Poor infection controls deadlier at nursing homes during pandemic
By Elizabeth Shogren / September 18, 2020 This story was originally published by Reveal from…
This story was originally published by Reveal from The Center for Investigative Reporting, a nonprofit news organization based in the San Francisco Bay Area. Learn more at revealnews.org and subscribe to the Reveal podcast, produced with PRX, at revealnews.org/podcast.
Anita Lymber was wearing her favorite wig and jamming to live music when her daughter arrived for a visit at her assisted living facility in Boca Raton, Florida, in late February.
Carrie Morris had traveled from Gaithersburg, Maryland, to spend the week with her mother. Once she settled in at her hotel, she caught a troubling news report: COVID-19 was spreading in a nursing home in Washington state. As Morris glanced around the crowded lobby during the performance, she recalls thinking that much about her mom’s life suddenly concerned her with a pandemic looming. The room was packed, wheelchair to wheelchair, for the visiting entertainers, and Morris was alarmed that one resident was coughing a lot – a wracking, productive cough. She rushed to ask a staff member what was being done to protect residents from the coronavirus. She remembers being told not to worry and encouraged to wash her hands. Later, in the dining room, Morris noticed a resident with a trash bag full of used tissues hanging off her wheelchair.
A few days later, Florida announced its first cases of COVID-19 and declared a state of emergency.
Carrie Morris and her mother, Anita Lymber. Lymber lived at the Stratford Court assisted living facility in Boca Raton, Fla. She died of COVID-19 on May 3. (Courtesy of Carrie Morris)
For 10 years, Morris had been a helicopter daughter, trying to manage the details of her mom’s care from a distance. She knew her mom had experienced repeated infections at the facility, Stratford Court, that landed her in the hospital. As Morris said goodbye to return home, she recalled having a clear sense of foreboding.
“I stood there in the hallway for several minutes just looking at her,” Morris said of her mother. “And I wanted to memorize the scene because I knew I would not be seeing her again. I just knew it.”
Lymber’s story, as it unfolded at a nursing home owned by Welltower, the company with the most senior housing complexes in the United States, exposes how poor infection control at nursing homes became a deadlier threat during the coronavirus pandemic. For years, nursing homes have struggled to protect their residents from infections. The Government Accountability Office, a congressional watchdog agency, found in an investigation released in May that in five years preceding the pandemic, from 2013 to 2017, more than 80% of nursing homes were cited for infection control lapses and about half had persistent problems.
The GAO report found widespread failures to implement the kind of infection prevention practices that are essential to limiting the spread of COVID-19, including a failure by staff to properly wash hands, correctly use masks and other personal protective equipment, and isolate sick patients.
“These are basic and important steps for infection prevention control, including in the current COVID-19 environment,” said John Dicken, who directs the GAO’s health care team and authored the report. Studies have shown that infection control practices, such as flu and pneumonia vaccinations, have particularly lagged behind in nursing homes that serve more Black and Latinx residents.
“While we were looking before the pandemic,” Dicken said, “the COVID-19 situation certainly highlights all the more the vulnerability and the really devastating effects of infections in nursing homes.”
About 3 of every 10 U.S. COVID-19 deaths have been among residents of nursing homes, even though less than half of 1% of Americans, about 1.4 million people, live in these facilities. Lymber lived in Stratford Court’s assisted living facility, but spent recovery time in the facility’s nursing home every time she was hospitalized.
As of Sept. 6, the Centers for Medicare & Medicaid Services reported more than 356,000 confirmed and suspected COVID-19 cases and 54,000 deaths in nursing homes. After this story was published Sept. 18, a spokesperson for the agency told Reveal that there may be some overlap between suspected and confirmed cases. But academics, including University of Chicago health economist Tamara Konetzka, who advises the agency, have combined both confirmed and suspected cases when analyzing this data and stressed that even combined, these numbers understate the crisis because the federal government did not require reporting until mid-May. This data also does not include cases and deaths among residents of other senior housing, such as assisted living facilities, which are not federally regulated and not required to report cases and deaths.*
Buried in the underlying data is another set of numbers: deaths among nursing home staff.
