Sometimes nursing home aide Benjamin Foell works as long as 14 to 16 hours a shift. His back hurts from the hard labor. But still, he wishes he could do more for the residents who need him.
“You’re lucky if you can change the dirty diaper on your list of people you need to care for once in an eight-hour period,” he said. “You may not have time to wash their faces.”
He works for an Allentown agency that sends nursing aides to facilities that are short-staffed. And even before the coronavirus struck, he frequently felt like he was stretched too thin and forced to cut corners.
When the virus hit the United States, it caught many nursing homes off-guard and ill-prepared to protect residents, whose advanced years made them more likely than the general population to develop complications and die of the illness. Statistics bear that out, with long-term care residents making up more than a third of coronavirus deaths in the U.S. In the Lehigh Valley, around three-quarters of those who have died lived in nursing homes.
However, industry experts, advocates and workers say long-standing problems at nursing homes — staff shortages, lack of resources and poor infection control practices that regulatory agencies have done little to change — set the stage for the coronavirus to spread quickly and indiscriminately. The pandemic, they say, highlighted conditions that have plagued the industry for decades.
“The idea that a pandemic overtook nursing homes beyond their control is a misnomer and not relevant, and the reason for that is nursing homes are charged with the responsibility of infection control always,'” said Len Haberman, a Philadelphia lawyer who specializes in nursing home lawsuits.
The nature of nursing homes, where vulnerable people live in close quarters and in need of constant hands-on care, is conducive to infection spread. And the way many are staffed contributes to the problem.
Nursing homes generally pay nurses and aides comparatively lower than hospitals do, creating staff turnover and shortages that have been chronic in some places. Given staffing requirements — in Pennsylvania there must be at least one nursing services employee for every 20 residents and at least two nursing employees on every shift — some workers can pick up hours at multiple facilities. That situation drove the spread of the coronavirus in one particularly hard-hit nursing home in Washington state. And high turnover has driven experienced staff out of homes, to be replaced by staff that may be unfamiliar with practices and policies.
“Staff are not well paid. They come to work sick sometimes because they don’t have a choice,” said Diane Menio, executive director of Center for Advocacy for the Rights and Interests of the Elderly in Philadelphia.
She said that even during the coronavirus outbreak, some homes were telling nurses and aides to come in sick because there would be no health care workers without them. But even in the best of times, Menio said, long-term care facilities typically operate with 60% of the staff they need.
These problems collided with the coronavirus in February, when the virus first emerged in Washington state, killing 167 people by March 18, including 101 residents and 50 health care workers at a skilled nursing facility in King County. According to a study published in the New England Journal of Medicine, health care staff working at multiple facilities spread the virus as well as workers who showed up to work while experiencing symptoms. The staff wasn’t all familiar with infection control measures, didn’t have enough information or resources, such as protective equipment, and wasn’t sure how to recognize symptoms, the study found.
“The low staffing, poor infection control practices, this was just a disaster waiting to happen,” Toby Edelman, an attorney and consultant for the Center for Medicare Advocacy, said generally about nursing homes.
More than 4 in 5 nursing homes were cited for infection control problems between 2013 and 2017, according to an analysis by the U.S. Government Accountability Office of more than 16,000 inspections during that time.
But federal and state regulatory agencies don’t classify infection control oversights among the most serious health code violations. Because of that, facilities don’t prioritize infection control. “It’s pretty much ignored,” Edelman said.
In reviewing 171 deficiency surveys nationwide from late March to late April, Edelman found staff members failing to wash hands, change gloves, disinfect equipment used with multiple residents, and keep track of who’s infected.
“Staff aren’t washing their hands,” she said. “This is the No. 1 problem.”
These problems are well known to Pennsylvania officials. Last year, state Auditor General Eugene DePasquale released a report that outlined serious problems in the nursing home industry, including a crisis in staffing, inconsistent and inaccurate inspections and poor vetting of nursing home applicants. “We are facing an elder care crisis, and we continue to ignore it at our own peril,” he concluded.
The state Health Department inspects nursing homes annually and investigates about 300 complaints a month. However, the majority of infection control violations don’t result in financial penalties, according to a ProPublica database of nursing home inspections in about the last three years.
In Allentown, there were nine facilities with deficiencies, including seven with infection control issues. However, only Manorcare Health Services faced fines, and not because of infection controls.
Similarly, eight Bethlehem facilities had deficiencies, including four with infection control problems. However, only Moravian Village of Bethlehem faced a fine, and again, not for infection control problems.
“The department looks at a number of items to issue sanctions, and works to make sure sanctions are significant, but not punitive,” said Health Department spokesman Nate Wardle.
