The campaign to vaccinate millions of residents and staff in the nation’s thousands of nursing homes and other long-term care facilities against the coronavirus is gaining momentum and showing early, positive effects.
At the same time, however, information is emerging on shabby treatment of the vulnerable, including their exposure to illness exported into their facilities from hospitals, explaining the increasing number of civil lawsuits that owners and operators face.
Good news has been so rare with the pandemic that it may be worth considering first the coast-to-coast drive for long-term care facility vaccinations.
The federal Centers for Disease Control and Prevention reported (as of Feb. 12) that 5.5 million doses of coronavirus vaccine had been administered in long-term care facilities, with roughly 4 million residents and staff getting the first of two shots and more than 1 million of these individuals now fully vaccinated with two shots.
The increasing protection that residents and staff are getting from vaccines may be a key reason why data show a decline in the pandemic’s terrible toll on nursing homes and other long-term care facilities. The Centers for Medicaid and Medicare Services, in joint reporting with the CDC, tallied 10,000 cases and deaths in the facilities in the most recent week (Jan. 31) for which information is available (see figure above). That compares with more than 30,000 cases and deaths in each of the last weeks of December.
As the Wall Street Journal reported on the published research on the vaccination efforts:
“Case trends in nursing homes tend to mirror the broader community, waxing and waning alongside larger outbreaks, making the effects of resident inoculations hard to discern. But a new analysis from the research division of the American Health Care Association, a long-term-care industry group, also found some signs that vaccines are making a difference. Looking at 797 nursing homes that conducted their first vaccine clinics between Dec. 18 and Dec. 27, the analysis found a 48% drop in new resident cases three weeks later. Meantime, there was a 21% decline over the same period in about 1,700 homes in the same counties that hadn’t yet started vaccinating. This ‘suggests that spread may be decreased starting three weeks after receiving the first dose of the vaccine,’ though more work is needed to confirm the findings, the report said.”
For vaccinated residents, a glimmer of joy returns
The New York Times reported in a news feature on the joy experienced by residents of at least one facility — the Good Shepherd, a 192-bed Catholic home in Wheeling, W. Va., where the vaccinations have rolled out well and greater normality has returned:
“The first day back was full of ordinary moments: small talk over coffee, bidding wars at an afternoon auction, a game of dice. But after a year of loss, loneliness and disruption, the very ordinariness of it all brought joy and relief.”
The article also reported this:
“Even with the vaccinations completed, everything has not gone back to normal. Residents are allowed to socialize again together, but they also are asked to continue wearing masks. They sit several feet apart. And most relatives and friends still cannot come to visit. The continuing precautions offer insights into the complications of reopening, far beyond nursing homes. About 20% of people at Good Shepherd — mostly staff members and a few residents — declined to be vaccinated, reflecting a hesitance that has emerged across the country. Cases in the surrounding county remain high. More research is needed to understand whether vaccinated people might still be able to transmit the virus.”
For now, pluses and minuses weigh heavy still in thinking about vaccinations, the pandemic, and long-term care. Facility staff, many of them poorly paid, over worked, and savaged by the infection themselves or in their families, have sought to clarify to reporters: Yes, they are hesitant to get vaccinated, as the data show. But they are not refusing. They want more information, and, with mistrust running high with employers they feel have mistreated them and residents, they want to carefully consider the vaccines’ safety and effectiveness for themselves, the independent, nonpartisan Kaiser Health News Service reported.
Skeptics about nursing home care have much to consider these days.
As that New York Times article reminded:
“It has been a miserable year for American nursing homes. More than 163,000 residents and employees of long-term care facilities have died from the coronavirus, about one-third of all virus deaths in the United States. Infections have swept through some 31,000 facilities and nearly all have had to shut down in some way. For more than a million residents of nursing homes, the lockdowns themselves have been devastating. Cut off from family and largely confined to their rooms, many residents lost weight and saw ailments worsen. Some grew increasingly confused. Others sank into depression and despair.”
Facility treated residents with dubious drug regimen
Dozens of residents in a New York facility, shut off from loved ones and potentially unable physically or cognitively to make sound decisions about their care, were given a dubious coronavirus drug regimen, according to an investigation by The City news site, Columbia Journalism Investigations, a post-graduate project of the noted journalism school, and the independent Type Investigations group for the collaborative MISSING THEM project.
As the project reported:
“Hydroxychloroquine, an antimalarial drug first approved in the United States in 1955, was used widely throughout the country last spring as an experimental treatment for Covid-19. The drug, often combined with the antibiotic azithromycin, had been touted for months by officials at every level of government — most prominently by then-President Donald Trump. The state, which licenses and inspects all 613 nursing homes in New York, allowed the facilities to administer hydroxychloroquine to patients exposed to the virus, even after public health experts cautioned against its use in non-hospital settings or for elderly and vulnerable patients. Both drugs carry potential side effects, including anemia, neuromuscular damage, vision impairment and, of greatest concern, fatal heart arrhythmia. While rare in healthy patients, the risks increase with age and comorbidities like kidney or cardiovascular disease, experts say.