As of Sept. 6, nursing homes had reported nearly 300,000 workers known or suspected to have COVID-19 and 868 of them had died, according to an analysis of the federal data by Reveal from The Center for Investigative Reporting. Margarette Nerette, vice president of 1199SEIU, which represents more than 8,000 nursing home workers in South Florida, said more than 2,000 of her members have gotten COVID-19, and five have died from it. In an interview with Reveal, one of those members, a certified nursing assistant, described insufficient testing for residents, being instructed to reuse her gown, waiting up to two weeks for a new mask, and learning a patient had COVID-19 only when that person was transferred to the hospital. One of her colleagues, according to state data, had died of COVID-19.
The coronavirus overwhelmed nursing homes such Fair Havens Center in Miami Springs, Fla., where medical staff line up to use an outdoor sink. State data shows 52 residents there have died of COVID-19. (Chandan Khanna/AFP via Getty Images)
“We’ve had the complete nursing homes population decimated in some nursing homes in this country. That should not have happened. That’s indicative of the fact that these nursing homes were already in trouble; they weren’t prepared,” said Jamila Taylor, director of health care reform at The Century Foundation, a progressive think tank. “Nursing homes were already grappling with ensuring quality care, meeting standards in terms of cleanliness and proper hygiene before COVID-19, and COVID-19 just sort of blew all of that up.”
She notes that understaffing in nursing homes serving communities of color has exacerbated problems there. “That’s where we see structural racism manifest in the health care system,” Taylor said.
Nursing homes in communities of color have been particularly hard hit. Research from the University of Chicago found “a strong and consistent relationship between race and the probability of COVID-19 cases and deaths.” Nursing homes with the lowest ratio of White residents were more than twice as likely to have COVID-19 cases and deaths than those with the highest ratio of White residents.
Federal strike teams that went into nursing homes with COVID-19 outbreaks over recent months found many examples of staff not properly washing hands, using personal protective equipment incorrectly or failing to social distance, according to Seema Verma, administrator of the Centers for Medicare & Medicaid Services.
“What we are seeing are significant deficiencies in infection control practices,” Verma told nursing homes in a conference call last month.
She warned nursing homes with few or no cases to be vigilant. “I cannot emphasize enough that that situation can turn very, very quickly. And, you know, in a matter of hours, you could go from having two or three cases to having half of your nursing home impacted. … Make sure that you’re doubling down on infection control and that you’re prepared.”
The agency fined nursing homes in 22 states nearly $10 million for infection control deficiencies during the pandemic and last month launched a new training program for all nursing homes focused on infection control.
But that same University of Chicago research, using samples from 12 states, found that even the best nursing homes, with the highest quality ratings, failed to protect their residents from the coronavirus. (Other analyses in individual states have found a correlation.) Tamara Konetzka, the study’s author, blames the high death rate in nursing homes on “the almost complete absence of federal leadership,” of a plan to provide ample protective equipment and testing while also funding increased staffing. Such a coordinated federal strategy, she said, also should have set high standards for infection control, such as isolating residents and staff with suspected and confirmed COVID-19 cases. Some countries with more stringent national requirements saw lower death rates in nursing homes.
“There’s absolutely been no national leadership, no national plan, no national strategy for how we’re going to tackle this pandemic,” said Katie Smith Sloan, president and CEO of LeadingAge, a trade group for nonprofit senior care facilities. “It puts our nursing homes that are on the ground trying to care for older, frailer people in a terrible bind, trying to scratch and scrounge for themselves.”
Six months into the pandemic, the crisis at nursing homes is far from over. After a dip in COVID-19 cases early in the summer, they surged again in July.
“It’s the confluence of factors of the frail older adults, the workers that come in and out of the nursing homes, and just the setting itself that has made it really challenging to manage COVID, which is why testing is important and why infection control is important,” Sloan said.
A report issued this week by a commission assembled by the Centers for Medicare & Medicaid Services highlighted “devastating consequences of leaving long-standing systemic issues unaddressed.” It exhorted the agency to save lives by quickly requiring improvements, from upgrading ventilation systems to better training and compensating nursing assistants and hiring infection control experts.
