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Nursing home inspectors found infection control miscues months after pandemic swept across state

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Nursing Home MAP 0420.JPG

An OIG December 2020 analysis of infection control onsite survey data between March and May 2020.

Much of the controversy over the state’s oversight of nursing homes has focused on the initial months of the pandemic. 

In much of rural Pennsylvania, however, the COVID-19 virus didn’t arrive until months later.

Despite having that additional time to prepare, inspectors found a range of infection control mistakes when those outbreaks triggered concerns and state surveys,

The most common problem cited by inspectors was improper use of or failure to wear personal protective equipment, according to inspection records reviewed for this story.

Other problems included:

-- Cases where employees were allowed to work while exhibiting symptoms of COVID or when the employees’ family members had tested positive for COVID;

-- Cases where nursing home residents weren’t adequately tested for COVID or appropriately monitored for symptoms;

-- Cases where staff neglected to ensure that residents’ washed their hands;

-- Cases of improper handling of used gowns.

In the six weeks from Nov. 13 to Dec. 28,--  the date Pennsylvania began devoting COVID vaccine to nursing home residents -- 2,411 residents of nursing homes and personal care homes died with COVID, according to Department of Health data.

  On May 1, just over six weeks after Pennsylvania reported its first COVID death, the Department of Health had reported 1,560 COVID deaths among nursing home and personal care home residents.

Republicans in both chambers of the House and Senate have called for greater scrutiny of the Wolf Administration’s moves regarding nursing homes in the first months of the pandemic when in-person inspections were halted and nursing homes were told to re-admit residents who’d been treated for COVID in the hospital.

House Majority Leader Kerry Benninghoff, R-Centre County, asked the House oversight committee to examine the actions by the Department of Health in March 2020,  particularly related to the order to admit COVID patients.

“Even a year after the pandemic began, data reported about deaths in Pennsylvania’s nursing homes remains incomplete and, in some cases, contradictory,” Benninghoff said in announcing the move.

Benninghoff said the investigation is intended to respond to concerns from members of the public.

“I respect the fact that everyone was caught off-guard” by COVID, Benninghoff said. “The goal at the end of the day is that our constituents ask these questions and it’s frustrating when we can’t answer them,” he said.

Through April 28, the death toll from COVID in the state’s nursing homes had hit 13,103 -- more than half the state’s COVID death toll of 26,129.

“We've got some fantastic providers in Pennsylvania. And we've got some really poor providers in Pennsylvania,” said Margaret Barajas, Pennsylvania’s Long-Term Care Ombudsman. “There were a number of facilities who continue to disappoint us, in their lack of responsiveness to the folks who they're serving. Long-term care should not be the only industry in which the consumer is not always right. 

"You go to a restaurant, you go to a hotel, you go to any other business, and they're focused on providing a quality consumer experience for you. And unfortunately, we don't always see that across the board in long-term care,” she said.

Adam Marles, CEO of LeadingAge PA, the trade group representing many of the state’s nursing homes, said that “to the best of our knowledge” the Department of Health never forced a nursing home to accept a resident when facility operators said they weren’t equipped to handle the resident’s care due to COVID.

“I think the spikes we saw in nursing homes early in the pandemic were mostly due to lack of knowledge about COVID but also due to real problems with accessing PPE,” Marles said.

The nursing home industry was frustrated and hamstrung because hospitals were given top priority for PPE and later testing supplies, he said.

At the same time, in-person inspections and in-person visits by family members were halted.

In-person inspections didn’t resume until July. In-person visits didn’t resume until after vaccination efforts in nursing homes prompted the CDC to revise its guidance. Family members unable to visit the facilities themselves took to contacting the Department of Health whenever they heard a rumor that something was amiss. That  triggered complaint-driven inspections that wouldn't have occurred under normal circumstances, nursing home administrators said.

"A lot of families were calling the Department of Health. They'd call and complain," said Dee Nasri, executive director at Cambria Care Center in Ebensburg. "It was a tough time for residents, families and employees. My heart goes out to them," she said.

Between inspections triggered by outbreaks and inspections triggered by complaints, “there was a period where they were here three times in one month,” said Timothy Mock, CEO of Laurel View Village in Davidsville, in Somerset County.

“The Department of Health continued to ensure the safety of Pennsylvania's health care facilities during this time by conducting virtual inspections and in-person inspections if necessary. Additionally, during this time, we continued to intake and triage complaints according to the federal guidelines from CMS in reference to inspections of facilities during COVID-19,” said Maggi Barton, a Department of Health spokeswoman.

Deadliest nursing homes

According to the Department of Health, 19 nursing homes in Pennsylvania each had more than 50 residents die with COVID.

That includes Mountain View in Coal Township, Northumberland County, where 59 people died with COVID, as well as the Cambria Care where 84 residents died of the virus.

Nasri, at Cambria Care, said that she and her staff were diligent in trying to protect residents and they’ve been “open and transparent” in communicating with families about what’s happening in the facility.

