Nursing Homes Create Phony Diagnoses to Sedate Patients with Dangerous Drugs, Doubling Risk of Death

The New York Times (NYT), in a recent front-page Sunday article, "Phony Diagnoses Hide High Rates of Drugging at Nursing Homes," explores and exposes the use of chemical restraints, including antipsychotic medications, to control behavior of  long-term care residents. This blog has previously discussed the use of pointless  and dangerous drugs dispensed to terminally ill dementia patients in nursing homes.  See, "Most Terminal Dementia Patients in Nursing Homes Given Pointless and Potentially Dangerous Drugs."

Antipsychotic drugs have faced criticism for decades as “chemical straitjackets. They are medically unnecessary and dangerous for older people with dementia, nearly doubling their chance of death from heart problems, infections, falls and other ailments. Understaffed nursing homes have, nonetheless, often used the sedatives so they don’t have to hire more staff to handle residents.  

The battle against this pernicious practice is not new.  In 1987, President Ronald Reagan signed a law banning the use of drugs that serve the interest of the nursing home or its staff, not the patient.

But the practice persisted. In the early 2000s, studies found that antipsychotic drugs like Seroquel, Zyprexa and Abilify made older people drowsy and more likely to fall. The drugs were also linked to heart problems in people with dementia. More than a dozen clinical trials concluded that the drugs nearly doubled the risk of death for older dementia patients.

In 2005, the Food and Drug Administration (FDA) required manufacturers to put a label on the drugs warning that they increased the risk of death for patients with dementia.  While FDA advisories generated public awareness, it is well known that prescribers’ compliance with black-box warnings is low. Seven years later, in 2012, with antipsychotics still widely used, nursing homes were required to report to Medicare how many residents were getting the drugs. That data is posted online and becomes part of a facility’s “quality of resident care” score, one of three major categories that contribute to a home’s star rating.

The only catch: antipsychotic prescriptions for residents with any of three uncommon conditions, schizophrenia, Tourette’s syndrome and Huntington’s disease, are not included in a facility’s public tally. The theory was that since the drugs were approved to treat patients with those conditions, nursing homes shouldn’t be penalized.

The loophole was opened. The NYT has discovered that residents are simply  given "new" diagnoses of, for example, schizophrenia, attempting to justify the sedation associated with major antipsychotic medications, such as Haldol, despite the fact that such medications are contraindicated for dementia patients. According to the NYT, since 2012, the share of residents classified as having schizophrenia has risen to 11 percent from less than 7 percent.  The diagnoses rose even as nursing homes reported a decline in behaviors associated with the disorder. The number of residents experiencing delusions, for example, fell to 4 percent from 6 percent.

Today, one in nine residents has received a schizophrenia diagnosis. In the general population, the disorder, which has strong genetic roots, afflicts roughly one in 150 people.  Moreover, Schizophrenia, which often causes delusions, hallucinations and dampened emotions, is almost always diagnosed before the age of 40.

“People don’t just wake up with schizophrenia when they are elderly,”  Dr. Michael Wasserman, a geriatrician and former nursing home executive who has become a critic of the industry told the NYT. “It’s used to skirt the rules.”

Some portion of the rise in schizophrenia diagnoses probably stems from the fact that nursing homes, like prisons, have become a refuge of last resort for people with the disorder, after large psychiatric hospitals closed decades ago.

But unfounded diagnoses are also undoubtedly driving the increase. In May, a report by a federal oversight agency said nearly one-third of long-term nursing home residents with schizophrenia diagnoses in 2018 had no Medicare record of being treated for the condition.  Even for those for which there was some record of treatment, the treatment records, do not provide important details about the drug use (e.g., which antipsychotic drugs were prescribed; at what quantities and strengths; and for what durations).  The lack of treatment records suggest the drugs are not being prescribed to treat a legitimate condition, but are being used for other purpose.

