By Sam Levin, The Guardian, April 27 2020
A poorly regulated industry, chronic understaffing, and inadequate infection control combined for an inevitable public health catastrophe
Linda Maynard sounded upbeat in a voicemail to her daughter on 21 March, joking about her fried chicken cravings and threatening to go “on strike” until she got fast food. There were no signs coronavirus had entered the nursing home facility in Hayward, California, where she was living.
Seven days later, the 74-year-old woman suffocated to death from Covid-19, and by mid-April, the virus had also killed two of her friends at the facility.
Arena Burke, Maynard’s daughter, told the Guardian her family heard little from the staff at Gateway care and rehabilitation center as the infection spread to encompass at least 100 residents and employees at the facility. Precautions to curb the outbreak at the center seemed non-existent, Burke said. So far, at least 13 residents have succumbed to the virus.
“There are so many people there who should not have died,” Burke said. “They cheated us out of so many good times.”
Like facilities in New York and New Jersey, nursing homes in California have been hit hard by coronavirus. Gateway is one of more than 250 skilled nursing homes in the state suffering from coronavirus outbreaks, with a total of more than 5,700 confirmed cases inside the facilities.
Every corner of California is hit. In Los Angeles county, nursing home residents have accounted for more than 30% of Covid-19 deaths and 72% in the city of Long Beach. At one Central Valley facility, nearly all 167 residents and staff tested positive, and at a home in Riverside, nearly 100 residents were evacuated after staff failed to show up due to an outbreak. The Gateway center is now under criminal investigation.
Behind the staggering numbers, advocates say, is a poorly regulated industry with a long history of chronic understaffing, inadequate infection control, a lack of critical equipment and weak labor standards. Experts and attorneys say the public health catastrophe was preventable, and that the botched response of some nursing homes constitutes criminal neglect.
‘They think they are above the law’
Skilled nursing facilities care for older residents with advanced medical needs, a population that is uniquely vulnerable to Covid-19 and at higher risk of death regardless of the standards of care. But experts say the crisis in these care facilities is exacerbated by longstanding problems with staffing and training, and because of a massive delay in testing.
Even before corona, nearly 400,000 people die each year from infections inside long-term care facilities in America, said Charlene Harrington, a University of California, San Francisco professor emerita and an expert on nursing homes.
Undertrained staff are responsible for too many patients with complex challenges, which means they rush from room to room and skip basic steps such as proper hand-washing, she said.
In the case of a pandemic, the emergency quickly spirals.“When a virus comes along, they just aren’t able to cope. The nursing homes should have immediately staffed up, but they don’t want to spend the money,” she said. “The staff is calling in sick. They are skimming on care … And now a lot of them are trying to cover it up.”
Nearly one in every 10 nursing homes across the US is reporting coronavirus cases. But the situation is worse in California where the vast majority of the facilities are for-profit operations incentivized to make cost-cutting decisions with potentially fatal consequences, said Tony Chicotel, a California nursing home reform advocate.
“For years and years, we’ve tolerated really bad infection control, which has killed a lot of people. It’s not surprising once Covid-19 enters the building, it spreads like wildfire.”
Like hospitals, the nursing facilities have recently struggled with a lack of personal protective equipment (PPE) with staff forced to take care of patients without masks and gloves, labor officials said. But unlike doctors and nurses, many long-term facility workers are low-wage workers who may not be trained to handle a virus outbreak and who frequently work multiple jobs to make ends meet, sometimes at different nursing homes. That means in some cases they may be bringing Covid-19 from one facility to another.
April Verrett, president of SEIU Local 2015, which represents nursing home employees, said some workers have sent photos of themselves in recent weeks wearing rain ponchos and garbage bags, because they lacked isolation gowns. Others were using plastic bags on their hands instead of gloves, and she heard of one facility running out of plastic sleeves for thermometers. And if the workers get sick or may have been exposed, she said, “They cannot afford to miss a shift, let alone two weeks.”
Harrington said the crisis is exacerbated by a lack of testing in the facilities. She argued the state of California should test every staff member and resident in all nursing homes and immediately adopt stricter requirements for staffing levels and reporting of Covid-19 outbreaks. It’s unclear how quickly the state could accomplish this given ongoing testing problems.
Toni Greene, whose 89-year-old mother was diagnosed with Covid-19 in a Santa Monica nursing home, said she didn’t blame the facility, but was frustrated that the government failed to do widespread testing, which would have probably saved her mother from the virus. “The nursing homes have to take in Covid people. They are stuck between a rock and a hard place. But it didn’t need to get this far if we had tested in the beginning.”
The operators of Gateway, the northern California facility facing a criminal investigation, have a long history of violations, records show. The owners, husband and wife Antony and Prema Thekkek, operate several facilities. They were required to close one nursing home due to problems and the state has denied them licenses five times due to concerns, according to a Bay Area News Group investigation.
