With coronavirus cases surging in Florida nursing homes, assisted living facilities, group homes and other long-term care facilities, families throughout the Sunshine State are facing difficult questions.
Is their loved one or friend at great risk of catching the COVID-19 illness if they remain in their current facility? Should the family move the elder to a different facility – or try to care for their loved one at home? What are the risks of transferring older, often frail loved ones from one location to another? And what factors should a family weigh when considering how to help a loved one or friend in a long-term care facility in the midst of the coronavirus pandemic?
To get answers to these questions, we sought help from Dr. Kathryn Hyer, a professor at the School of Aging at the University of South Florida. A researcher whose academic work has been cited thousands of times, Dr. Hyer is president of The Gerontological Society of America (an organization of more than 5,500 experts in aging) and a nationally recognized expert on elder care during natural disasters. Dr. Hyer has testified before the U.S. Senate and House of Representatives on these issues.
She compiled this information with the help of several experts on long-term care in Florida. This blog story has been lightly edited.
1) How serious is the risk to residents of a nursing home or assisted living facility if a case of COVID-19 illness is confirmed in their facility?
It’s serious. Our entire world is coping with a pandemic precisely because COVID-19 is extremely contagious, and nursing home and assisted living residents are at highest risk for COVID-19 morbidity and mortality. More than 50 percent of the residents have dementias and most have multiple chronic illnesses. While the COVID-19 fatality rate is changing daily as we learn more and have more people tested, this is much more serious than the seasonal flu.
Older adults have less strong immune systems to fight off the infection and often have many underlying health conditions. Residents of nursing homes and assisted living communities are especially susceptible because they live in a congregate setting precisely because they need help. The intimate care they receive involves things like help with brushing teeth, dressing, changing bandages, and taking medications. The individuals providing care and reassurances — direct care workers — range from skilled nurses, physical therapists, and social workers to personal care aides and housekeeping staff.
Having said it’s serious doesn’t mean everyone who gets it will be hospitalized or die.
There are no known treatments for COVID 19 and the focus of care is on symptom management regardless of the setting. One advantage of being in a long-term care setting such as a nursing home is that your loved one will get symptom management quickly including such things as oxygen, intravenous support if needed, and appropriate medications such as an antibiotic if there is evidence of pneumonia or morphine to facilitate more comfortable breathing.
2) What are the key steps that an elder-care facility should be taking now to protect their residents?
Every nursing home and assisted living community should be prohibiting the public from entering the building. All employees, vendors, clinical staff, state inspectors, ombudsmen, etc., must be screened, and have their temperature taken every time they enter. Some providers take temperatures during a work shift to be certain people don’t become ill after they enter. If family members are allowed into the building for a compassionate visit (because a resident is dying), those visitors must be screened. If anyone has a fever, is coughing, or sick, they just can’t be allowed in the building. COVID-19 spreads quickly and anyone sick must not be with residents of a long-term care facility
Facilities should have a designated unit and designated staff to care for COVID positive residents and anyone suspected of COVID 19 (until testing is returned). Staff should be wearing protective equipment — gowns, masks, gloves, and face protection — when caring for COVID positive residents. ALL staff should wear a mask when interacting with any of their residents. Likewise, residents should wear masks if they are out of their rooms and potentially interacting with others. Physical distancing should be maintained as much as humanly possible between staff and residents and residents and residents and staff and staff.
Nursing homes should have testing widely available for staff and residents.
Families should learn about precautions that are being required of residents, including covering of noses and mouths when staff is in the room. It is important that families learn about how the nursing home is helping the residents to learn how to comply with the regulations and keep them safe, especially if the resident has dementia. Are there signs posted in rooms and bathrooms reminding residents about protective clothing, keeping distance between residents, and washing hands?
Facilities should have canceled communal dining and all group activities, but there should be opportunities for other activities. Puzzles, music, books, movies, religious programs and exercising should be available to residents either in their room or in larger rooms with few people at a time.
All staff and residents should be washing their hands multiple times a day and housekeeping staff should be disinfecting common areas multiple times a day.
If anyone in the home has COVID-19, the residents with infections should be isolated and staff should have protective equipment. Only certain staff should be helping residents with COVID-19 and those staff should not be allowed to work anywhere else. Areas for completely changing clothes before and after shifts should be made available.
Sanitizer and cleaning materials should be widely available and visible.
The facility should be sending out a daily update to families about the status of COVID 19 with regard to number of residents and staff affected.
3) Nearly all visitation by family members and friends to nursing homes and assisted living facilities has been shut down by government order in Florida and nationwide. How can family members check to determine if their loved ones or friends are doing well?
Although we have to practice distancing, we must encourage physical separation without social isolation.
I have been amazed at the creative and caring ways families and friends have been communicating with residents. I know church and community groups that are mailing letters and cards or dropping off care packages at the facility.
