What can be done to stop COVID-19 from ravaging skilled nursing homes in Sonoma County?

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By Martin Espinoza, The Press Democrat, August 3 2020

Laura Cunningham blows a kiss to her mother, Susan Nickel, as they finish their video chat at Lakewood Meadows Park in Windsor on Thursday, July 30, 2020. Cunningham’s mother is hospitalized at Petaluma Valley Hospital while recovering from COVID-19. (Alvin Jornada / The Press Democrat)

It was nearly a month ago when Laura Nickel-Cunningham received the call from the Petaluma skilled nursing home where her mother was staying.

Susan Nickel, 73, had been at EmPres Post Acute Health and Rehabilitation for the past two years and was not in good health. She’s got heart failure, chronic obstructive pulmonary disease and other health issues. But she’s always been a fighter, said Nickel-Cunningham, who lives in Windsor. Late last year, her mom pulled through after she was treated for a collapsed lung.

But now came the frightening news on the telephone: the nursing aide who was caring for Nickel-Cunningham’s mother had tested positive for the coronavirus.

Soon, residents near Nickel started getting sick with the virus, including a resident in another room with whom she shared a bathroom.

“There were more residents next to my mom who were also positive within the next couple of weeks,” said Nickel-Cunningham. “I knew it was only a matter of time.”

On July 25, her frail mother was admitted to Petaluma Valley Hospital with pneumonia and a severe urinary tract infection, she said. Only then did Nickel-Cunningham learn the results of a coronavirus test done July 21. Her mother had COVID-19.

As of Friday, 30 residents of EmPres Post Acute and at least one staffer had been stricken with the virus. It is one of three skilled nursing facilities in Sonoma County that have reported deaths, according to data from the California Department of Public Health.

Of the 37 coronavirus-related deaths in the county, at least 30, or more than 80%, have been among residents of skilled nursing homes and residential care facilities. While the pandemic has been a trying time for many, no other group of people in Sonoma County has experienced the deadly consequences of the virus as much as the residents of these senior care homes.

Last week marked the deadliest week of the pandemic in Sonoma County since the virus was first detected locally March 2. On Tuesday, local health officials reported seven people had died within a week’s time, between July 23 and July 28, three from skilled nursing homes and four from a residential care facility for the elderly. Another woman from a skilled nursing home died on Wednesday, and finally on Friday, health officials reported that four more people — two skilled nursing residents and two residential care home residents — had succumbed to the virus.

As total cases since the pandemic began passed 3,000 on Saturday, the death toll keeps mounting. County officials, senior care home administrators and local and state health officials are trying to come up with ways to keep people alive. As early as Monday, the state is sending strike teams of infection prevention specialists to Sonoma County to help conduct onsite monitoring, isolate sick residents and beef up infection control protocols at the most affected skilled nursing facilities.

State infectious disease specialists have made periodic visits to Sonoma County before, but county Health Officer Dr. Sundari Mase has asked the state strike team to maintain a daily presence in the county until the situation improves. She said everyone involved — local hospitals, skilled nursing homes, state health officials — is doing everything they can to stop the spread of the virus in these facilities and prevent even more deaths.

For months, the county has been trying to designate one of the facilities as a treatment hub for coronavirus-positive residents of nursing homes, a place where those who have been diagnosed with COVID-19 can be sequestered with others suffering from the virus and kept away from patients who have tested negative. That effort has been unsuccessful.

Existing facilities are full or don’t have the space, while other sites are not capable of providing the necessary level of care, Mase said. And still other facilities have been shuttered and no longer have the proper licensing, though she’s asking the state to waive some rules in light of the current crisis, she added.

Mase has said she has no authority over the state-regulated skilled nursing facilities in Sonoma County, which are privately owned, and she cannot force them to take certain actions or shut them down.

“With different places we’ve approached, there are different barriers,” she said.

Nickel-Cunningham said she doesn’t blame EmPres, the skilled nursing facility where her mother was living. She said the facility is simply not designed to adequately isolate those who test positive for the virus; staff work at multiple facilities and in some cases family members also work as staff.

“There’s nowhere to isolate, nowhere to move them to,” she said. “Their hands are tied. I can’t believe that the county isn’t doing more. If we can come up with housing for the homeless who have COVID, why can’t we find a facility for these patients?”

Teresa Fallon, 60, of Santa Rosa has a mother-in-law who is in the “red zone” at Broadway Villa Post Acute, a skilled nursing facility in Sonoma. She said that’s what they call the area of the facility where the COVID-19-positive residents are isolated.

Fallon said care at the facility has been excellent and that staff there are doing everything they can to stop the virus from spreading even more. She gets periodic updates from staff and, from what she can tell, infections have tapered off.

Her mother-in-law, Donnabel Carley, who celebrated her 90th birthday in February, has been at Broadway Villa for a couple of years. She moved after Fircrest Convalescent Hospital was shuttered in 2018.

Carley was thriving at Broadway Villa until she contracted the virus, Fallon said.

No other Sonoma County skilled nursing home has experienced as severe an outbreak as Broadway Villa. As of Friday, the nursing home has reported 46 infections among residents and 23 among staff. The exact number of Broadway Villa residents who have died is unknown.

