“Infection control has been a challenge for nursing homes long before COVID”

Thank you for your reporting about the COVID 19 outbreaks at Redwood Springs and Lindsay Gardens. Please allow me to shed some light and additional information regarding COVID 19/nursing homes and infection control.

I have been a licensed nursing home administrator in California since 2002, since 2009 here in Tulare County.   In 2016 I transitioned to Assisted Living Administration.  Every year nursing homes have annual inspections by CMS/California Department of Public Health Licensing and Certification Division. Almost every year in every building I have administered I received citations for infection control.    Infection control tags are some of the most  frequently cited deficiencies given to nursing homes.  Infection control has been a challenge for nursing homes (also called SNFS) long before COVID.  Physicians, politicians, and everybody familiar with nursing homes knew it.

There are many reasons why it is nearly impossible to  prevent and control an infection like COVID 19 in a nursing home:

  1. The very nature of the work: CNAs and caregivers cannot provide the personal care that residents need without getting up close and having direct contact. Every single resident in a SNF needs personal care or they would not be there.
  2. Buidling design: Nursing homes have a minimum of 2 in a room, many times 3.  The beds ( where the resident spends the majority of their time ) are only several feet apart with a curtain for privacy.  Shared bathrooms are normal. Common spaces in most nursing homes don’t exist.  The dining room doubles as an activity room. Space for staff is an afterthought.  Break rooms are small and cramped. Many administrative nurses and other department heads wind up in converted closets  with no windows for offices because when the building was built their positions did not exist.    About ten years ago a company I was working for was building a brand new SNF. I suggested they do all private rooms for infection control purposes. It was never able to be considered. Land is too precious in California, Medi-Cal reimbursement rates are too low and they must build 99 beds  with shared bathrooms so the building will be profitable and benefit from the economies of scale.  Thus we continue to warehouse older adults.
  3. Dementia, Alzheimer’s and Mild Cognitive Impairments. Even in units that are not specially designed for memory care, residents have at least a mild cognitive impairment or greater . Some estimates are as high as 60% How do you get a group of 99 residents who are dependent on care and services to wash their hands before eating? After going to the bathroom?   If a dementia resident is picking their nose or coughing without covering their mouth, what can anyone do to stop it?
  4. Staff work two jobs: The main reason staff say they work two jobs is to cover bills and one job simply  isn’t enough. Anywhere from 10% to 30% of staff at any given nursing home or assisted living have a 2nd  A 2nd job means double opportunities for exposure from staff to resident and resident to staff. Tulare County Public Health recommends that during the pandemic essential health care employees work in only one facility, but there is no way to enforce it.  It is likely that is how the virus spread among our SNFs in Tulare county.

Given these harsh realities, why are nursing homes and their administration/management blamed for the outbreak and the subsequent deaths that occur?  We know the coronavirus is invisible and highly contagious. It is inevitable. Even before COVID 19 is over and the bodies are cold the trial attorneys are advertising: “Did your loved one die in a nursing home because of COVID 19?”   If anyone needs liability protection it would be the nursing home industry.  I do not see the public or attorneys blaming hospitals or food processing plants where there are also outbreaks ( not that I think they should be blamed either).

Three of our county supervisors must not understand basic public health. They voted to open up the county last week, despite the county not meeting the criteria.

Here is the scenario that has played out across the country, has already happened in Tulare county,  and may happen again:  Everything opens up, people carry on as usual, people fail to practice social distancing, avoid wearing masks as a badge of liberty and freedom, the virus spreads to an essential worker, who  unaware carries it to the nursing home.  There the 92 year old great grandma who already has Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) gets the virus from the essential worker. Her body is unable to fight it and she dies.  The nursing home gets citations and fines from the California Department of Public health. Then,  the nursing home gets sued.  Hundreds of thousands of dollars just vanished from the health care system. Why does no one else see this trajectory? Why do we continue to expect nursing homes can prevent the virus and stop it from spreading?

David B. Shellhamer,  MHA (Masters in Health Services Administration), Licensed Nursing Home Administrator. Executive Director Prestige Assisted Living at Visalia

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