Months after it became painfully clear that the elderly were the most likely to die from COVID-19, poor infection control has resulted in multiple enduring outbreaks in the overwhelming majority of nursing homes across the country, according to US Government Accountability Office reports.
Of the 50 states and the District of Columbia, California ranked 19th for COVID-19 outbreaks sustained for more than five weeks from May 2020 to January 2021.
But nowhere was safe: 99.5% of U.S. nursing homes supervised by the Centers for Medicare & Medicaid Services (CMS) experienced at least one outbreak, and 74% had three or more outbreaks, in the period under review .
“The collective nature of nursing homes, with staff caring for multiple residents and residents sharing rooms and other common spaces, as well as high incidence rates in the surrounding community, can increase the risk that the COVID-19 enters the home (for example, by staff) and spreads easily, ”GAO said.
“Asymptomatic transmission can further complicate a nursing home’s efforts to prevent and control the spread because it allows the virus to continue to be transmitted in the home undetected. A growing body of evidence shows that asymptomatic transmission may be a contributing factor to COVID-19 outbreaks in nursing homes. “
A lack of personal protective equipment can also increase the risk, and staff issues – frequent turnover and a shortage of manpower due to the disease, have become acute during the pandemic – make it more difficult to follow health practices. infection control, nursing home officials said.
In a series of polls over the past year, GAO has also found that many nursing home staff are reluctant to get vaccinated against COVID-19, which can complicate infection control efforts. and that consumers cannot easily find the number of residents. and staff members were vaccinated in each nursing home.
“It was striking that so many staff members had cases of COVID-19,” said John Dicken, director of the GAO health care team. “We recommended that CMS communicate vaccination rates for staff and residents of the homes, so that consumers, families and CMS itself are able to better understand which facilities may be more susceptible to outbreaks.
CMS is working on this recommendation. It’s responsible for ensuring that the country’s 15,500 Medicare and Medicaid-certified nursing homes – which house 1.4 million elderly and frail people – meet federal quality standards. But the agency appeared loath to crack down on homes after discovering infection control issues, GAO found.
Profit vs Profit
Whether nursing homes were for-profit or not-for-profit didn’t seem to make a difference in the severity and number of COVID-19 outbreaks they suffered, but the sheer size of the facilities did.
Nursing homes with lingering outbreaks were more likely to have more beds than homes with short-lived outbreaks, GAO found.
Once COVID-19 entered a home – more likely when community transmission was high – the home’s ability to quickly test, identify, and separate infected residents and staff before infecting others was overwhelming. critically important to stopping the spread, nursing home officials said. However, asymptomatic infections have made this more difficult.
“This analysis highlights the challenges most nursing homes have faced in responding to the COVID-19 pandemic – responding to repeated outbreaks, many with weeks of continuous spread and marked by high numbers of cases and deaths, ”GAO said.
But even before the pandemic, California nursing homes had the nation’s worst record when it comes to infection prevention issues, according to another GAO study.
Tarnish on Golden State
As federal surveyors watched, a licensed practical nurse at a California nursing home was coughing and looking sick. She had been ill for at least two days with a fever, diarrhea, cough and a runny nose, she told federal investigators. Yet she worked with frail and elderly people.
Another nursing assistant at the same facility failed to properly clean her hands while caring for an incontinent patient, creating the potential for spreading disease and infection. Seven other employees had not been tested for tuberculosis before being hired. Others who had not been vaccinated against the flu did not wear face masks.
Despite these problems, and despite the facility’s “model of behavior,” no law enforcement action has been taken against the nursing home by federal authorities, GAO found.
In California, 1,174 nursing homes were surveyed and 60.6% of them were cited for deficiencies in infection prevention and control in a single year. It was the worst in the country, well above the national average of 39.6% and 3.8% for Rhode Island.
But it’s not just a big state versus a small state issue. Other large states performed much better than California: In New York City, only 21.2% of nursing homes were cited for infection prevention during the study period. In Texas it was 48.2%; in Florida, 43%; Pennsylvania, 45.9%.
Most nursing homes had infection control weaknesses before the pandemic, GAO said – and half had lingering problems. Despite this, 99% of these shortcomings were classified as “not serious” and enforcement actions were extremely rare: only 1%.
“A small minority ended up with enforcement action and sometimes it can be valid – the homes may have taken action to improve things – but in many cases there have been genuine lapses in supervision. Dicken said.
The GAO takes a closer look at California – and three other states – to understand precisely why nursing homes had bigger-than-average problems. Are there underestimates or inconsistencies in data collection between states? Are the inspection processes different? This investigation is ongoing and will be released later this year.
Dicken and his colleagues are also analyzing this once-in-a-century pandemic to extract a full set of lessons learned, especially when it comes to nursing homes. Emerging themes: the importance of having solid, real-time data to guide policymaking in dynamic situations, and the importance of making this data transparent so that everyone can access, analyze and understand it. They are trying to understand the effects of social distancing and visiting restrictions on mental health, and the impact of the end of federal inspections on the quality of care.
This work is vital because, even as COVID-19 infections decline in America as millions of people get vaccinated, the virus is not going away. At best, it is expected to reduce to flu-like proportions – and the flu kills tens of thousands each year, with older people particularly vulnerable.
“It’s really an underrated theme, to address the real issues of resident care and infection control,” Dicken said.