Restricted visiting is part of ramped-up efforts to protect residents.
By Lisa Esposito, Staff Writer for U.S. News
March 18, 2020, at 1:36 p.m.
The reasons many people live in nursing homes – they’re sick, they’re frail from age, they need caregiving – also make them more vulnerable to COVID-19 infection. The nature of long-term care facilities like nursing homes – residents living at close quarters, sharing rooms and bathrooms, and coming into daily contact with multiple caregivers and an influx of visitors – heightens that vulnerability.
The CDC has released a COVID-19 preparedness checklist for nursing homes and other long-term care settings to use in developing a comprehensive response plan. Important areas for facilities to self-assess and address include:
- Rapid identification and management of ill residents.
- Protocols for visitors and other people coming into the facility.
- Supplies and resources.
- Occupational health considerations including sick leave.
- Training and education for staff.
- Surge capacity for staffing, supplies, and equipment.
Instead of waiting for potential COVID-19 symptoms – such as fever, cough or shortness of breath – to appear, facilities must now implement active screening of both residents and health care providers. Here’s what to look for.
Ramping Up Precautions
The Hebrew Home at Riverdale takes care of about 750 long-term care residents on a 32-acre campus in New York. The nonprofit nursing home is part of a continuum that includes home care, housing, assisted living and managed care, says Daniel Reingold, president, and CEO of RiverSpring Health, which operates these residences.
“Our infection control procedures are procedures that are in place year in and year out to deal with the flu, norovirus or any other communicable disease,” Reingold says. With COVID-19, he says, “First and foremost is to do what the CDC and the departments of health are recommending – at a minimum.”
Restricting visitors per the new COVID-19 guidelines should help, Reingold says. “The fewer people on campus, the better, in terms of exposure.”
They’re not taking any risks with staff either. “We’ve been adamant that if people don’t feel well, they must stay home,” Reingold says. “We’re taking a completely hard line that if you feel in any way under the weather, it’s not just don’t come in – you may not come in. So that’s been a much more stringent standard than we’ve applied.” Staffing schedules are being evaluated to accommodate the situation and address potential shortages.
Supply shortages of personal protection items to prevent the spread of infection haven’t been an issue at Hebrew Home so far, Reingold says, with one exception. “We have enough disposable masks for now, probably for a week or two. Then I’m concerned about getting more supplies in because that’s one of the most critical pieces of equipment.”
In common with many other U.S. health care facilities, Hebrew Home doesn’t currently have access to coronavirus testing supplies. “I’m hoping we’ll get them,” Reingold says. “Nursing homes need testing supplies – we’re at the front line of the disease.”
Mealtimes in dining rooms on individual units are being staggered as needed with multiple seating times to allow better distancing among residents. “We’re also being much more conscientious about how food is being served,” Reingold says, both in residential dining areas and the staff cafeteria.
Flu and other respiratory infections are always a concern at this time of year, Reingold says. Now, the potential of spreading coronavirus adds another concern. “The good news for us is that about 50% of our rooms are private, with full bathrooms,” he notes. If a resident in a semiprivate room appears to be at risk with any contagious illness, he says, “We’ll find a private room and create an isolation situation.”
Sanitation – always an essential component of infection control in nursing homes – is more crucial than ever with the emergence of a new virus to which no one has built up immunity. The Environmental Protection Agency lists disinfectants that meet EPA criteria for use against SARS-CoV-2, the virus that causes COVID-19.
“We often take for granted the health logistics behind the operations of health facilities,” says Paula Nersesian, an assistant professor at Johns Hopkins School of Nursing who specializes in public health. “It’s coming into keen view, as this epidemic unfolds, that we need a lot of supplies. For example, for infection prevention, we need hand hygiene supplies: soap and water, paper towels, alcohol-based hand rub.”
Respiratory and cough etiquette is a necessity. “If people have a respiratory problem, they need a mask to contain any respiratory secretions,” Nersesian says. “They need tissues to be able to cough into tissues and throw them away in a plastic-lined rubbish bin.”
Nursing home caregiving routinely involves close personal contact with residents. Protective personal equipment for staff includes facemasks, gowns, eye protection such as face shields or goggles, and disposable gloves. Respirator masks (which include a filter to prevent wearers from breathing in small air particles ) when fitted correctly over the mouth and nose, provide more protection for staff members taking care of residents with known or suspected COVID-19.
“We’re all in this together,” Nersesian says. “Nobody’s been exposed to this virus before – so we’re all quite vulnerable. But some pockets of the community are particularly vulnerable and it’s our duty to provide extra care and support for those populations.”