At Gateway, located in the city of Hayward, just south of Oakland, inspectors found the facility broke infection control rules in 2017 by not changing gloves or swapping out urine bags. In 2019, a patient with sepsis didn’t receive antibiotics because no one on staff was qualified to handle care, the newspaper found.
Attorneys investigating current conditions say it appears little has changed. In March, as the pandemic escalated, Gateway pressured its staff to continue working even if they might be sick and did not require them to wear masks or gloves, according to a letter filed with prosecutors on behalf of a patient. One staff member was responsible for 37 patients during the crisis, and at least one doctor stopped coming to the facility due to Covid-19 risks, the letter said.
“What you have is a nursing home run like a business, which thinks they are above the law,” said Adante Pointer, a civil rights attorney representing families. “It’s a place that is supposed to preserve life, but it’s turned into a place where lives are being taken.”
Unanswered phone calls
Scott Akrie knew nothing of Gateway’s history when his 88-year-old father, Costell Akrie, was transferred there on 6 March for physical rehab after complications with diabetes. When the family arrived a week later to visit, Gateway staff told them the facility was on lockdown and they could not enter, though the employees did not say anyone had the virus.
On 27 March, a doctor told the family Costell had a fever and was getting a Covid-19 test, but again Gateway gave no information about whether it had any positive cases inside. Then on 31 March, the family learned Costell had tested positive. Over the next four days, the family kept calling, Scott said, but could not get their father on the phone. A receptionist repeatedly put them on an endless hold: “It was infuriating. I would try to call, my mother would try to call, my sister would try, no one could speak to him,” said Scott.
On 4 April, a doctor finally called back and said Costell was having trouble breathing. A few hours later, the doctor called again: Costell had died.
“I felt like I was going to pass out,” Scott recalled. . “I couldn’t believe what was going on. I felt like a part of me was dying.”
Scott said it was painful to process that his father spent the final four days of his life unable to talk to a single loved one on the phone. Gateway officials did call Scott to discuss his father’s body. “‘He has to be out of here within one hour, that is our policy’,” Scott recalled them saying. “The coldness was mind-boggling. It was like they would put him on the curb if we didn’t get him,” Scott said.
Arena Burke’s communications with staff at Gateway as her mother fell ill were equally confounding. Staff told neither Maynard or her mother coronavirus was spreading in the facility: “[My mother] did not know there was reason for concern. She thought they had locked down the facility as a precautionary measure.”
When Maynard was hospitalized and tested positive for Covid-19, Gateway told her daughter that she was the first case, suggesting she had somehow brought it to the facility, even though her mother had stayed in her room. After her death on 28 March, Gateway made no arrangements to mail her belongings, Burke said. At one point, the facility called and left a voicemail, saying it left seven boxes outside. Burke called back to plead that the possessions be mailed. Weeks later, she’s still waiting for her mother’s things.
“I just want her belongings. It’s not much, but I don’t feel like my mother’s life should be disposable,” said Burke, noting that there are sentimental photos and jewelry, and that her mother may have taken notes about the way the facility treated her. She said she was speaking out because she feared for the residents’ safety. Only one of her mother’s friends is alive at this point.
“People are still living there being neglected and mistreated and it’s just not right,” Burke said.
Gateway did not respond to repeated requests for comment. Hayward officials announced last week the city would help with testing at the facility.
Nursing homes seek broad immunity: ‘It’s abhorrent’
The California public health department began publicizing a list of nursing homes with coronavirus outbreaks last week, after weeks of intense public pressure.
The state is also sending teams of nurses to facilities with outbreaks “to ensure infection measures are in place, mitigate further infections, isolate residents, and assess for exposures”, a spokesperson said in an email. The health department is further working to place positive patients in alternative sites when they don’t require hospitalization.
But because of Covid-19, the department has stopped doing routine in-person inspections, a development that has deeply worried advocates. The spokesperson said the state was still doing on-site investigations for “issues that might cause serious risk to residents”.
Lobbyists for the nursing home industry are now pushing for California’s governor, Gavin Newsom, to grant the facilities broad immunity from civil lawsuits and criminal prosecution, arguing that liability laws should be waived and they should be shielding from litigation while fighting the pandemic.
Advocates said they have already been limited in their ability to uncover what’s happening inside due to the lockdowns, and that immunity would have dire consequences.
“It’s abhorrent,” said Scott Akrie, whose family intends to sue Gateway. “It’s absolutely ridiculous for them to ask to not be held accountable for anything.”
For families who have lost loved ones inside nursing homes, it was particularly devastating that Covid-19 robbed them of a proper goodbye.
Burke said she was cherishing the goofy voicemail her mother left her in March, in which she joked that she and her friends would “rally and wave banners” until the nursing home provided Kentucky Fried Chicken, one of her favorites.
When she heard it the first time, she never imagined it would be her mother’s final voicemail.