With coronavirus cases and deaths multiplying daily, nursing homes and assisted living facilities face special challenges in protecting their uniquely vulnerable residents and the people who care for them.
“Because we’re dealing with older patients, many of whom have underlying diseases, we are going to see more severe illness from coronavirus and we are going to see deaths,” said Dr. Glen Solomon, chairman of the department of internal medicine at the Wright State University Boonshoft School of Medicine. “The problem with the nursing homes and the coronavirus is that the people who are most likely to get very sick are the people with underlying illnesses and diseases.”
On March 18 local health officials announced Koester Pavilion in Troy had Ohio’s first confirmed cases in a nursing home of COVID-19, the illness caused by the novel coronavirus. Both staff and residents were infected and the outbreak spread to SpringMeade Health Center in Tipp City, another Premier Health-owned nursing home that shared a now-infected staff member with Koester.
Three Koester residents and one SpringMeade resident with COVID-19 have died.
The disease’s first U.S. epicenter was the Life Care Center, a Kirkland, Washington, nursing home where 35 residents infected with COVID-19 have died since late February. Coronavirus cases have been reported in 147 nursing homes across 27 states, the Centers for Medicare and Medicaid Services said on March 23.
Citing privacy rules, Ohio Department of Health spokeswoman Melanie Amato declined to provide tallies or other information about other nursing home outbreaks in Ohio. Media outlets are reporting confirmed cases in nursing homes in Cuyahoga, Summit and Franklin counties.
Pete Van Runkle, executive director of the Ohio Health Care Association, said he has had to rely on media reports to know where COVID-19 is surfacing at the state’s long-term care facilities. He is frustrated that there is no centralized public reporting for that data for him to share with the group’s more than 1,000 members, which include providers of skilled nursing centers, assisted living communities and agencies that serve people with intellectual and developmental disabilities, deliver home care or provide hospice care.
“Skilled nursing facilities and assisted living both are populated by a large number of people who are living close together and, more importantly, are medically compromised. And they are elderly. All of those things make them particularly vulnerable due to COVID-19,” Van Runkle said.
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About 75,000 Ohioans live in skilled care nursing homes, according to Robert Applebaum, director of the Ohio Long Term Care Research Project at Miami University’s Scripps Gerontology Center. Another 35,000 are in assisted living facilities and 35,000 live in continuing care retirement communities where people typically live independently in houses or apartments.
“The health issues that often accompany aging, including underlying conditions such as heart disease, the need for ‘hands-on’ help with activities of daily living among many short and long-term care residents, and the long delay in onset of symptoms for COVID-19 — all of these factors combine to make this virus a challenge, even when all public health guidance is followed to the letter,” said Dr. Roberto Colon, system vice president for quality and safety at Premier Health.
Strict restrictions the state put in place allow visits only in end-of-life situations and require increased sanitizing and protective equipment for staff at nursing homes. But Van Runkle said a concern is that staff who go home and come back to work may unknowingly be carriers.
“There’s no way to know for sure because people can carry it and not have any symptoms,” Van Runkle said. “They still could come down with the disease at any moment.”
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Van Runkle said multiple other issues are surfacing statewide for nursing homes:
• The state and national shortage of personal protective equipment like face masks, gowns and gloves, has Van Runkle working to connect facilities with local “sewing circles,” individuals who are hand-making protective masks.
• In order to keep employees from quitting, nursing homes are paying hazard pay, adding $2 to $10 per hour to employee wages.
• It is uncertain how or when additional state and federal funding will begin to flow and some facilities are struggling with cash flow problems and have to apply for loans.
• Nursing homes are looking for ways to open isolation centers for COVID-19 infected patients who do not need the acute care that is provided in a hospital. They would be tended to by skilled care providers who do not work anywhere but in the isolation center so non-infected residents are not put at risk.
“Those don’t exist today and we are working with the state on how this would work,” Van Runkle said. “One of the issues that we’re dealing with that’s really hot right now is hospitals moving people with COVID-19 into skilled nursing facilities or trying to get them to take them. It’s a real big concern for our members right now.”
Employees at risk
Even before the coronavirus pandemic nursing homes and health care providers were already dealing with difficulties in finding and keeping nurses and other health care staff.
Van Runkle and others said health care workers are bravely confronting the illness on the front lines, even as the number of health care workers getting infected grows and as shortages of personal protective equipment make them feel more at risk.
