 4,711 nursing home residents had been infected and 663 had died by the end of April, about a third of all COVID-19-linked deaths that homes in the state have reported to authorities.

The KHN analysis is the first to compare Medicare’s public quality measures for the 198 California nursing homes that registered coronavirus cases by late April with the 983 homes with no cases reported to either the state public health department or Los Angeles County, where a majority of homes with infections are located. KHN found that California homes with coronavirus cases averaged 2.8 stars on Medicare’s five-star overall quality rating, while other homes averaged 3.5 stars.

On average, the homes that have had coronavirus cases had more complaints lodged against them and were fined 29% times more often. In addition, Medicare also calculated that their health violations of all types were 20% more serious. They also tended to be larger, averaging 105 patients versus 83 on the homes without virus cases.

The analysis found no substantial difference in the homes’ numbers of nurse aides or licensed practical nurses, but fewer registered nurses, who have the most medical training and supervise the other caregivers. On average, there was one registered nurse for every 39 residents at a California home without a patient coronavirus infection versus one RN for every 52 residents for homes with infections, KHN’s analysis found.

Certainly, nursing homes with stellar quality ratings also have had coronavirus outbreaks. Nursing Home Compare, the federal government’s consumer website, gave its top overall rating of five stars to Life Care of Kirkland, the Seattle-area nursing home that was the first reported to have a slew of infections. In California, 12 of the nursing homes with coronavirus infections had above-average ratings for both staffing levels and inspection results, although only three had no history of infection control citations.

The prevalence of coronavirus infections in lower-rated nursing homes could be explained by poorer care, but there might be other factors, said David Grabowski, a professor of health policy at Harvard Medical School. For instance, the lower-rated homes might be primarily located in low-income areas with high rates of coronavirus cases in those neighborhoods, he said.

“This suggests a very different set of policies if we want to protect nursing homes from further outbreaks,” Grabowski said.

Representatives of nursing homes rated as below average on Nursing Home Compare say that the coronavirus has thrown everyone off guard and that registered nurse staffing levels are irrelevant to whether a patient is infected by the new virus.

“It’s really hard to draw a straight line from” issues raised in previous years’ inspections “to this pandemic that even the experts didn’t see coming and were not prepared for,” said Elizabeth Tyler, a spokesperson for Longwood Management Corp., which runs three nursing homes with coronavirus infections that were also poorly rated before the pandemic: Studio City Rehabilitation Center, Burbank Healthcare and Rehabilitation Center and Sunnyview Care Center.

Burbank and Sunnyview have a health inspection rating of one out of five stars, which is much below average, while Studio City has two stars. Tyler said that health inspection ratings are a “very, very complex system” taking into account hundreds of different factors, and she hesitated to make any connections between past reviews or staffing levels and the current outbreak.

Lakeview Terrace in Los Angeles, which has recorded three cases of COVID-19, has been on a list of 15,000 nursing homes around the nation that health inspectors are required to visit more frequently because of repeated violations of patient safety rules. It has an overall Medicare rating of one of five stars — the lowest rating — and almost six times the national average of health deficiencies.

In August 2019, inspectors faulted the home after they saw a nursing assistant deliver a breakfast tray into an isolation room without putting on personal protective equipment. They also discovered the home was not keeping logs to track signs and symptoms of possible infections.

DJ Weaver, an administrator for Lakeview Terrace, said that on the rare occasion that mistakes happen, the facility counsels and trains staff and makes systemic improvements to prevent future occurrences.

“Overall, we have done a good job not allowing cross-contamination of any infectious organisms, which is the real danger,” Weaver said in an emailed statement.

Lakeview’s cases came as a result of accepting a hospital patient who had undiagnosed COVID-19, Weaver said. His infection of two roommates couldn’t have been prevented by the facility’s policies designed to protect residents from the virus. Those include banning staff from working at multiple nursing homes and suspending group dining and activities.

“That kind of thing is really hard to foresee,” Weaver said.

Jennifer Newbery entered the Rehabilitation Center of Santa Monica in April 2019. Up until the day of the video conversation, Jorge Newbery said he and his four siblings had been told by staff that the nursing home had only three cases of COVID-19, and that everything was under control.

But after the home transferred Jennifer Newbery to a local hospital, doctors told her family she tested positive for the coronavirus and had pneumonia, Newbery said.

When Newbery later called to thank the staffer for facilitating the video chat, he asked if the facility had seen any deaths.

The staffer said yes, Newbery recalled, and it floored him. “We absolutely had no idea,” he said.

Newbery said his mom is getting better at UCLA Medical Center Santa Monica. After she’s discharged, Jorge wants to take her to Chicago to live with him and his family.