It didn’t stop COVID, especially when the rate of infection in the community around the facility began to increase in the fall, she said.

“We were successful until November when the community spread in Cambria County went up,” she said “We just had a spark that ignited a fire,” Nasri said.

Controlling the virus once it gets into a facility is difficult. “It’s in the air,” she said.

Nasri said that the facility's numbers are higher than many neighboring nursing homes because, with 300 beds, Cambria Care is larger. 

"Our families know we did everything we could" to control the outbreak, she said.

The facility was visited 20 times by inspectors since the start of the pandemic. Nasri said some of those inspections were triggered by complaints from family members concerned because they couldn’t get into the nursing home.

But she acknowledged that inspectors did flag the nursing home’s staff for infection control lapses.

“We deserved every deficiency we got,” she said. “The rules are the rules,” Nasri said.

During a COVID survey in July, the inspector noted that a nurse’s aide was spotted leaving a room wearing a surgical mask instead of an N-95 mask. The inspector noted that when the nurse’s aide was asked, he conceded he was supposed to be wearing an N-95 mask.

Four months later, as the facility was dealing with its most major COVID outbreak, an inspector again noted that a nurse’s aide wasn’t wearing her face mask properly -- this time the staff member had her mask pulled under her nose, according to the inspector’s report.

“Nurse Aide 2 was in the room for approximately three minutes and returned to the hall with the mask still below her nose. Other staff on the hall then alerted Nurse Aide 2 that the surveyor was there, and the nurse aide pulled her mask up and put it on properly,” according to the inspector’s report. When the inspector questioned the nurse’s aide, she said she was wearing the mask improperly because “I needed a breather for a minute,” according to the report.

Cambria Care was far from alone in having inspectors note problems during COVID surveys.

Inspection reports for 65 nursing homes in 12 rural counties -- Bedford, Cambria, Crawford, Lawrence, Mercer, Montour, Northumberland, Snyder, Somerset, Union, Venango and Warren -- were reviewed for this story.

The nursing homes in those counties collectively accounted for 1,034 nursing home deaths -- about 8% of the state’s total of 13,054 nursing home deaths. The counties’ combined population represents about 6% of the state’s total population.

On average, the nursing homes have been inspected 8 times in the year since the pandemic erupted, including virtual inspections that took place between March and June.

Those include an average of 3.6 inspections specifically flagged by the state as COVID-19 Focused Emergency Preparedness Surveys. Twenty-four -- about one-third of the nursing homes in the 12 counties -- were cited for violations during the COVID preparedness surveys.

That includes Mountain View in Northumberland County.

An inspector flagged that facility based on a September survey in which a staff member was observed helping a resident with her hearing aids while not wearing a gown and gloves. That resident later tested positive for COVID, based on a test taken the day before the inspector’s visit, according to the Department of Health’s report. 

The administrators at Mountain View did not return repeated phone calls seeking comment for this story.

Complaint-driven inspections

Mock, at Laurel View Village, said that his facility didn’t experience its first serious outbreak until late November. Even so, inspections triggered by complaints and COVID cases increased dramatically, even if the inspector might only check in remotely.

Mock said his facility was contacted by the Department of Health when an employee submitted a complaint to the state after seeing that the supply of gloves appeared to be dwindling.

The inspector didn’t physically come to the nursing home, but administrators had to forward invoices and photos to prove they actually had gloves, he said.

Mock said thinks one outbreak started after the virus was brought in by employees who’d had minor symptoms. But in another case, the facility had an outbreak and they have no real idea how COVID came into the building, he said.

Rick Wilson, administrator, Arbutus Park Retirement Community in Johnstown, said that all of the nursing homes have faced similar struggles.

Relief has only come by way of the vaccine, he said.

“I truly feel that the best course of action that was taken was the vaccine,” he said.”Most employees and almost all of the residents are fully vaccinated. We almost have a breather now,” Wilson said.

Ombudsman

Barajas said that to help families and residents stay connected and informed while most nursing homes were closed to visitors, her office established a Virtual Family Council, on which over 500 families have participated.

“We've brought speakers in from all over the Commonwealth -- grief counselors, trauma experts, essentially any resource that they've been looking for, and we've done that to try to shore up that gap,” she said.

The office has also worked to establish a program -- the Pennsylvania Empowered Expert Residents -- for long-term care residents to volunteer to serve as advocates for residents in their facilities, she said. These residents are trained to educate others in their community about their rights and how act upon them, she said.

John Finnerty reports from the Harrisburg Bureau for the New Castle News and other Pennsylvania newspapers owned by CNHI. Email him at jfinnerty@cnhi.com and follow him on Twitter @cnhipa.

 

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CNHI PA State Reporter

John Finnerty reports from the Harrisburg Bureau for the New Castle News and other Pennsylvania newspapers owned by CNHI. Email him at jfinnerty@cnhi.com and follow him on Twitter @cnhipa.

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