At the Stratford Court senior complex, Lymber, 84, was affectionately known as Diva Anita. Morris described her mom as someone who took pride in her beauty and said she wouldn’t leave her room at Stratford Court without first applying makeup and putting on a wig and jewelry.
Anita Lymber, shown in an old photograph, was affectionately known as Diva Anita at Stratford Court. (Courtesy of Carrie Morris)
Lymber had picked Stratford Court in 2017 because she’d heard that it had a good in-house rehabilitation center. She was determined to walk again, after ending up in a wheelchair in the wake of a knee surgery a few years earlier. That left her dependent on staff to change her adult diapers. Because of her high risk of urinary tract infections, Morris said, Lymber paid extra at Stratford Court to get more frequent assistance changing her diapers. Even so, that help often didn’t come soon enough, and she would then call her daughter, 1,000 miles away.
“It’s almost two hours, I’m sitting here in wet pants,” Lymber said in one voicemail shared with Reveal. She begged her daughter to call the front desk because she was afraid of getting yet another infection.
Sitting in wet or soiled undergarments heightens the risk of UTIs, and Lymber got infections repeatedly. She typically needed hospital care and intravenous antibiotics to recover, according to hospital records reviewed by Reveal. What neither Lymber nor Morris knew was that Stratford Court had been cited for infection control violations for the past three years, 2017 to 2019. An inspector specifically cited the facility for not protecting residents from urinary tract infections, which are prevalent in nursing homes and can be deadly if infections spread to the bloodstream and cause organ failure or septic shock, a life-threatening plunge in blood pressure. Some of the same infection control practices that help prevent UTIs can limit the spread of COVID-19 – proper hand hygiene among staff and patients, correctly handling soiled linens, keeping infected patients isolated, and having a qualified infection control expert on staff.
Among the infection control citations the federal Centers for Medicare & Medicaid Services issued against Stratford Court in June 2019 were hand hygiene lapses, such as staff touching dirty surfaces after hand-washing, and laundry issues: “The facility failed to store, process, and transport linens so as to prevent the spread of infection as evidenced by the unsanitary conditions in the service hallway and with laundry processing,” according to the inspection report.
Like most nursing homes, Stratford Court wasn’t fined for its infection control failures. Regulators fined nursing homes for infection control deficiencies less than 2% of the time, the GAO’s Dicken said, citing his agency’s findings.
“I find that both curious and unacceptable as a family member,” Morris said after reviewing Stratford Court’s record of infection control citations. “If they’ve been cited numerous times, then why was there no oversight to see if proper measures had been instituted?”
Just days after Morris’ visit came to an end, in early March, Lymber was back in the hospital with another UTI. She had two infections, E. coli and methicillin-resistant Staphylococcus aureus, or MRSA – a hard-to-treat superbug.
When Lymber returned to Stratford Court, she was admitted to the facility’s nursing home to recover. Not long afterward, Morris got a call telling her that the coronavirus was present at Stratford Court.
“I knew it was coming,” Morris said. “I was really devastated.”
The news heightened Morris’ worries about her mom. An email Stratford Court sent to residents and families March 27 acknowledged the “presence” of COVID-19 in the complex, without any details about the number of cases. The email, signed by Stratford Court’s executive director, Eric Francese, then reassured families that “we implemented extra infection control precautions to prevent the spread of infection,” and “we are well prepared to respond to this situation.”
Lymber had always rebounded after urinary tract infections, but in video chats with her daughter over the next several weeks, her health palpably declined. In one voicemail, Lymber told her daughter: “I don’t even know what my name is right now.”
As she had for more than a decade, Morris worked the phones to try to make sure her mom was getting what she needed. Because of the pandemic, Morris didn’t feel safe returning to Florida and, in any case, she wouldn’t have been allowed into Stratford Court to see her mom. Like nursing homes across the country, it was in lockdown.
During a video call in late April, Lymber slouched over the arm of her wheelchair, and Morris could not make out what her mother was saying.