From February to May, the Health Department conducted nearly 1,500 inspections, including about 900 complaints during the pandemic. As a result, it issued 10 sanctions, including civil penalties totally $93,500. Typically, facilities with multiple problems are sanctioned, Wardle said.
The sanctions and fines represent a sliver of the problems at nursing homes because the punishments result from a small fraction of the complaints, Menio said.
“Just because they’re not substantiating that complaint, it doesn’t mean the complaint wasn’t legitimate,” she said. “Our ombudsman makes complaints and sees things but they’re not substantiated.”
The root of these problems is lack of training and lack of experienced staff, Haberman said.
“These are business decisions and not nursing decisions. …The problem is the education is not there. Supervision is not there. It’s coming from the top,” he said.
Corporations haven’t helped
A Morning Call review of inspection reports of long-term care facilities in the Lehigh Valley from 2017 to 2019 showed health care workers routinely failing to follow infection control protocols, like hand washing and sanitizing equipment.
In the two years before the coronavirus hit, the Health Department cited Lehigh Valley nursing homes with such violations as:
Staff wearing a gown while disposing of bodily fluids of an infected person and keeping the gown on when interacting with other patients.
Staff not washing hands during a wound dressing change.
Staff not wearing a gown when interacting with a patient and not washing hands afterward.
Staff not washing hands after handling bloody bandages.
Staff not changing gloves often.
Staff feeding someone without gloves.
Recognizing such lapses in homes across the country, the Centers for Medicare and Medicaid Services this month beefed up enforcement of infection control measures and upped the financial penalties for breaches.
A study of nursing home data by New York University School of Business suggests that a sharp rise in the number of nursing homes owned by private equity firms has contributed to a decline in patient health and an increase in violations of quality standards. While such firms owned fewer than 600 nursing homes in 2004, they owned more than 1,500 in 2019, the study noted. It found that the quality declines were largely due to nursing staff cuts.
“In the nursing home setting, it appears that high-powered profit-maximizing incentives can lead firms to renege on implicit contracts to provide high quality care, creating value for the firms at the expense of patients,” the study said.
The coronavirus brought such issues to the surface. Among other things, it revealed gaps in infection control training for health care workers, said Chase Cannon, executive director of the Pennsylvania Coalition of Affiliated Health Care and Living Communities, which represents county nursing facilities.
“With what we knew at the time, we were completely following the standard of care,” he said. “The problem is, we didn’t know that sort of training was insufficient until it was too late.”
In the Lehigh Valley, the virus has been particularly virulent in the two large county-owned homes: Cedarbrook, in Lehigh County, had 177 cases and 37 deaths as of June 10; and Gracedale, in Northampton County, had 63 deaths and 229 cases, putting it close to the top in both categories among all nursing homes in the state. The virus also hit both staffs hard, with 119 cases sprouting among workers at the two homes.
Nursing homes workers should be familiar with infection control practices because every year the flu, which similarly is spread through coughing and sneezing, threatens residents, Cannon said. However, the coronavirus was more challenging to contain because people frequently show no symptoms as they infect others. And unlike the flu, there’s no vaccine, he said.
Since the pandemic, nursing homes have implemented temperature checks for staff and regular testing of staff and residents for the virus — a new Health Department mandate that many of the state’s more than 600 facilities have been slow to adopt, according to a SpotlightPA investigation.
Mandates alone can’t keep infection from spreading. Homes need the necessary staff to carry out such protocols. The staffing shortage has affected nearly every facility in the state, with some nursing homes moving staff or residents from one building to another to make up for severe shortages. The situation is made worse by the isolation imposed by the virus, which keeps residents from congregating in common areas, where staff members can monitor multiple people at once.
Providers have had to increase pay to keep staff working, said Zach Shamberg, president and CEO of the Pennsylvania Health Care Association. Nursing home workers have not only gotten sick, but some have left over coronavirus fears or because they had no child care for children who were forced to stay home when schools and day care centers closed.
“That’s a new reality for many providers,” Shamberg said. “How do providers keep staff? Wage increases, hero pay, bonuses, incentives, whatever it takes for facilities.”
For $13 an hour
Nursing aides are on the front lines of the coronavirus pandemic, doing most of the feeding, washing and caring for residents. They earn a median wage of $13 an hour, according to the U.S. Bureau of Labor Statistics, prompting some to work multiple jobs.
One Lehigh Valley nursing aide, who has worked in the industry for 15 years at different facilities, said staff and resources are regularly stretched.
At the worst staffing times, residents were just left in their beds because two people weren’t available to lift them, said the aide, who didn’t want to use her name for fear of losing her job.
One home kept running out of soap and wipes, she said, so aides making just above minimum wage were buying soap and baby wipes for residents.