The revelation should come as no surprise: many facilities have found ways to hide serious problems, like inadequate staffing and haphazard care, from government audits and inspectors.  The problem with misreporting staffing was so outrageous that, in 2019, CMS actually demanded payroll reports to verify nursing home reporting of staff numbers, immediately after which implementing such verification, more than one-third of nursing homes saw their ratings decline. See, this blog's article: "Medicare Ratings Fall for Short-Staffed Nursing Homes- One-Third of Nursing Homes See Ratings Drop."  There were a minority of nursing homes that didn't even have a staff nurse, resulting in home closures. 

The NYT, demonstrating the power of investigative journalism, reports:

According to Medicare’s web page that tracks the effort to reduce the use of antipsychotics, fewer than 15 percent of nursing home residents are on such medications. But that figure excludes patients with schizophrenia diagnoses.

To determine the full number of residents being drugged nationally and at specific homes, The Times obtained unfiltered data that was posted on another, little-known Medicare web page, as well as facility-by-facility data that a patient advocacy group got from Medicare via an open records request and shared with The Times.

The figures showed that at least 21 percent of nursing home residents...are on antipsychotics [link included in original].

That means a full one in five nursing home residents are receiving potentially unnecessary and dangerous medications!  The reasons why this practice continues are obvious: caring for dementia patients is time- and labor-intensive. Workers need to be trained to handle challenging behaviors like wandering and aggression. But many nursing homes are chronically understaffed and do not pay enough to retain a sufficient number of employees, especially the nursing assistants who provide the bulk of residents’ daily care. 

Studies have found that the worse a home’s staffing situation, the greater its use of antipsychotic drugs. That suggests that some homes are using the powerful drugs to subdue and sedate patients to avoid having to hire extra staff, or alternately to relieve already over-worked staff from the burden of caregiving.  According to the NYT analysis of Medicare data, homes with staffing shortages are also the most likely to misrepresent the number of residents on antipsychotics.

Staffing shortages are extreme, and threatening, made worse by a pandemic that has battered the industry. Nursing home employment is down more than 200,000 since early last year and is at its lowest level since 1994.

As staffing dropped, the use of antipsychotics rose.

Recent vaccine mandates further threaten industry staffing. In fact, following an announcement from President Biden that all nursing home staff will be required to be fully vaccinated against COVID-19 in a forthcoming regulation, the nursing home industry warned about the potential impact on the profession’s already challenging workforce situation. Industry leaders are deeply concerned that it may cause a "mass exodus" from the nursing home profession, leaving frail seniors without the caregivers and access to care they need.

In Ohio, only 54.3% of nursing home staff have been vaccinated, according to federal data.  Pete Van Runkle, head of the Ohio Health Care Association, which represents the state's for-profit long-term care facilities, fears additional staffing shortages. A facility in Ohio on average has 19 open positions it can't fill, according to a recent Ohio Health Care Association survey. The mandate could make things worse, Van Runkle has said.

"I'm scared to death of what that's going to look like," he said.

Van Runkle noted there was one large long-term care company that voluntarily mandated vaccines, only to walk it back later after workers threatened to leave.

Staff exodus will only increase the already strong incentives to misuse and abuse drugs as chemical restraints.  According to the NYT, the country’s leading experts on elder care are already "taken aback" by the frequency of false diagnoses and the overuse of antipsychotics.  Barbara Coulter Edwards, a senior Medicaid official in the Obama administration, told the NYT she discovered that her own father was given an incorrect diagnosis of psychosis in the nursing home where he lived even though he had dementia.

“I just was shocked,” Ms. Edwards said. “And the first thing that flashed through my head was this covers a lot of ills for this nursing home if they want to give him drugs.”

In 2019 and again in 2021, Medicare said it planned to conduct targeted inspections to examine the issue of false schizophrenia diagnoses, but those plans were repeatedly put on hold because of the pandemic.

In an analysis of government inspection reports, The NYT found about 5,600 instances of inspectors citing nursing homes for misusing antipsychotic medications. Nursing home officials told inspectors that they were dispensing the powerful drugs to frail patients for reasons that ranged from “health maintenance” to efforts to deal with residents who were “whining” or “asking for help.”  

"Asking for help."  Let that sink in.