“I wanted to reach through the screen and physically, like, tilt her in the other direction,” Morris said. “And I was so incensed. She was drooling. She was in such poor shape. I was beside myself.” Morris recalled trying to call out, through the video, to staff she could hear talking in the background, pleading for someone to help.
As soon as she hung up, Morris said she called the nursing home administrator, seeking urgent help for her mother. The next day, Lymber was taken to the hospital with a fever, low blood pressure and shortness of breath.
There, she tested positive for yet another UTI – and COVID-19.
After just two days, a doctor at the hospital told Morris that her mother would be discharged. Morris was shocked, but she said the doctor assured her that the nursing home was capable of doing everything the hospital would. Yet once Lymber returned to Stratford Court, her condition deteriorated rapidly. Within a few days, she was sent to hospice care.
Hospice staff set up a video connection between Morris and her mom, who died May 3. “It was a gift, as painful as it was, to see her in her final moments,” Morris said.
Morris never got an explanation of how her mother contracted COVID-19. But what she has pieced together raises questions about potential problems with infection control. Her mother was never wearing a mask during their video calls, even when staff members were close by, and Morris doesn’t recall the staff wearing masks, either. Her mother was abruptly moved to a new room a few days before she was diagnosed with COVID-19, for “medical reasons, not your mother’s,” according to a voicemail she received from Stratford Court and shared with Reveal.
Reveal repeatedly asked for interviews with Stratford Court and Sunrise Senior Living, the company that operates the facility. Stratford Court turned down the requests and provided only an emailed statement from Denise Falco, vice president of operations, stressing that the facility “significantly expanded” its infection control practices amid the coronavirus and had not been cited for infection control lapses since the pandemic started.
Sunrise declined to answer Reveal’s questions about Lymber and other residents who have died of COVID-19 at Stratford Court. But it reported to the federal government that seven residents died in its nursing home section, which has served about 30 patients during much of the pandemic, according to federal data, and where Lymber was sent March 10 after her UTI hospitalization.
A July letter to families and residents makes it clear that the complex’s nursing home was hit hardest. It reports 16 cases among Stratford Court residents, including 12 in the nursing home – a number that likely included Lymber – and 16 among staff members, including 10 in the nursing home. Morris received the letter from the family of another resident, after her mother died.
A letter from Stratford Court’s executive director, Eric Francese, shows the complex’s nursing home section was hit hardest by the coronavirus.
Morris is upset that a urinary tract infection landed her mother in the hospital and then in Stratford Court’s nursing home section, which is where she appears to have caught COVID-19, like hundreds of thousands of other nursing home residents across the U.S.
“I think that it is a tragedy. I think it is a national tragedy. I think it could have been avoided,” Morris said. “That I believe to my soul.”
Welltower, the corporation that owns Stratford Court and about 1,300 other senior housing complexes, declined requests for interviews, saying it doesn’t provide care for residents.
Welltower, the largest owner of senior housing in the U.S., hasn’t made public the total number of deaths at its facilities. Reveal analyzed federal data on 67 Welltower-owned nursing homes and found about half had COVID-19 deaths – a total of 344 as of Sept. 6. But in a call with investors last month, company executives cited progress against the coronavirus in recent months.
“COVID-related deaths, which peaked during the last week of April, are down 92% since then … despite a spike in nationwide cases,” said Shankh Mitra, Welltower’s chief operating officer and chief investment officer.
Because of the pandemic, Morris was unable to travel to Florida to bury her mom. So in August, on Morris’ birthday, she decided to scatter her mom’s ashes on the Delaware shore, where Morris has a beach house. One spot she chose was a park with an old-fashioned covered well with a sign that reads, “fountain of youth.”
“OK, Mom, you always aspired to drink from the fountain of youth. I think you did for quite some time,” she said as she scattered Lymber’s ashes. “Rest in peace, Mom.”
*UPDATE, Sept. 22, 2020: This paragraph was updated after a response from the Centers for Medicare & Medicaid Services on its confirmed and suspected COVID-19 case data.
This article was edited by Esther Kaplan and Soo Oh and copy edited by Nikki Frick.
Elizabeth Shogren can be reached at [email protected]. Follow her on Twitter: @ShogrenE.