Distancing and Isolating
Staff members who develop possible COVID-19 symptoms should not report to work, the CDC says. Staff members who get sick on the job should stop work immediately, self-isolate at home, inform the facility’s infection control team and contact their local health department for guidance on testing – if tests are actually available – and treatment locations.
In addition to self-monitoring, all health care providers at nursing homes should have their temperature taken and be screened for respiration symptoms at the start of each work shift, the CDC advises.
Residents with confirmed or potential COVID-19 symptoms will be evaluated on a case-by-case basis to determine if they need to be transferred to a hospital. During that time, they will be moved to a single room away from other residents to prevent a possible spread of infection.
However, many nursing homes don’t have a lot of private rooms. Although residents with known or suspected COVID-19 should be placed in a private room with their own bathroom, room-sharing could be necessary if multiple residents in a facility fall into this category.
Moving Into a Nursing Home?
Another issue facing families is whether it’s a good idea to move a family member into a nursing home now if they become in need of extra care. And if so, whether nursing homes are even admitting new residents at this time.
“Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 is or was present,” CDC guidelines say. The CDC advises dedicating a unit or wing exclusively for any residents coming or returning from the hospital, if possible.
Some nursing homes offer virtual tours so you can at least get a sense of the facility. It’s also a good time to research local long-term care options and consult with your nearest area agency on aging. These agencies provide services for older adults including information on long-term care facilities.
Unless your parent absolutely needs to enter a nursing home right away, this might be a good time for using interim measures such as family caregiving or hiring a home health care provider.
Virtual Links to Residents
Sara McCumber, a geriatric nurse practitioner in Duluth, Minnesota, is adapting the care she provides to nursing home residents in light of COVID-19 precautions. “They’re asking us to do a lot of our work through telehealth,” she says. “They’re really trying to limit unnecessary people in the facilities.”
It’s understandable that adult children of nursing home residents are worried, says McCumber, who is also an associate professor in the School of Nursing at the College of St. Scholastica in Duluth. “Having a family member in a nursing home is a very difficult situation. We just have to acknowledge that and understand where they’re coming from, and try to be empathic and recognize their concerns.”
Although the potential exists for residents to feel more isolated with the new restrictions, facilities already have systems in place to connect them with family members, who often live at a distance, McCumber points out.
“Facilities are working really hard to try to develop strategies to help people stay connected,” McCumber says. “They have quality of life and wellness staff and are looking at alternative communication (methods).” In lieu of visits, she says, facilities are encouraging strategies such as using FaceTime, video calls through iPads and social media to help residents and their loved ones stay in touch.
In family conversations with residents, perhaps through a coffee chat via FaceTime, avoid letting coronavirus dominate the discussion, McCumber advises. “If they have questions, answer them,” she says. “Have an appropriate level of concern, but don’t be transferring your anxiety to them.” Instead, she says, focus on positive topics. Share pictures on social media and talk about whatever the resident enjoys.
“There’s a great deal of fear and anxiety out there,” says Bill Walsh, an AARP vice president. “We’re getting a lot of questions about it: How do I know if the nursing home or the assisted living facility is taking the precautions necessary?”
Communication channels between facilities and families are now more important than ever. Many facilities are taking proactive measures like daily updates, social media bulletins, and group emails to keep family members in the loop.
“This is the time to really be advocates for our loved ones,” Walsh says. “Even if we’re not able to visit them, there are a lot of things that we can do. Asking questions of the staff: What protocols have they put in place? Are they following the guidelines that the federal government has set out?”
Questions for Nursing Home Administrators
Here’s what you might want to ask about the care your family member is receiving:
- Have you had any confirmed or presumed COVID-19 cases among staff or residents?
- Will you let me know right away if my family member develops possible symptoms?
- Are you using hospital-grade cleaning supplies that meet EPA criteria?
- Do staff members have adequate personal protective supplies to provide care?
- Are rooms well-stocked with soap, hand sanitizer, tissues, and paper towels?
- Does my family member understand why we can’t visit right now?
- Is it possible to arrange a video chat?
- Are you halting communal dining and group activities as the CDC recommends?
- Does my family member feel lonely or isolated?
- What can I do to help them stay feeling connected?
- How have staff been trained to deal with COVID-19?
Nursing homes and their staff members are dedicated to providing the best care they can for residents, McCumber says. One positive is the increased emphasis that the Centers for Medicare & Medicaid Services and state health departments have put on infection control in the past years, she adds.
“Facilities have had to develop very detailed emergency care plans, emergency preparation plans and they’ve also had to develop pretty robust staff training and policies and procedures around infection control,” McCumber says. “I’ve seen it change immensely in the last five years – I’ve seen it improve.”