By Jordan Rau MARCH 4, 2020
Long
before the novel coronavirus made its surprise appearance, the nation’s nursing
homes were struggling to obey basic infection prevention protocols designed to
halt the spread of viruses and bacteria they battle daily.
Since
the beginning of 2017, government health inspectors have cited more nursing
homes for failing to ensure that all workers follow those prevention and
control rules than for any other type of violation, according to a Kaiser
Health News analysis of federal records.
In all,
9,372 nursing homes, or 61%, were cited for one or more infection-control
deficiencies, the analysis showed. It also found violations were more common at
homes with fewer nurses and aides than at facilities with higher staffing
levels.
Even
among nursing homes crowned with the maximum government rating of five stars
for overall quality, 4 in 10 have been cited for an infection-control lapse.
Those include the Life Care Center of Kirkland, Washington, a Seattle suburb,
where five people who had lived at the facility have died.
Inspection
reports from around the country show many errors are rudimentary, such as
workers not washing their hands as they moved to the next patient, or failing
to don masks, gloves and gowns when in the rooms of contagious patients in
isolation.
“It’s
all these little things that are part of infection-control practices that when
they are added up can create an environment for an infection outbreak,” said
Patricia Hunter, the Washington State Long-Term Care Ombuds, who addresses
complaints from residents and families and pushes for improvements in
facilities.
In
recent years, the federal government has been ramping up the standards for
nursing homes, but inspectors remain frustrated by the prevalence of sloppy or
nonexistent handwashing. “We have got to do better on handwashing,” Evan
Shulman, the director for the nursing home division of the Centers for Medicare
& Medicaid Services, told an association of nursing home directors in 2018.
While
citations are rampant across the industry, health inspectors have classified
all but 1% of violations as minor and not warranting fines, the KHN analysis
found. A single low-level citation usually has limited impact on the overall
star rating, the only metric most consumers examine.
The
coronavirus has demonstrated its potential lethality among the old and frail in
Kirkland, but the infections that nursing homes already battle with mixed
success — influenza and antibiotic-resistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA)
— can be equally fatal. As many as 3.8 million infections occur in nursing
homes each year, killing nearly 388,000 residents.
Dr.
David Gifford, the chief medical officer for the American Health Care
Association, the primary nursing home trade group, told reporters Monday that
these facilities were ready to deal with coronavirus infections through the
prevention plans they have in place. “We prepare for seasonal influenza every
year — it’s very similar to that,” he said.
“We are
reinforcing the information for basic procedures for how to prevent the spread,”
he added, such as keeping infected residents away from others and having sick
employees stay home.
Yet the
same industry deficits that have hampered past infection-control efforts are
in play with the coronavirus. Nursing homes experience frequent staff turnover,
and new or temporary workers are less likely to be familiar with a facility’s
protocols. Also, inspectors have found that these homes have had difficulty
making sure that potentially infected workers stay home, a problem compounded
by the low pay and limited time-off benefits many receive.
During
a norovirus outbreak in 2017 at another Washington state nursing home, for
instance, at least six infected employees returned to work earlier than they
were supposed to. Inspectors discovered the virus ultimately spread to 32
employees and 43 residents — more than 40% of those living in the home,
according to an inspection report.
Even if
nursing homes are successful in getting infected workers to take days off, they
may run into trouble finding replacements. Dr. David Nace, director of
long-term care and flu programs at the University of Pittsburgh Department of
Medicine, said staffing issues are compounded by a national shortage of health
care workers. “Facilities may be faced with the issue of closure if they don’t
have the staffing,” he said.
KHN’s
analysis found that 53% of homes with the most nurses and aides — which CMS
awards five stars for staffing on its Nursing Home Compare website — had been
cited for infection-control violations in the past three years, while 65% of
homes with the fewest staff — garnering only one star — were cited for the same
type of failing. The staffing stars make up one component of the overall
rating.
“So
many times, when there aren’t enough staff, the aides and nurses are literally
trying to do 50 things at once, running from person to person,” said Lori
Smetanka, executive director of the National Consumer Voice for Quality
Long-Term Care, a nonprofit based in Washington, D.C. “That’s when things fall
through the cracks, like handwashing, which is the most useful thing to do to
prevent infections.”
More
sparsely staffed nursing homes were also cited more often: one-star facilities
averaged 1.5 deficiencies while five-star facilities averaged 1.3 deficiencies.
But out of more than 13,000 citations for infection-control lapses, regulators
classified only 109 as serious harms or threats to patients. That finding
echoed the results of a similar investigation KHN
conducted in 2017. “It shows how ineffectual the enforcement
situation is,” said Toby Edelman, a senior policy attorney at the Center for
Medicare Advocacy.
One such violation was cited last
April at the Kirkland nursing home after inspectors there observed a registered
nurse treating a patient whose feet were touching the floor, even though one
heel had a pressure sore that the resident’s daughter said she feared was
infected. “It was unhygienic,” the daughter told inspectors.
Inspectors
also watched another nursing home employee work in the room of a patient with
pneumonia without wearing a mask, gown and gloves as required by a sign outside
the room. They noted in their report that the facility had experienced two
outbreaks of influenza that year, affecting at least 17 residents and seven
staff members all told. Inspectors labeled the violations they observed as low
level because they caused “minimal harm or potential for actual harm.” The
nursing home pledged to reeducate staff on procedures and investigators found no problems when
they revisited two months later.
Life
Care Center, in an upscale, wooded neighborhood less than a mile from Lake
Washington’s popular Juanita Beach Park, said in a statement released Monday
that it is screening workers before they start work and after and has suspended
visits and new admissions.
“We are
also following infection control recommendations, including proper hand-washing
techniques and wearing masks, gowns and gloves when caring for any symptomatic
patients,” the statement said. The facility declined to discuss its previous
citation.
Seema
Verma, the CMS administrator, said during a press briefing at the White House
Tuesday night that her agency is sending inspectors to the nursing home, as well
as a hospital and dialysis center that treated coronavirus patients, to see if
federal health and safety regulations were followed.
Hunter,
the Washington state ombud, said that during her recent visits to 14 nursing
homes in three Northwestern states, she observed that aides were generally good
about using hand sanitizer but rarely washed residents’ hands. Not every
resident room had a sink, she said. “I haven’t seen one resident have their
hands washed during lunchtime or dinnertime,” she said.
While
some nursing homes are making concerted efforts, “there are nursing homes that
are really dirty and there are concerns that they’re not getting the job done,”
Hunter added.” The trouble is when you don’t have enough workers, or you don’t
have a stable workforce that’s trained to follow your protocol, that’s a
weakness in the system.”
In
2016, CMS updated and expanded its infection-control rules, requiring among
other things that each facility appoint one person to be in charge of infection
control. CMS required the employee in that position, known as an infection
preventionist, to complete specialized training and work at the facility either
part time or full time. The Trump administration has proposed eliminating the
on-site requirement.
Instead,
CMS proposed the preventionist be someone who has spent “sufficient time” at
the facility to oversee its infection-control efforts. It has asked the public
for advice on how to define sufficient.
“We
believe this is an appropriate standard,” the agency wrote in its proposed
rule, issued last July. “However, we are also concerned that there could be a
substantial variance in how LTC [long-term care] facilities interpret this
requirement.”
KHN
senior correspondent JoNel Aleccia contributed to this report.
Jordan
Rau: jrau@kff.org, @JordanRau
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