“Between March and late April last year, the 250-bed St. Albans home administered hundreds of doses of the unproven drug combination to at least 62 residents, some of whom had not tested positive for the virus, according to interviews, medical records, and other documents … Most residents who received the drug were men and women ranging from 70 to 97 years old, many of whom had underlying conditions such as high blood pressure, diabetes, cognitive impairment and kidney or heart disease. THE City, CJI and Type Investigations were able to track down the families of 10 residents who received the drugs. None of those families recall being informed of the laundry list of potential side effects. Eight say they did not learn about the use of the drugs until after they were administered — in some cases, months later when families received a medical bill or were contacted for this story. While not all were official health care proxies, the families maintain that they were in charge of their relatives’ medical decisions at the time.”
As this project also noted:
“The allegations … echo those made about the use of hydroxychloroquine in nursing homes in Pennsylvania and Texas, which spurred calls from Democratic U.S. senators for a federal investigation. Separate questions have been raised about the U.S. Department of Veterans Affairs, which gave hydroxychloroquine to at least 1,300 veterans for Covid-19.”
Just to be clear: hydroxychloroquine has been debunked as a therapy in any part of coronavirus care. It is interesting to compare the race to use it versus what has occurred with vaccines. Early on, CVS and Walgreens — the big chain pharmacies that have run big swaths of the long-term care vaccinations across the country — said their efforts were slowed by facilities’ push to ensure they had appropriate consent for residents and staff to get shots.
Cuomo under new fire for nursing home transfers
In New York, Gov. Andrew Cuomo faces persistent and intensifying criticism over his administration’s decision to safeguard hospitals in the state by allowing them to reduce their case loads during an early and big coronavirus spike by moving patients to nursing homes. Many of these individuals had the virus or were insufficiently recovered, data show. Critics say that New York’s explosive coronavirus spread and deadly cases in nursing homes can be tied to hospital transfers.
The Associated Press says it has found that “9,056 recovering patients [were] sent to hundreds of nursing homes … more than 40% higher than what the state health department previously released. And it raises new questions as to whether a March 25 directive from … Cuomo’s administration helped spread sickness and death among residents, a charge the state disputes.”
The New York Times said recent concerns have increased about the nursing home-hospital transfers because of revelations by Cuomo staffers:
“Gov. Andrew M. Cuomo and his administration faced new allegations … that they had covered up the scope of the coronavirus death toll in New York’s nursing homes, after a top aide to the governor admitted that the state had withheld data because it feared an investigation by the Trump Justice Department. The remarks by the top aide, Melissa DeRosa, made in what was supposed to be a private conference call with Democratic lawmakers, came as a cascading series of news reports and a court order have left Mr. Cuomo, a third-term Democrat, scrambling to contain the political fallout over his oversight of nursing homes, where more than 13,000 people have died in the pandemic in the state. Lawmakers from both parties have called for stripping the governor of the emergency powers that he has exercised during the pandemic, while Republicans have demanded the resignations of top Cuomo administration officials and new federal investigations.”
Cuomo has taken greater blame for the flawed, emergency policy but denied covering up nursing home deaths and declining to offer a full apology.
In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by neglect and abuse in nursing homes and other long-term care facilities. The pandemic has provided the public with a shocking view of the rocky state of long-term care in a country that is rapidly graying and desperate need of options to give the aged, injured, and seriously ill good, safe, comfortable, and pleasant places to live — not to rot and die.
It will be a great relief to residents, their loved ones, and staff of long-term care facilities if the vaccination can quell the coronavirus infections and deaths. But problems laid bare by the pandemic — including infection control, staffing, inadequate and negligent care, and inappropriate consent for medical treatment — these require difficult and sustained response from regulators, lawmakers, and all of us.
As always, those at the center of controversies — the facilities’ owners and operators — are crying poor me and toiling by the instant not necessarily to address their challenges as to shirk their responsibilities. This is forcing residents and their loved ones to make tough decisions, for example, whether to seek justice with lawsuits in the civil system.
Growing numbers of plaintiffs are pursuing this option, Modern Healthcare reported, and they already are confronting a legal gantlet, including from the wealthy equity investors and big corporations who have looked at nursing homes and other long-term care facilities for their profit potential, not necessarily for how and how well they care for real people.
We have much work to do to get nursing homes and other long-term care facilities not just past this health crisis but to a much better place.
