1. Nelson, Roxanne


COVID-19 exposes ongoing risks to residents.


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The COVID-19 pandemic has spotlighted persistent failures in the U.S. long-term care industry to safeguard frail and elderly residents from harm. Staff and supply shortages, inadequate safety measures, and poor emergency preparedness have resulted in more infections and deaths from COVID-19 than would likely have occurred if quality and safety standards were enforced throughout the industry, experts say.


Although the quality of both management and clinical care vary greatly among the roughly 15,600 nursing homes in the United States, it is not surprising that COVID-19 found its way into some facilities early in the pandemic. The nursing home industry has been criticized for uneven performance, with some poorly staffed and equipped facilities functioning as little more than warehouses for frail and vulnerable older adults. Such deficiencies are never more apparent than when disaster strikes.


Contagious disease is not the only threat. Previous crises have illustrated the range of operational failures that can put residents at risk. For example, at least 12 residents died due to extreme heat in a Florida nursing home in 2017 after Hurricane Irma knocked out the facility's air-conditioning. Hurricane Katrina in 2005 also showed the tragic consequences of poor nursing home management. One facility became a death trap when administrators refused to evacuate before the storm; 34 elderly and disabled residents drowned in the ensuing flood. A post-Katrina follow-up study of nursing home residents in Louisiana and Mississippi found increases in mortality, hospitalization, and functional decline 30 days after the hurricane compared with the previous two years.



The COVID-19 pandemic has similarly afflicted residents of long-term care facilities in disproportionate numbers. While they represent only 0.6% of the U.S. population, as of August 31, these residents had accounted for 42% of all U.S. deaths from COVID-19. Data from the Centers for Medicare and Medicaid Services (CMS) show that, as of October 6, there have been 238,283 confirmed cases in nursing homes and assisted-living facilities, 138,783 unconfirmed cases, and 57,008 deaths.


Of course, older adults and/or those with comorbidities are the populations known to be prone to severe illness or death from COVID-19. Thus, it is not surprising that residents of long-term care facilities such as nursing homes would be particularly vulnerable to the effects of the disease.


Nevertheless, the statistics are alarming, and a growing body of research into the underlying causes of nursing home disease outbreaks points to chronic management deficiencies, including staff shortages, high resident-to-staff ratios, frequent staff turnover, supply shortages, and inadequate infection prevention and control measures. Nursing homes have long struggled to control commonly occurring infections among residents such as influenza; conjunctivitis; and infections of the urinary and intestinal tracts, lungs, and skin. The safety of the setting itself has also been called into question. "Nursing homes have all the ingredients to make a very volatile combination," said Patricia Davidson, PhD, MEd, RN, FAAN, dean of the Johns Hopkins University School of Nursing. "There are a lot of close interactions, communal places, and people with comorbid conditions."


Before COVID-19 spotlighted the vulnerability of nursing home residents, 82% of these facilities had been cited between 2013 and 2017 for infection prevention and control deficiencies. In addition, 40% were cited for a lack of emergency preparedness and 40% were found to have sanitation violations, according to Charlene Harrington, PhD, RN, professor emerita, University of California San Francisco. "They have been treated as businesses and not made to comply with basic health standards," Harrington said in an AJN podcast. "They've gotten away with it for years because of lax enforcement."


Not long after the first reported U.S. death from COVID-19 occurred in a Seattle-area hospital, there was a large outbreak of viral illness in a nearby long-term care facility. A total of 81 residents, 34 staff members, and 14 visitors were found to be infected, and 23 people died. A subsequent investigation by the Seattle Times found that nursing homes in Washington State had long been dealing with staffing issues and other deficiencies. Between 2018 and the onset of the COVID-19 pandemic early this year, inspectors had cited 118 nursing homes-more than half of all skilled nursing facilities in the state-a total of 225 times for having insufficient or unqualified staff. But the facilities were rarely penalized by state regulatory bodies.



Nursing staff is largely responsible for infection control in the nation's nursing homes, which according to 2016 Centers for Disease Control and Prevention data, serve approximately 1.3 million residents. Inadequate staffing has been cited as a contributing factor to outbreaks despite research evidence that better staffing can improve both the process of achieving high quality care and actual outcomes. One 2015 integrative review in Nursing Economics of 67 studies of nursing home quality consistently found a correlation between more RNs, as well as higher ratios of RNs in the nursing skill mix, and better overall quality.


Minimum staffing levels to ensure appropriate care have been developed by the CMS, but one large study reported that in the period 2017-2018, 75% of nursing homes were almost never in compliance with these guidelines. However, 96% of the facilities did meet the federal eight-hour RN staffing requirement for the majority of days. The authors concluded that "these conflicting results suggest that the eight-hour requirement does little to ensure adequate RN staffing levels needed to care for people who live in nursing homes."


Ann Kolanowski, PhD, RN, FAAN, professor emerita, College of Nursing at Penn State University, commented that the "lack of 24-hour RN coverage and the chronic inadequate RN staffing levels in [nursing homes] underscore a dangerous assumption that anyone designated as a 'nurse' can function as a professional nurse, and it is costing lives."


Kolanowski cited a study of 215 Connecticut nursing homes that showed an association between low RN staffing levels and poor COVID-19 infection control. Published online June 18 in the Journal of the American Geriatrics Society, the study found there were confirmed COVID-19 cases in 108 of the nursing homes, and that residents died from COVID in 84 of these. The authors estimated that among facilities with at least one case, every 20-minute increase in RN staffing "was associated with 22% fewer confirmed cases" of COVID-19 and in facilities where there were deaths, every 20-minute increase in RN staffing "significantly predicted" 26% fewer deaths. "There is no substitute for the RN in nursing homes that aim to promote, restore, and protect the health of its residents," Kolanowski said in an interview with AJN. "The bottom line is that poor care is costly care."


A study published in the August Policy, Politics, and Nursing Practice looked at the relationship of nurse staffing and COVID-19 infection rates in California nursing homes. It found that those with fewer RNs than the CMS-recommended minimum standard of 0.75 hours per resident day had a twofold greater probability of having infected residents. A higher probability of infection was also found in "nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds."



The proportion of nursing homes today with for-profit ownership is nearly 70%. Research has shown a correlation between the type of nursing home ownership and the quality of care residents receive.


In 2011, the U.S. Government Accountability Office reported that nursing homes acquired between 2004 and 2007 by the top 10 private equity firms had more deficiencies and lower nurse staffing ratios. By contrast, studies of nonprofit nursing homes showed better performance than for-profits when it came to staffing and outcome-oriented measures of quality, such as the prevalence of pressure injuries, use of restraints, and hospitalization rates.


Another study published in 2012 in Health Services Research compared the 10 largest for-profit nursing home chains with other types of facilities, including government-run homes, and found that for-profit chains had lower RN staffing and total nursing hours than government facilities. Additionally, the top 10 chains had 36% higher deficiencies and 41% higher serious deficiencies than government facilities.


Paula Chatterjee, MD, MPH, of the Perelman School of Medicine at the University of Pennsylvania, and colleagues analyzed quality measures, including nurse staffing, of 8,943 nursing homes in 23 states and the District of Columbia that might have come into play in COVID-19 outbreaks. Their findings were published July 29 in JAMA Network Open.


"We did not find large differences in total direct care staffing, or hours of care specific to RNs or LPNs between nursing homes reporting COVID-19 cases compared to those that did not," Chatterjee told AJN. However, they did find more for-profit facilities among nursing homes that reported cases (2,383 or 78.9%) than in the group that did not (4,090 or 69.1%).-Roxanne Nelson