It was clear almost from the outset that the elderly and frail were in the greatest danger from Covid-19. And it was clear to anyone familiar with American nursing homes that these facilities would not be up to the task of protecting their older and infirm residents.
As of Thursday, Covid-19 has killed over 10,000 residents and staff members in long-term-care facilities in 23 states that report fatality data, about 27 percent of the Covid-19 deaths in those states, according to the Kaiser Family Foundation.
The weaknesses in patient care and oversight at nursing homes that made those deaths more likely were longstanding, widespread and well known.
One-third of Medicare beneficiaries admitted to nursing homes suffer harm within about two weeks of entering the facility, according to a 2014 report from the federal Office of Inspector General. These are the short-term residents for whom facilities are paid the most and who are typically most able to articulate their concerns if something is wrong. Where does that leave a majority of residents who are in the facility long-term, most of whom are older, frail and cognitively impaired?
These existing problems intensify the risk that residents will suffer and die not only from Covid-19 but also from the erosion of care the pandemic is causing, increasing neglect and abuse in a system that on a good day too often failed to fulfill its duties.
Despite the absence of federal reporting requirements, we are seeing that residents and families are being devastated by Covid-19. In New Jersey, an anonymous tip led authorities to a nursing home that was storing corpses in a shed. At least 29 of its residents have died from Covid-19 and many more residents and staff members have been infected. Unsurprisingly, this for-profit nursing home has a history of seriously low staffing and citations for substandard infection control.
In a Houston-area nursing home, more than 80 residents and staff members have tested positive for the coronavirus. This facility also has seriously low staffing and close to four times the number of substantiated claims than the national average.
The tragedy is that government standards of safety and care at homes certified under Medicaid or Medicare (a large majority) are strong. If enforcement of those standards had not been so lax, the devastation we have seen in nursing homes could have been mitigated.
Those standards were developed in response to reports of horrific conditions in the 1970s and 1980s. The federal Nursing Home Reform Act of 1987, and the regulations and guidance through which the law is carried out, most recently revised in 2016, require effective infection control and prevention including hand hygiene and the use of personal protection equipment.
Still, according to the Centers for Disease Control and Prevention, one million to three million serious infections occur every year in nursing homes and other long-term-care facilities, and as many as 380,000 people die of those infections every year.
The most important precautions against infection are inexpensive and simple, and the most common violations involve simple sanitation and hygiene practices, like hand washing. Nevertheless, infection control and prevention problems were the most frequently cited violation in nursing homes last year.
In New York, inspectors observed an aide cleaning an incontinent resident with a soiled washcloth then, without washing his hands, “proceeded to transport the resident to the common area.”
Such poor care persists because regulators let the nursing home industry treat standards of care as goals rather than actual requirements. The nursing home industry wields enormous influence in Washington and state capitals through multimillion-dollar trade associations, powerful law firms and generous contributions to politicians and political action committees. As a result, nursing homes, rather than nursing home residents, are often viewed by policymakers as the constituency whose interests merit protection. After President Trump was elected, the Centers for Medicare and Medicaid Services started openly referring to the nursing home industry as its “customer.”
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