Newbery said he had been unaware of Medicare’s critical assessment of the Rehabilitation Center, which has two stars out of five overall on Nursing Home Compare, denoting below-average care. Inspection records show that during a visit in May 2019, health inspectors faulted it for failing to sanitize a blood pressure cuff before it was used on a second patient, and for allowing a urinary drainage bag attached to a catheter to be touching the floor. In August 2019, inspectors determined the home violated California’s minimum staffing requirements because it lacked enough nurse assistants on 10 out of 24 days.

Huang, the administrator, noted Medicare gave the facility five stars, the best rating, in a quality category that assesses things like the frequency of patient trips to the hospital or emergency room and homes’ self-reported assessments of how often residents improved during their stays. The regulators who issued the May 2019 deficiency found no evidence of harm to a resident, he said.

Michael Connors, an advocate with the California Advocates for Nursing Home Reform, said nursing homes with fewer staff members and poor compliance with infection control practices are ripe for the spread of the virus.

“No place could be more dangerous to live right now,” Connors said. “It’s these characteristics that make nursing homes ground zero for COVID-19 outbreaks and deaths.”

Written by: Kacey Sycamore

Published: 10 May 2020

As many states begin to reopen — most without meeting the thresholds recommended by the White House — a new level of COVID-19 risk analysis begins for Americans.

Should I go to the beach? What about the hair salon? A sit-down restaurant meal? Visit Mom on Mother’s Day?

States are responding to the tremendous economic cost of the pandemic and people’s pent-up desire to be “normal” again. But public health experts remain cautious. In many areas, they note, COVID cases — and deaths — are still on the rise, and some fear new surges will follow the easing of restrictions.

“Reopening is not back to normal. It is trying to find ways to allow people to get back out to do things they want to do, and business to do business,” said Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials. “We can’t pretend the virus has gone away. The vast majority of the population is still susceptible.”

(Image: Lidvina Mikulic, Army and Air Force Exchange Service concessionaire, helps a customer at the Base Exchange at Ramstein Air Base, Germany, April 21, 2020. U.S. Air Force photo by Senior Airman Elizabeth Baker)

So far, state rules vary. But they involve a basic theme.

“They are making assumptions that people will use common sense and good public health practice when they go out,” said Dr. Georges Benjamin, executive director with the American Public Health Association.

As states start to reopen, people will have to weigh the risk versus benefit of getting out more, along with their own tolerance for uncertainty. The bottom line, health experts say, is people should continue to be vigilant: Maintain distance, wear masks, wash your hands — and take responsibility for your own health and that of those around you.

“It’s clearly too early, in my mind, in many places to pull the stay-at-home rules,” said Benjamin. “But, to the extent that is going to happen, we have to give people advice to do it safely. No one should interpret my comments as being overly supportive of doing it, but if you’re going to do it, you have to be careful.”

An added caveat: All advice applies to people at normal risk of weathering the disease. Those 60 or older and people with underlying health conditions or compromised immune systems should continue staying home.

“Folks who are at higher risk of having a more severe reaction have to continue to be very careful and limit contact with other people,” Plescia said.

So, should I go to the beach?

There’s nothing inherently risky about the beach, said Benjamin. But, again, “if you can, avoid crowds,” he said. “Have as few people around you as possible.”

Maintain that 6-foot distance, even in the water.

“If you are standing close and interacting, there is a chance they could be sick and they may not know it and you could catch it,” Plescia said. “The whole 6-foot distance is a good thing to remember going forward.”

Still, “one thing about the beach or anywhere outside is that there is a lot of good air movement, which is very different than standing in a crowded subway car,” he said.

Even so, recent images of packed beaches and parks raise questions about whether people are able or willing to continue heeding distancing directives.

But if we’re all wearing masks, do we really need to stay 6 feet apart?

Yes, for two reasons. First, while masks can reduce the amount of droplets expelled from the mouth and nose, they aren’t perfect.

Droplets from sneezing, coughing or possibly even talking are considered the main way the coronavirus is transmitted, from landing either on another person or surface. Those who touch that surface may be at risk of infection if they then touch their face, especially the eyes or mouth. “By wearing a mask, I reduce the amount of particles I express out of my mouth,” said Benjamin. “I try to protect you from me, but it also protects me from you.”

And, second, masks don’t protect your eyes. Since the virus can enter the body through the eyes, standing further apart also reduces that risk.

Should I visit Mom on Mother’s Day?

This is a complex choice for many families. Obviously, if Mom is in a nursing home or assisted living, the answer is clearly no, as most care facilities are closed to visitors because the virus has been devastating that population.

