By Katie Mettler and Jennifer Oldham The Washington Post March 30, 2020
By Katie Mettler and Jennifer Oldham March 30, 2020 at 7:29 a.m. PDT
In the scramble to contain the novel coronavirus, seniors are having difficulty returning to their nursing homes and rehabilitation centers after leaving for hospital visits, routine medical appointments or funerals. Nursing home staff say the residents need to provide a negative test before returning out of fear they could import the disease.
Anticipating a surge in patients, hospitals are discharging those who do not need extensive care. At the same time, nursing homes are closing their doors to try to prevent the kind of outbreaks that have invaded at least 146 facilities in 27 states, including Life Care Center in the Seattle suburbs, where more than 30 people have died of covid-19.
Administrators at elder care institutions are navigating conflicting and fast-changing guidance from local, state and federal authorities, according to interviews with advocates and medical professionals in nine states. Two of the leading medical associations in the nation have joined together to rebuke orders mandating that nursing homes accept coronavirus patients.
Testing shortages at hospitals and limited availability at nursing homes have only exacerbated the challenges.
The tension has thrown seniors into a dangerous limbo and tugged at families already burdened by intense social distancing mandates.
“This is the most strained and anxious that I’ve seen the system and staff and families and patients,” said Alice Bonner, a registered nurse and adjunct faculty at Johns Hopkins who has worked in nursing homes for decades. “People are trying really hard to do the right thing and to do the best they can.”
When asked about this dilemma, the U.S. Centers for Medicare and Medicaid Services — the federal agency that regulates the nation’s 15,000 nursing homes — referred The Post to recently released guidance outlining the process for accepting patients who might have been exposed to the coronavirus.
The guidance says nursing homes can and should readmit residents who have tested positive for or been exposed to the virus but only if their facilities are equipped to prevent spread within the nursing home as mandated by the Centers for Disease Control and Prevention.
If a nursing home cannot comply with those CDC rules, which include creating isolation wings and using personal protective equipment, CMS guidance says a facility “must wait” until a returning resident has been without fever and respiratory symptoms and taken two negative tests 24 hours apart. If tests are not available, the CDC says a resident can go home after three days without a fever and improved respiratory symptoms and at least seven days after the person first got sick.
Further confusing the process, the CDC guidelines also say residents do not need to meet that criteria before being discharged from the hospital.
What the guidance doesn’t address is whether nursing homes have the right to refuse residents who leave or are hospitalized for reasons other than the coronavirus.
Absent that clarity, and because the coronavirus can turn even an asymptomatic person into a vector, nursing homes are treating anyone who leaves the facility and returns — including for nonmedical trips — as a threat. Residents have been instructed to self-quarantine with family or remain at the hospital until they can prove they aren’t infected with the virus.
Doctors and advocates from around the country told The Post that nursing home and hospital employees have been working through these difficult conversations with residents since CMS mandated all nursing homes close their facilities to visitors indefinitely in an attempt to keep the disease out.
One Alzheimer’s patient at a Pennsylvania facility was hospitalized for a respiratory illness and had to wait a week for a negative coronavirus test before being allowed back into the nursing home. In another case in the commonwealth, a nursing home resident left for dialysis, got a fever and was told not to come home for fear of exposure.
An emergency room doctor in Texas said one of his patients left for a funeral and was given two options: self-quarantine outside the facility for 14 days or get admitted to the hospital for three days, then have a doctor write a letter certifying no presence of infection.
Advocates in New York are concerned short term nursing home and rehab residents — those who need temporary care for an injury or illness — are being involuntarily discharged to make room for an anticipated surge of patients because of the coronavirus, said Susan Dooha, executive director of the Center for Independence of the Disabled in New York.
Residents are being shut out of long-term-care facilities in California, Florida and Colorado, demonstrating the lengths facilities are going to fortify themselves against the infection.
Janet Snipes, the executive director of Holly Heights Nursing Center in Denver for the past 43 years, said she has a responsibility to keep everyone in her building as safe as possible. She has one resident who is hospitalized for a non-respiratory issue. Snipes said the resident, upon return, will need to be screened carefully and probably quarantined for 14 days.
“While we want to be part of the solution and not have hospitals back up, we want to protect our current residents,” Snipes said.
One solution is robust testing, doctors say, but both the shortage of test kits and lag time for results is placing residents in more danger. Testing criteria remain a moving target. Guidance from health officials varies from state to state and hospital to hospital. Patients are being treated, but not tested, which means nursing homes aren’t getting official confirmation to trigger isolation measures that can save lives.
“This is hugely concerning,” said Karl Steinberg, a nursing home and hospice medical director in San Diego County in California. “It’s really frustrating for the providers to not even have a diagnosis.”
For those able to get a test, the waiting period for results can last up to 10 days. Long waits at a hospital increase the likelihood of exposure to the virus — and of hospitals burning through dwindling reserves of masks and gloves.
At Sarasota Memorial Health Care System in Florida, about 70 patients were being held in isolation awaiting test results as of Thursday morning, a spokesperson said.
It’s “triggering a cascade of events” that “backlogs the hospital system,” said Chief Medical Officer James Fiorica.
In California and New York, two states with the most cases, advocates and physicians reported confusion over conflicting guidance from government officials.
On Wednesday, the New York State Health Department mandated, “no resident shall be denied readmission or admission to the [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.” The directive also prohibited nursing homes from “requiring a hospitalized resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.”
In a rebuke, national nursing home advocates said the state’s edict contradicts federal guidance from CMS, which stipulated, “such decisions to accept a patient be made with the understanding that the facility can safely care for such patients,” according to a statement from AMDA-The Society for Post-Acute and Long-Term Care Medicine.
“We find the New York State advisory to be over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles,” the statement said.
On Sunday, the American Health Care Association joined AMDA in calling the mandates “a short-term and short-sighted solution that will only add to the surge in COVID-19 patients that require hospital care.”
“We are aware that other states may already be adopting a similar approach in order to free up hospital beds,” their joint statement said.
Last week in Los Angeles, county health officials gave nursing homes a similar mandate, prompting concern among administrators who felt unprepared to accept and isolate coronavirus patients.
In Colorado, advocates called on the governor to mandate the process for transferring patients from hospitals to nursing homes and prioritizing those patients for testing.
“We’re in unprecedented times with profoundly difficult decisions wrapped in a fog of confusion and stress,” said geriatrician David A. Nace, who is the post-acute society’s president-elect and the chief medical officer for a collection of senior living facilities under the University of Pittsburgh Medical Center.
Nace acknowledged the importance of getting residents home to familiar surroundings and caretakers, but he said he does not believe coronavirus-free facilities should be forced to accept positive residents.
“The nursing home is often the adopted family. People want to get back, and it’s their home, and they view it as such,” Nace said. “The difficult part is making sure that that transition is safe.”
What advocates and doctors agree on is the importance of preparation, which includes following the federal government’s recommendations for creating isolation facilities outside of a hospital or nursing home for those awaiting tests. Long-term-care facilities also have been advised to create coronavirus wings in anticipation of a positive test.
In Pennsylvania, Nace said hospital and nursing home leaders in his region are trying to get ahead of the surge with planning calls, one of which revealed that a facility already prepared a 15-bed isolation unit for coronavirus patients. Vivage Senior Living in Colorado offered to accept overflow patients who aren’t sick with the coronavirus so hospitals can prioritize space for those who test positive.
“This is a time for everybody to be working together,” said Steinberg, the California doctor. “It’s a fluid situation, and we just don’t know where it’s all going to go.”
“This whole conversation might be moot in a month,” he said.