“They care about their patients,” said Yvonne Curington, a registered nurse who is retired but represents National Nurses United on the AFL-CIO Dayton-Miami Valley Regional Labor Council.
“That’s why we are nurses. We care about what happens. We think about what if that was our loved one? I would want someone to take care of them,” said Curington, whose union represents nurses at the Dayton Veterans Affairs Medical Center.
Officials at Premier Health, Kettering Health Network and the Dayton VA all say they currently have enough protective gear. Premier has the two Miami County nursing homes, the VA has a nursing home on it’s medical center campus and Kettering operates Sycamore Glen Retirement Community, a Miamisburg independent and assisted living facility.
“We have the personal protective equipment that we need right now. The impact, felt by all health care providers, is the regular conversation about whether there will be enough such equipment during later stages of the pandemic,” Colon said. “Our focus has been ensuring that we do not overuse PPE outside of recommended situations to ensure we can maintain an adequate supply if and when a higher number of cases challenges our health care system.”
“Many people are working proactively to address that long-term need, including ways to extend the life of our PPE equipment and it is something that is on everyone’s minds right now,” Colon added.
Curington said it is infuriating that the people on the front-line of the battle against COVID might face using handmade masks. She said the North American Building Trades Union has agreed to donate protective gear to National Nurses United.
“We are the richest country in the world. We have been very lax in how we manage things,” Curington said. “It isn’t like they haven’t known this. The Centers for Disease Control has known for a long time that it is not a matter of if, it’s a matter of when, the next pandemic occurs. We should have been prepared.”
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Staff have quit Koester and SpringMeade in the wake of the COVID-19 outbreak, said India Chrisman-Williams, regional vice president of operations for AdCare Health Systems, which operates the two facilities for Premier Health.
“We’re doing outreach and maintaining open dialogue with them. We’re calling people, we’re talking them through it, we’re educating them, and we’re making them aware of available resources to support them,” Chrisman-Williams said. “We want to maintain relationships with them, and hopefully welcome them back at some point.”
She said staff are wearing masks while working with all patients, as well as protective gowns, “in accordance with public health guidelines.” Even though the masks are critical to staunching the spread of COVID-19, Chrisman-Williams said they present a unique challenge in a nursing home setting, where residents may have Alzheimer’s disease and other forms of dementia.
“Sometimes people don’t understand why their caregiver is wearing a mask,” Chrisman-Williams said “They want that mask off for the sake of human interaction and for communication, not understanding that the mask is there for their safety.”
Residents and family members restricted
Rules are in place across the state restricting interaction among residents and banning all visitors to nursing homes and assisted living facilities except in end-of-life situations.
“One of the biggest challenges is keeping our residents comfortable in their own apartments. We have a very active community with multiple opportunities for socialization throughout each day,” said Michele Brooke, director of Sycamore Glen Retirement Community. “During this challenging time we have to find innovative ways to meet their psycho-social, emotional, mental and spiritual needs on an individual basis.”
She said one big change is Sycamore’s popular dining room had to be closed, so staff now deliver 400 trays of food to residents each day.
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Sycamore and other facilities also are looking for ways to improve remote interaction between residents and loved ones.
Since the nursing home restrictions began earlier this month some people resorted to standing outside the nursing home windows and looking in while talking on the phone to a resident. Sycamore is working with residents so they can learn to Skype or FaceTime with family members, and Van Runkle said some facilities are buying iPads so residents can have virtual visits with friends and family.
“We know it’s been particularly difficult for families and residents.” said Lori Smetanka, executive director of National Consumer Voice for Quality Long-term Care, which represents interests of residents of long-term care facilities. “It’s is very concerning and very troubling.”
She said family members have typically not only provided residents with companionship, but many also provided additional care-giving tasks, such as help with feeding or getting glasses of water, and monitoring the quality of care.
The pandemic may have some people thinking it is time to bring home a loved one who is in a nursing home, but Solomon said that is probably not the best option for people with the kind of serious medical needs that put them into a nursing home in the first place.
“If someone needs to be in a nursing home, they should be in a nursing home,” Solomon said.
By the numbers
75,000: Ohioans in nursing homes
35,000: Ohioans in assisted living facilities
35,000: Ohioans in continuing care retirement communities
Source: Robert Applebaum of Scripps Gerontology Center-Miami University
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