The California Department of Public Health, which regulates skilled nursing homes, does not disclose the exact number of COVID-19 cases and deaths of residents and staff at these facilities until it’s greater than 11. It’s not possible to know the size of the outbreak unless a facility administrator agrees to confirm it.

Calls and emails to EmPres and its representatives over the past week were not returned. Calls and messages on Friday to the administrators of Petaluma Post Acute and Broadway Villa were also not returned. The three facilities are experiencing the biggest outbreaks and each has had COVID-19 related deaths.

Fallon said Broadway Villa staff have established three zones for patients, a “red zone” for coronavirus-positive residents; a “green zone” for those who have tested negative; and a “graduate zone” for those who have recovered.

“You go from red zone to graduate when you test negative, that’s kind of a holding zone,” she said. “When you still continue to test negative, you have the opportunity to go into the green zone, where they also have patients who have not tested positive at all.”

Carley, her mother-in-law, whom she refers to as her mother, was in the green zone until July 4, when she spiked a fever and was put into quarantine. The next day her COVID-19 test came back positive and she was put in the red zone. Her family put her into hospice care on Monday.

But she doesn’t point fingers at the facility.

“I’m going to lose Donnabel,” Fallon said. “I don’t blame them. It’s COVID and it’s people not wearing masks, that’s who I blame.”

But some do blame skilled nursing homes.

Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform, said it is true that skilled nursing homes are not designed to properly isolate and quarantine coronavirus patients. Many have multiple residents in a room or sharing bathroom facilities, close quarters that facilitate the rapid transmission of the virus.

But Chicotel said these facilities were isolating and treating residents with contagious diseases, such as norovirus, before the arrival of the new coronavirus. He said nursing homes that have been successful in keeping COVID-19 from getting out of control have very aggressive and consistent testing plans, ample supplies of personal protective equipment for staff, and dedicated rooms or wings to isolate and quarantine residents.

One of the biggest predictors of a large outbreak is a low ratio of nurses caring for a large number of residents, said Chicotel, who has examined coronavirus outbreaks across the state, with some of the worst being in Los Angeles County.

Nurses are the highest level of medical care at a skilled nursing home, and the state only requires them to have one on staff eight hours a day, he said. Larger facilities are supposed to have a registered nurse on duty 24 hours a day.

But staffing to meet specific nurse-patient ratios, he said, are not required. The “sweet spot,” Chicotel said, is to have 0.75 nurse staffing hours per resident per day; the state average is 0.43 nurse hours per resident per day.

“The average of the 25 nursing homes in the state with the worst outbreaks is 0.26 nurse hours,” he said. “When you have sufficient RN staffing, not only can they provide the highly skilled nursing they provide, such as feeding tubes, suction and tracheostomies, they also have time to observe the performance of the rest of the staff on infection control.”

Chicotel’s nonprofit has come up with an emergency action plan to help save lives at California nursing homes and assisted living facilities. These include designating facilities to provide care to COVID-19 patients after they are discharged from hospitals; deploy strike teams of public health and EMS professionals to intervene at facilities when residents are endangered; and ensure staffing is sufficient to keep residents safe, among other steps.

He said counties should use empty buildings and repurpose them as COVID-19 designated nursing homes instead of trying to use skilled nursing homes that are experiencing large outbreaks.

“The state was going to do that with overflow hospital patients,” he said. “It seems like there was a lot more creativity assisting hospitals through the COVID-19 crisis than there has been with nursing homes.”

The Press Democrat invited family members of skilled nursing and residential care home residents to describe the experience of their loved ones, and their own, during the current crisis. Several replied with positive statements about the facilities where their relatives were living.

Mary Jo Swan, 88, of Santa Rosa, said her sister-in-law has been at Broadway Villa for two years after being transferred there from another facility. She was diagnosed with COVID-19 about 12 days ago and is now in the red zone.

“When my sister-in-law was transferred to Broadway Villa she became a whole new person,” she said. “She thought she was on vacation.”

Swan said she doesn’t know why or how the virus got so out of control at Broadway Villa. But she said, it was not “for lack of care.”

Nickel-Cunningham said she feels some level of gratitude toward EmPres, despite the fact that her mother was exposed to others with the virus for weeks. She said that staff at Petaluma Valley Hospital and Santa Rosa Memorial Hospital, where her mother received treatment, resisted admitting her and only did so when EmPres refused to take her back. Nickel-Cunningham said she asked EmPres to deny Petaluma Valley’s request to transfer her mother.

Officials at Providence St. Joseph Health, which runs both Santa Rosa Memorial and Petaluma Valley, declined to comment on Nickel’s care due to federal and state privacy rules. Christina Harris, a spokeswoman for the health care provider, said it is committed to providing “high quality, compassionate care” to patients and abides by federal infection control recommendations.

“Once the COVID started popping up at (EmPres), I started getting concerned,” she said. “They were doing everything they could.”

Nickel-Cunningham said her mother is doing “OK” but is not bouncing back as quickly as she had in the past. She does frequent FaceTime videos with her mother and she’s hoping she’ll recover.

“My main concern is that typically she’s made more progress by now,” she said. “She’s still making progress with the infections, the pneumonia and the UTI, but she’s not back to her baseline, and I’m very worried about that.”

You can reach Staff Writer Martin Espinoza at 707-521-5213 or martin.espinoza@pressdemocrat.com. On Twitter @pressreno.