By Barbara Feder Ostrov Cal Matters, April 14, 2020
Some nursing homes may run afoul of California officials, who say they may be required to accept recovering, but still infectious, COVID-19 patients.
Dr. Noah Marco might never have known that he’d unwittingly admitted a COVID-19 patient into his Los Angeles area nursing home last month if his nursing director wasn’t friends with her counterpart at another nursing home nearby.
The elderly man had been transferred to the Los Angeles Jewish Home, where Marco is chief medical officer, from another nursing home just before it experienced a severe coronavirus outbreak that infected 17 and killed two residents.
Marco had isolated the man as he began showing symptoms, and tested him right after his nursing director received an apologetic call from her counterpart at the stricken home. The man’s positive results arrived from a commercial lab days later —an hour or two, Marco said, before he died.
“They sent him to us not knowing he had COVID,” Marco said. “We found out only because of a happenstance relationship between two nurses in two different buildings.”
In California and nationwide, some skilled nursing facilities have gone well beyond the measures recommended by the U.S. Centers for Disease Control earlier in the pandemic — including closing communal dining rooms and banning outside visitors — to protect their elderly or disabled patients who are at most risk of dying if infected with the novel coronavirus.
They’re checking residents, and sometimes workers, for fever each day. Setting up special units for dialysis patients who need to leave the nursing home regularly for care. Requiring new residents to isolate in separate areas for 14 days. In some cases, nursing homes are requiring COVID-19 tests of new patients or returning residents before they can be readmitted, all the while worrying about false negative results that have been reported in some tests. Some homes are refusing new patients altogether.
Headline-grabbing outbreaks at nursing homes in Riverside and Orinda underscore how quickly coronavirus can spread through facilities and just how quickly it can fell patients and staff.
“JUST BECAUSE THEY ARE OLD AND HELPLESS IS NOT AN EXCUSE FOR RISKING THEIR LIVES, WITHOUT THEIR KNOWLEDGE OR CONSENT.”Nursing home resident Dorothea Lack
In Riverside, 83 patients were evacuated Wednesday from Magnolia Rehabilitation and Nursing Center in the middle of its outbreak there because so many employees failed to show up for work. One COVID-positive certified nursing assistant, not among the no-shows, has died, a relative said Monday. Contra Costa County health officials asked the state to take over management of the Orinda Care Center after nearly a third of its staff members fell ill along with 27 patients, two of whom died.
An estimated 1,266 patients or staff in California’s 1,244 skilled nursing facilities have been infected to date, Gov. Gavin Newsom said Friday in an online press conference. California public health officials are monitoring 191 nursing homes with infected patients or staff
But in trying to secure their facilities against viral intrusion, some nursing homes may run afoul of state public health officials, who have said that to free up hospital beds, skilled nursing facilities may be required to accept recovering COVID-19 patients — even if they’re still infectious.
After an outcry from the nursing home industry, the controversial requirement was loosened so that nursing homes may refuse to accept these patients if the facilities lack adequate protective gear for workers or other ways to prevent transmission.
“Nursing homes are NOT the right place for the virus patients,” nursing home resident Dorothea Lack, an 81-year-old retired psychotherapist with chronic obstructive pulmonary disease, wrote in an email to CalMatters. “They are like incubators. These helpless, fragile patients should not be exposed to this virulent disease! Just because they are old and helpless is not an excuse for risking their lives, without their knowledge or consent.”
Still, the moral equation is grave: save hospital beds for the sickest COVID patients or endanger the elderly, who are most at risk of dying if infected?
Los Angeles County’s public health director last week even advised families to consider pulling their loved ones out of nursing homes. It would be “perfectly appropriate,” said Dr. Barbara Ferrer.
But many families cannot properly care for their elderly relatives, some of whom may have severe dementia or chronic medical conditions that require daily nursing care.
The federal government does not track nursing home deaths specifically. The Centers for Medicare and Medicaid Services has suggested nursing homes should dedicate “if possible” a wing or unit for patients transferred from hospitals. Its only guidance for nursing homes accepting patients from hospitals during the pandemic is that they should admit anyone they’d normally admit to their facility as long as they can follow CDC guidelines to prevent infection.
Without more specific federal direction, states are making up their own rules about what role skilled nursing facilities must play in housing recovering COVID patients.
“I’M NOT TAKING IN A COVID-POSITIVE PATIENT FOR THE SOLE PURPOSE OF EMPTYING ONE HOSPITAL BED. IN TWO WEEKS, I’M SENDING THEM BACK 20 NEW PATIENTS.”Los Angeles Jewish Home Dr. Noah Marco
New York is requiring nursing homes to accept patients at the request of public health officials, no exceptions. Louisiana takes the opposite approach, prohibiting nursing homes from accepting hospital patients who have tested positive for COVID-19 or have a pending test, or who have respiratory symptoms.
At the Los Angeles Jewish Home, Dr. Marco said he simply will refuse any COVID-19 patients from hospitals.
“I’m not taking in a COVID-positive patient for the sole purpose of emptying one hospital bed. In two weeks, I’m sending them back 20 new patients,” he said. “No facilities have the kind of personal protective equipment they need. We don’t have isolation gowns, we’re out. We’d ordered as many as we can and we used them. You know what we’re using? We are using patient hospital gowns for our caregivers.”
The only approach that makes sense, Marco and other nursing home doctors say, is to use other facilities for recovering patients that don’t already have vulnerable seniors living there. “This is these people’s home and you cannot bring a COVID-positive person into a senior’s home, everyone would agree with that,” Marco said.
To date, California’s Public Health Department has not required any nursing homes to accept COVID-positive patients to free up hospital beds, but those orders, if they come, are likely to originate from county health departments. Some nursing homes are trying to prepare for this worst-case scenario, including the Campus for Jewish Living in San Francisco, which has prepared a separate wing where COVID-patients from hospitals could recover, the San Francisco Chronicle reported.
Nursing home officials may find some relief in plans announced Friday by Gov. Newsom to deploy what he called “SWAT teams” of infectious disease experts to assist nursing homes experiencing large outbreaks, and 600 public health nurses more generally to help homes improve infection control. The state also will provide $500 stipends to as many as 50,000 nursing home workers, a consequence of a Facebook donation of up to $25 million. Officials also plan to offer free or heavily discounted hotel rooms to infected or exposed nursing home workers who don’t need to be hospitalized.
Newsom also said that more non-COVID patients could be treated and recover on the hospital ship Mercy, docked at the Port of Los Angeles to reduce the burden on overloaded hospitals. He added that the state has identified seven additional, as yet undisclosed, sites outside of nursing homes where patients could recover. That could take the pressure off some nursing homes.
“This state has a disproportionate number of aging individuals and we have a unique responsibility to take care of them,” he said.
Since then, however, at least three sailors on the Mercy have tested positive for COVID-19, possibly upending Newsom’s plans. They are isolated and recovering off the ship.