There’s still risk beyond such venues. Data from the Centers for Disease Control and Prevention shows 8 out of 10 reported deaths from the coronavirus are among those 65 or older. Underlying conditions, such as heart or lung disease and diabetes, appear to play a role, and older adults are more likely to have such conditions.

So, what if Mom is healthy? There’s no easy answer, public health experts say, because how the virus affects any individual is unpredictable. And visitors may be infected and not know it. An estimated 25% of people show no or few symptoms.

“A virtual gathering is a much safer alternative this year,” said Benjamin.

But if your family insists on an in-person Mother’s Day after weighing Mom’s health (and Dad’s, too, if he’s there), “everyone in the family should do a health check before gathering,” he said. “No one with any COVID symptoms or a fever should participate.”

How prevalent COVID is in your region is also a consideration, experts say, as is how much contact you and your other family members have had with other people.

If you do visit Mom, wear masks and refrain from hugging, kissing or other close contact, Benjamin said.

My hair is a mess. What about going to the salon?

Again, no clear answer. As salons and barbershops reopen in some states, they are taking precautions.

States and professional associations are recommending requiring reservations, limiting the number of customers inside the shop at a given time, installing Plexiglas barriers between stations, cleaning the chairs, sinks and other surfaces often, and having stylists and customers wear masks. Ask what steps your salon is taking.

“Employees should stay home if they are sick or in contact with someone who is sick,” said Dr. Amanda Castel, professor of epidemiology at Milken Institute School of Public Health at the George Washington University. “Also, employers should make sure they don’t have everyone congregating in the kitchen or break room.”

Some salons or barbers are cutting hair outside, she noted, which may reduce the risk because of better ventilation. Salons should also keep track of the customers they see, just in case they need to contact them later, should there be a reason to suspect a client or stylist had become infected, Castel said.

Consider limiting chitchat during the cut, said Plescia, as talking in close proximity may increase your risk, although “it feels a little rude,” he admitted.

What if your stylist is coughing and sneezing?

“I would leave immediately,” he said.

What about dining at a restaurant?

Many states and the CDC have recommendations for restaurants that limit capacity — some states say 25% — in addition to setting tables well apart, using disposable menus and single-serve condiments, and requiring wait staff to wear masks.

“That’s the kind of thing that does help reduce the chance of spread of infection,” Plescia said.

If your favorite eatery is opening, call to ask what precautions are in place. Make a reservation and “be thoughtful about who you are having dinner with,” said Plescia. Household members are one thing, but “getting into closer physical contact with friends is something people should be cautious about.”

Overall, decide how comfortable you are with the concept.

“If you’re going to go to a restaurant just to sit around and worry, then you might as well do takeout,” he said.

And travel?

Consider your options and whether you really need to go, say experts.

Driving and staying in a hotel may be an option for some people.

If hotels are adequately cleaned between guests, “you could make that work,” said Plescia. Bring cleaning wipes and even your own pillows. Again, though, “if you’re going to see an elderly parent, you don’t want to contract something on the way and give it to them.”

Regarding air travel — airlines are taking steps, such as doing deep cleaning between flights. Fresh and recirculated air goes through special HEPA filters. While there is little specific research yet on the coronavirus and air travel, studies on other respiratory and infectious diseases have generally concluded the overall risk is low, except for people within two rows of the infected person. But a case involving an earlier type of coronavirus seemed to indicate wider possible spread across several rows.

Maintaining distance on the plane and in the boarding process is key.

“Wear a mask on the plane,” said Benjamin.

And plan ahead. How prevalent is the coronavirus in the areas you are traveling to and from? Are there any requirements that you self-isolate upon arrival? How will you get to and from the airport while minimizing your proximity to others?

But if it’s not essential, you might want to think twice right now.

“People who absolutely don’t have to travel should avoid doing it,” said Plescia.

Worship services are important to me. What precautions should be considered?

The distance rule applies as houses of worship consider reopening.

“As much as you can within religious rules, try to avoid contact,” said Benjamin.

He is not giving any advice on Holy Communion, saying that is up to religious leaders. But, he noted, “drinking from the same cup raises the risk if a person is sick or items are touched by anyone who is sick.”

Finally, keep in mind that much is being learned about the virus every day, from treatments to side effects to how it spreads.

“My own personal approach is, try to play it on the cautious side a bit longer,” said Plescia.

Castel agreed.

“We need a little more time to fully understand how COVID-19 works and more time to ramp up our testing, find treatments and hopefully a vaccine,” she said. “We all have social distancing fatigue. But we can continue to save lives by doing this.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

Written by: Kacey Sycamore

Published: 09 May 2020

Written by: Kacey Sycamore

Published: 08 May 2020