During the pandemic, residents have had to wait longer to get fed, washed or helped to the bathroom because aides are out sick or have quit, according to several nursing home workers who spoke on the condition of anonymity.
In March, Phoebe Allentown transferred residents from its Montgomery County assisted-care facility, Phoebe Wyncote, to Allentown because too many employees were out sick with the coronavirus.
Three Phoebe employees who spoke to The Morning Call said they did not know they would be getting additional residents until the day the residents arrived. Staff had short notice because the decision was made quickly, said Donna Schudel, a spokeswoman for Phoebe.
“All of this happened in less than 24 hours,” she said.
In a June email to staff, Cedarbrook administrator Jason Cumello said the facility would temporarily consolidate units because it’s short on staffing, low on funding and planning for a second wave.
“We lost a significant number of staff members to resignation during the pandemic. At this point, we are down so many positions and heading into vacation season, which is totally notoriously difficult to staff, I am not sure we can reliably staff 15 units in July and August without changes,” he wrote in the email, which was reviewed by The Morning Call.
A nursing aide at the facility, who did not have permission to speak to the media, said a unit of 50 residents, which typically had four aides and two nurses, was down to two aides and two nurses.
Cannon, whose group represents county homes, said the tough working conditions and poor pay has made recruiting aides difficult for decades.
“Working at a long-term facility is extremely difficult. There’s a lot of pressure on staff, heavy workload on staff, both physical and emotional,” he said. “You’re dealing with people who are close to the end of their life.”
During the pandemic, he said, staffing issues proved to be “a real serious hurdle to get over.”
Turnover is so common that some facilities may see an entirely different staff in a year, said Edelman, from the Center for Medicare Advocacy.
“There’s so much turnover of staff that people may not know where the equipment is, where the policies are,” she said.
Haberman, the plaintiffs’ attorney, sees the repercussions. “I have a slew of cases where a grandmother is ringing the bell to call for assistance because she has to go the bathroom or she will soil herself. Fifteen or 20 minutes later, nobody comes because of what is called alarm fatigue in the medical community,” he said.
Families feel powerless
In many cases, family members make up the difference, feeding a parent or grandparent during regular visits, sometimes changing their outfits and monitoring their health because they’re concerned overworked aides won’t be able to.
Family members who would regularly visit and care for their loved ones are now barred from facilities as a way to limit virus exposure in nursing homes. That has only heightened their worries.
“I have such guilt,” said Jenifer Lawrence, of Bethlehem, who has been second guessing her decision to keep her mother at a nursing home during the outbreak. Her fears were realized when her mother was infected with the coronavirus and hospitalized.
“We put her in there in good faith thinking she’s safe, now she’s not,” Lawrence said. “I regret that she didn’t live with us, I should have pulled her out so that I can watch her better.”
Lawrence decided against it because her mother had a private room at a small facility, so her exposure to others was limited.
Marla Roman would visit her mom and mother-in-law at Whitehall Manor three to five times a week.
Her mother has dementia so she’d have her read flash cards to keep her mentally stimulated. With that option gone, Roman, who lives in Whitehall, would go to her mother’s window, but the experience just left her and other family members sad.
“You hug your mom. You hold her hand. She needs reinforcement to know,” Roman said.
“We’d leave there crying.”
For MaryEllen Miller, of Alburtis, fear turned to advocacy for her mother, who lives in a Lower Macungie Township assisted living facility.
She called local, state and federal officials in April to get routine testing in nursing homes, believing that the only way her mother would be safe was if there was frequent testing to isolate infected patients. By early May, Lehigh Commons was testing everyone in the facility, a move the state would follow.
Throughout the pandemic, nursing homes have been struggling to stay ahead of the virus and without much help. As state and federal officials rushed to provide funding and resources to help the health care industry fight the coronavirus, they prioritized hospitals over long-care facilities, Shamberg, of the Pennsylvania Health Care Association, said.
“This is not to knock the hospitals in anyway. When this started, we assumed if there was a surge, the hospitals would need that help. The point of contention is when we didn’t see surge outside of Philly, every priority should have been on long-term care facilities seeing death. That didn’t happen quickly,” he said.
While the federal government allocated nearly $200 billion for hospitals in March and April, by late May, only $4.9 billion was earmarked for skilled nursing facilities, where the bulk of the coronavirus deaths have occurred nationally.
“The things we pushed for or asked for from the state: staffing help, help with personal protective equipment, help with testing. Those calls weren’t answered,” Shamberg said. “We saw providers struggling to get [personal protective equipment], keep staff and get tests. Those problem compounded with problems in the sector for years. We are where we are now.”
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Morning Call reporter Binghui Huang can be reached at 610-820-6745 and Bhuang@mcall.com.