Many providers have social service staff arranging video calls, texts, and emails to connect family and friends — even others in the same building. Libraries and other groups are volunteering to help older adults to learn to use equipment via a phone call or video chat.
The Florida Department of Elder Affairs and the Alzheimer’s Association are donating large iPads with music, games, and video chat programs to 150 assisted living and nursing homes in Broward County. The Alzheimer’s Association has volunteers training staff at these facilities on how to use the equipment. We at USF are working with them to help see how well the equipment works to reduce isolation and improve well-being with new activities.
It’s wonderful if family and friends send short video messages. Residents can watch those at any time and staff members can play them if residents are anxious or ask about the family members who sent them.
We’ve seen inspiring pictures or residents meeting through windows or glass doors. I’ve seen performances given in a central courtyard and groups dressing up as bunnies with Easter Baskets outside a Florida building. There are many ways to try to bring joy and show caring for the residents and staff.
If family members do resident laundry or deliver food, set up a drive-through system to exchange items without needing to enter the building.
Having a loved one who needs care at home is also a 24-hour job – depending on their care needs. The facility has staff with expertise in how to manage things like bathing when there may be resistance to care and safety with regard to transfers and ambulation. Further there may be daily medical monitoring that is occurring that would be very difficult to get in the home settings (monitoring heart rates, blood pressures and fluid accumulation).
4) Long-term care experts often caution that transferring a frail older resident can be dangerous in itself. Why is that and are there factors to consider about the condition of your loved one or friend?
Our research shows that hurricanes increase death and hospitalization rates for all residents in the path of the hurricane. But we also found that any residents who were evacuated during the storm were at increased risk for death and hospitalization. We’re not entirely sure why, but hurricanes and COVID-19 are stressful events. The anxiety for residents and staff is increased.
The usual routines, such as morning common breakfast and exercise groups, are now disrupted. People aren’t seeing their families or friends — even friends in the nursing home or assisted living — in the same way they used to. The ability to wander around or walk outside is all different. Many staff are wearing masks and are not recognized. To address this, one hospital has large IDs with large facial portraits and names that staff wear to help residents recognize the person they know.
All of these things require everyone to develop new routines. For residents with dementia, the masks can be terrifying because they don’t know who is entering the room. Forcing residents with dementia to wear masks or to ask them to keep six feet from someone else can make the person seem uncooperative or even combative if the staff member isn’t calm and extremely patient. These things are frightening and difficult to explain.
We also know it is difficult to adjust to any new living arrangement. Moving is one of the most stressful life events. Nursing homes and assisted livings are a HOME, a place where the person should be comfortable and know their way to the dining area, outside walkways, recreation rooms, and exercise areas. The resident should know the administrator, nursing director, and staff. These are different in every setting.
5) Are there government records or reports that could help a family or friend make a more informed decision about transferring a loved one or friend from a facility?
For nursing homes, we have good data that is widely available. The Centers for Medicare & Medicaid Services (CMS) has a website called Nursing Home Compare. It ranks all nursing homes on a one- to five-star scale. There are overall ranking and individual components — such as the average hours of staffing, and inspection reports, which are how well the nursing home adheres to the federal and state standards.
Another area reported is how well residents fare. How many residents are in pain? How many residents are discharged to the community? There are many different measures that families can look at and determine if the specific nursing home does a better job than others. This allows families to look at the nursing home and see many different aspects of care.
In Florida, the Governor’s Panel on Excellence in Long-Term Care has established the Nursing Home Gold Seal Award, which recognizes nursing home facilities that demonstrate excellence in long-term care over a sustained period; promotes the stability of the industry; and facilitates the physical, social, and emotional well-being of nursing home facility residents.
Additionally, CMS recently announced new regulatory requirements that will require nursing homes to inform residents, their families, and representatives of COVID-19 cases in their facilities. Further, CMS will now require nursing homes to report cases of COVID-19 directly to the Centers for Disease Control and Prevention.
6) If a loved one is taken out of a facility, how likely is it that the loved one could be placed in a different facility, or return to a facility once the risk from the pandemic has passed?
As noted above, research indicates that residents who were evacuated during hurricanes were at increased risk for death and hospitalization. While COVID-19 is different, both events are highly stressful on the resident being relocated. The decision to relocate your loved ones to a different facility, or to have them live with a family member for some period of time, needs to be balanced with a realistic assessment of the possibility of an adverse impact on them as well as an assessment of the family member’s ability to provide uninterrupted, safe, consistent care.
If a family member takes a resident out for testing or to see a provider in a specialty practice, the resident will be strictly quarantined for two weeks. If you do remove a family member from the facility for an extended period, unless you continue to pay for the bed, the resident will likely be discharged.Similarly, upon return, the resident will be quarantined. These things must be done for the safety of the facility.