Medicare Advantage Plans and Staffing Shortages Slowing Hospitals Discharges to Nursing Homes

Skilled nursing admissions are being slowed by both staffing shortages and Medicare Advantage restrictions.  According to a recent article in Mcknight's Long-term Care News, the delays  are threatening log jams in "hospitals desperate to discharge patients to post-acute care and free up needed beds."  The problem is especially pronounced in states with high COVID-19 case rates. 

Hospital executives and healthcare leaders have complained that the prior authorizations needed to send no-longer acute patients on to post-acute care have always come slowly in states like Florida, Louisiana and Oregon. But the problem is limiting access to care for would-be hospital admits during the ongoing delta surge.

Many Medicare Advantage plans have suspended their restrictions during this stage of the pandemic, but their replacement requirements and expiration dates vary. Humana’s waiver for Louisiana lasts until Sept. 17, while Florida Blue’s is open-ended. 

Some want uniformity directed by state or federal regulation.  “The challenge when it is not being directed by a state or federal agency is you have significant variation from one plan to the next as to how they are providing the flexibility, which creates more confusion at a time when we need to minimize as much confusion as possible,” Mary Mayhew, CEO of the Florida Hospital Association, told Modern Healthcare.

In places where waivers exist, they can be highly effective. AdventHealth in Altamonte Springs, FL, estimated waivers issued by some Medicare Advantage plans cut transitions into post-acute care down to about 24 hours.

“If the waiver goes away, we are concerned hospitals could return to seeing delayed transfers contribute to challenging capacity constraints,” said Lisa Musgrave, vice president of home care administration and post-acute services.

The American Hospital Association has been working with the Centers for Medicare & Medicaid Services (CMS) and Medicare Advantage organizations to “encourage adoption of these waivers.”  For its part, CMS issued a memo that “strongly encouraged” plans to relax prior authorizations “to facilitate the movement of patients from general acute-care hospitals to post-acute care and other clinically-appropriate settings, including skilled nursing facilities.”

Whether skilled nursing facilities could accept patients more quickly if prior authorizations are lifted remains to be seen. Kristen Knapp, spokeswoman for the Florida Health Care Association, said the larger issue “is all about staffing.”

A survey of FHCA members in early August found half had had to reduce admissions in the previous month due to worker shortages.

“The workforce crisis is real, and while we want to be good community partners during the surge, nursing centers right now are doing everything they can to maintain and recruit more staff to support the patients they are currently caring for,” Knapp told McKnight’s Long-Term Care News.

Home Health Care Staff Shortages Threaten Health- Frustrates Aging in Place

This Blog has reported the threat staffing shortages pose to the long-term institutional care industry, its residents, and its patients.  Staffing shortages in the home health care industry present similar threats, both to the industry and to actual and prospective customers.  

There is a legal maxim that "Justice Delayed is Justice Denied."  In the long-term care and the health care industry there is no simple maxim that  warns that "freedom delayed is freedom denied," but there should be.  A shortage of home health care workers means that some seniors may be unable to safely return to their homes, and may, instead, be forced into institutional care alternatives otherwise avoidable.  This may seem an anomalous result, but it is real.  Seniors are transferred to institutions that are woefully understaffed every day.  

There is no compromise possible, however, for a family seeking return of their mother or father to a home when they cannot demonstrate adequate and sufficient support services.  The systemic choice is clear; it is unacceptable for a senior to be at risk in their own home, but acceptable if that risk is institutional.  The Trump Administration learned, for example, that there were nursing homes opened and operating, without a nurse.  Medicare did not, and to this day, does not prohibit the transfer of a patient from a hospital to a poorly staffed nursing home or assisted living facility!     

Aging in Place Planning is specifically designed to reduce the risk of unnecessary and avoidable institutional care.  Unfortunately, many seniors may need home health care workers for short periods of time following acute needs or hospitalizations in order to rehabilitate safely at home.  "Freedom," may be denied these seniors if there is no choice but institutional care.   

