Lawmakers ask what went wrong at nursing homes

COVID-19 learning curve steep, but many problems ignored

A MARCH 18 report from the US Centers for Disease Control and Prevention indicated just how deadly COVID-19 could be at a nursing home. The report indicated a woman at a facility in Kirkland, Washington, had tested positive on February 28 and not long after a total of 129 people – 81 residents, 34 staff members, and 14  visitors – had been infected and 23 had died.

“The findings in this report suggest that once COVID-19 has been introduced into a long-term care facility, it has the potential to result in high attack rates among residents, staff members, and visitors. In the context of rapidly escalating COVID-19 outbreaks in much of the United States, it is critical that long-term care facilities implement active measures to prevent introduction of COVID-19,” the CDC report said.

“That was a big wakeup call for all of us,” said Dr. Larissa Lucas, who is part of a physicians group overseeing more than 400 residents at five nursing homes on the North Shore. Lucas was testifying on Tuesday before the Legislature’s Elder Affairs Committee, which is investigating what went wrong at Massachusetts nursing homes and whether those problems could resurface this fall.

Lucas said Massachusetts was slow to respond to the warnings contained in the CDC report, in part because officials were preoccupied with making sure hospitals were not overrun by COVID-19 patients. While relatively mild restrictions on nursing home visitors were put in place on March 10, staff at nursing homes were not required to wear masks until April 6. By then it was too late, Lucas said.

“While the government focused on hospital capacity, the virus quietly crept into our buildings undeterred and undetected in March,” Lucas told committee members.

When infections and deaths started to mount, most nursing homes were not prepared. “During the pandemic we were suddenly treating the same illnesses as the hospitals but without the staff, skills, and technology of the hospitals,” she said.

The state had been gathering data on COVID-19 deaths at nursing homes, but did not release it publicly until Friday, April 10. The news was shocking. Of the 599 people that had died from COVID-19 in Massachusetts, 247, or 41 percent, were at nursing homes. The death toll rose quickly from there.

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Marylou Sudders, the state’s secretary of health and human services, said nursing home residents have accounted for 40 percent of deaths nationwide, but 66 percent of deaths in Massachusetts, the worst rate in the country. In total, 6,209 residents of nursing homes have died, an extraordinary number given that the state’s 383 long-term care facilities house 36,000 residents.

Sudders offered two caveats to the data. She said Massachusetts has taken a very broad approach to categorizing COVID-19 deaths at nursing homes. She said the death certificate doesn’t have to list COVID-19 as the cause of death; the deceased merely has to exhibit symptoms consistent with COVID-19. She also said nursing home residents who were transferred to hospitals for care and died there would still be listed as nursing home deaths. Not all states treat nursing home COVID-19 deaths that way, she said.

Sudders chalked up a lot of the problems at Massachusetts nursing homes to the fact that so little was known about the coronavirus. “What we know about this virus today is completely different from what we knew in February and March, and it continues to evolve,” she said.

For example, Sudders said, the chief source of infection at nursing homes has turned out to be employees, which is why nursing homes located in communities where COVID-19 spread is high are at the greatest risk.

The potential for asymptomatic people to spread the disease also was not well understood. Indeed, officials are still learning. Sudders said asymptomatic transmission of COVID-19, which once was believed to account for 20 to 40 percent of cases, now may account for 70 percent of them, she said.

Yet while the learning curve on COVID-19 may have been steep, the underlying problems facing nursing homes were fairly well known. More than a year before the coronavirus, the nursing home industry in Massachusetts was saying it was badly underfunded, but those pleas fell on deaf ears on Beacon Hill. On April 10, Tara Gregorio, the president of the Massachusetts Senior Care Association, sent a letter to Beacon Hill leaders warning them of death and devastation if more funding was not forthcoming quickly.

“Given the vulnerability of the nursing facility population, this devastation will continue to increase at alarming rates without immediate and urgent action on the part of state government,” Gregorio wrote. “Specifically, we need any and all additional resources to immediately staff our nursing facilities, test all resident and staff working the frontlines, and access to enough lifesaving personal protective equipment.”

Sudders, who acknowledged on Tuesday that the nursing home industry had traditionally struggled with infection control and staffing, said the Baker administration responded to the crisis by funneling $400 million in state money and $180 million in federal funds to the facilities. She said the state ramped up testing dramatically of residents and staff and steered personal protective equipment to nursing homes. The state also launched in-person audits of nursing homes to determine compliance with a 26-point infection control checklist.

Now cases at Massachusetts nursing homes are down 99 percent since April and deaths are down 94 percent, Sudders said.

Rep. Ruth Balser of Newton, the House chair of the Elder Affairs Committee, asked Sudders if it made sense for hospitals to now be sending patients recovering from COVID-19 to nursing homes. Sudders said the state has seven standalone facilities for recovering COVID-19 patients and isolation units at 170 nursing homes. She said the isolation units are needed to keep infected and non-infected residents and employees separated.

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Bruce Mohl

Editor, CommonWealth

About Bruce Mohl

Bruce Mohl is the editor of CommonWealth magazine. Bruce came to CommonWealth from the Boston Globe, where he spent nearly 30 years in a wide variety of positions covering business and politics. He covered the Massachusetts State House and served as the Globe’s State House bureau chief in the late 1980s. He also reported for the Globe’s Spotlight Team, winning a Loeb award in 1992 for coverage of conflicts of interest in the state’s pension system. He served as the Globe’s political editor in 1994 and went on to cover consumer issues for the newspaper. At CommonWealth, Bruce helped launch the magazine’s website and has written about a wide range of issues with a special focus on politics, tax policy, energy, and gambling. Bruce is a graduate of Ohio Wesleyan University and the Fletcher School of Law and Diplomacy at Tufts University. He lives in Dorchester.

About Bruce Mohl

Bruce Mohl is the editor of CommonWealth magazine. Bruce came to CommonWealth from the Boston Globe, where he spent nearly 30 years in a wide variety of positions covering business and politics. He covered the Massachusetts State House and served as the Globe’s State House bureau chief in the late 1980s. He also reported for the Globe’s Spotlight Team, winning a Loeb award in 1992 for coverage of conflicts of interest in the state’s pension system. He served as the Globe’s political editor in 1994 and went on to cover consumer issues for the newspaper. At CommonWealth, Bruce helped launch the magazine’s website and has written about a wide range of issues with a special focus on politics, tax policy, energy, and gambling. Bruce is a graduate of Ohio Wesleyan University and the Fletcher School of Law and Diplomacy at Tufts University. He lives in Dorchester.

But Lucas raised concerns that patients coming from hospitals are testing positive after they arrive. She laid the blame on workers at hospitals and ambulance companies.

“It is unconscionable that across the health care system skilled nursing facilities are the only providers performing regular screening of all employees,” she said. “If colleges can test everyone, hospitals and ambulance companies can, too.”