Kaiser Health News, published a story about the on-going shortage, entitled, "Desperate for Home Care, Seniors Often Wait Months With Workers in Short Supply."  Using Maine as an example, the article explains:

"The Maine home-based care program, which helps....more than 800 in the state, has a waitlist 925 people long; those applicants sometimes lack help for months or years, according to officials in Maine, which has the country’s oldest population. This leaves many people at an increased risk of falls or not getting medical care and other dangers.  The problem is simple: Here and in much of the rest of the country there are too few workers. Yet, the solution is anything but easy."

Katie Smith Sloan , CEO of Leading Age, which represents nonprofit aging services providers, told Kaiser that the workforce shortage is a nationwide dilemma:

 “Millions of older adults are unable to access the affordable care and services that they so desperately need,” she said at a recent press event. State and federal reimbursement rates to elder care agencies are inadequate to cover the cost of quality care and services or to pay a living wage to caregivers."

This shortage was not unexpected.  Kaiser reported that "[f]or at least 20 years, national experts have warned about the dire consequences of a shortage of nursing assistants and home aides as tens of millions of baby boomers hit their senior years." President Biden even included funding for home and community-based care in the infrastructure bill ("human infrastructure").

And here we are. 

Picture Credit: Photo 19608638 / Help Wanted © Martinmark | Dreamstime.com

Staff Shortages Worsen in Long-term Care Industry

Among the many reasons supporting the decision to age in place is a worsening staff shortage in the long-term care industry.  A survey published by the American Health Care Association revealed 94% of long-term care facilities are struggling to hire staff. 

The U.S. faces a certified nurse aide shortage of about 200,000, with the situation made even more dire by a surging number of unvaccinated aides being forced to quarantine as cases of variant COVID-19 cases threaten to surge.  Regional variations make this shortage more or less extreme for the industry and residents.

There are many reasons that contribute to cause these shortages, but among the most surprising is the effect of workplace violence. Violence in all healthcare settings plays a role in the nursing shortage, with the "ever-present threat of emotional or physical abuse adding to an already stressful environment." 

Staff shortages, of course, negatively affect health outcomes. Nursing shortages lead to errors, higher morbidity, and higher mortality rates. 

Lori Porter, founder and CEO of the National Association of Health Care Assistants, is sounding the alarm.  "Bemoaning the twin crises (shortages and vaccinations) won’t resolve them. But neither will throwing just money at potential employees," Porter said, according to McKnights Long-term Care News, adding that "Medicaid pressures continue to make routine higher pay and better benefits elusive for many."

“Pay is one of the scariest things,” she said. “I’ve seen facilities giving up to $20 and hour … I’m not certain how you make that happen in today’s world.”

Porter suggested providers need to look at their individual recruitment efforts to address oversights and messaging, but she also suggested a federal recruitment campaign could be part of the solution.

“People want to be part of a team,” Porter said. “We want to blame the millennials because they don’t want to work. But I would hire millennials all day long because they don’t want to make a job. They want to make a difference.”

Some sociologists and economists have taken to calling the current labor challenge "The Great Resignation." Porter noted that it’s important to consider the cultural shift spurred by COVID-19 and seize on the industry’s intangible benefits to shift momentum.

“Pay and benefits (are) things we’re very weak on as a profession,” she said. “But the second thing we have to sell are emotional benefits, and we’re very high on emotional benefits if care centers and employers will learn how to articulate it in a way that resonates with ‘I want to be part of something that makes a difference.’”

Millennials are, though, among the most unlikely to want a COVID-19 vaccine, another issue that continues to plague providers. Porter told LeadingAge members that vaccine coverage among her membership remains her top concern. She has worked to counter hesitancy with information from AMDA, rather than the Centers for Disease Control and Prevention or the Centers for Medicare & Medicaid Services, and appealing with direct messages about the responsibility to residents.

But Porter said many of the workers her organization represents are still reluctant, at least until the vaccines receive full FDA approval.

“Many of their arguments are becoming weakened. More vaccines have been taken and no one has grown a third arm yet,” said Porter, who noted the rate of unvaccinated people in her area of Missouri recently led two major hospitals there to reopen their COVID units. “Now is the time to push harder than ever.”

Son's Filial Responsibility Nursing Home Debt Dischargeable in Bankruptcy; Not Required to Spend All of Mother’s Assets on Her Care

As previously discussed in this blog, nursing homes have devised various schemes to ensure collection of costs from family members of residents, notwithstanding a federal law making it unlawful to hold families contractually responsible as a condition of admission [the hyperlink will take you to all of the filial responsibility blog articles].  

A recent iteration of this effort includes contesting bankruptcy discharge of the debt.  One effort has, nonetheless, proved futile. A U.S. Bankruptcy Court has ruled that the judgment debt of a resident's son to a nursing home for his mother’s care is dischargeable in bankruptcy.  The Court found that the son’s failure to apply all of his mother’s income and assets towards her care did not constitute an attempt to defraud the facility. Geriatric Facilities of Cape Cod, Inc. v. Georges (Bankr. D. Mass., No. 19-01096-MSH), June 22, 2021).

In April 2010, acting as an agent under a power of attorney, Jonathon D. Georges signed a services agreement with Pleasant Bay, a Massachusetts nursing home to provide care to his mother, C. Doris Georges. The contract identified Mr. Georges as a “responsible party” and obligated him to apply his mother’s funds and assets to pay for the services being rendered to her. 

At the time the contract was signed, the nursing home’s monthly cost typically exceeded $8,000, while Ms. Georges’ monthly income was limited to $2,410.24, consisting of Social Security and payments from an annuity.

In March 2012, Mr. Georges sold his mother’s condominium to pay her obligations to Pleasant Bay, netting $247,395.03.  Mr. Georges paid $104,128.91 to the nursing home to bring his mother’s account current and spent another $63,500 on gifts to various family members, including himself.  By the fall of 2011, with the sale proceeds having been nearly all spent, Mr. Georges applied to Medicaid (MassHealth) for long-term care benefits for his mother.  At the same time, he stopped paying Pleasant Bay with his mother’s income, believing that once Medicaid was approved the balance would be resolved.  

Ultimately, the Medicaid application was denied due to the substantial gifts to family members.  Unable to reach an agreement with Pleasant Bay to settle the balance, Mr. Georges used his mother’s income that he had been setting aside to move her to another facility.  In October 2012, Pleasant Bay sued Mr. Georges in state court for the services rendered.  The case settled prior to any hearings when Mr. Georges agreed to a judgment being entered against him in the amount of $128,000, plus interest.  Ms. Georges died in 2013.

In May 2019, Mr. Georges filed a voluntary petition for relief under Chapter 7 of the bankruptcy code and included the judgment debt to Pleasant Bay in the bankruptcy schedule.  Pleasant Bay objected to the discharge of its debt, arguing that the debt was excepted from discharge because Mr. Georges had obtained the debt by false pretenses or false representations when he promised to devote all of his mother’s assets and income to pay for her care when he had no intention of doing so.  Mr. Georges countered that he had not understood or agreed that all of his mother’s income and assets had to be used to pay Pleasant Bay for her care and that he made gifts to himself and family members in accordance with his understanding of her wishes.

The U.S. Bankruptcy Court for the District of Massachusetts found that “no reasonable reading of the services agreement supports Pleasant Bay’s interpretation that Ms. Georges and Mr. Georges were contractually bound to devote every cent of Ms. George’s income and assets to pay Pleasant Bay.”  The court found that “[h]ad Pleasant Bay wanted to bind its residents to devoting the entirety of their income and assets to the payment of nursing home expenses, to the exclusion of everything else, it needed far more detailed and explicit contractual terms.”

COVID-19 Still Killing 800 a Month in Nursing Homes

Nursing home deaths from COVID-19 remain sharply down from their winter peaks, but the declines have now plateaued and more than 800 residents and staff members each month continue to die from the virus, according to an exclusive new analysis of federal data by AARP.  The analysis did not comment upon and likely did not factor recent data suggesting that seniors in nursing homes may have lower immune response from the vaccines. 

There was little change in the national rates of COVID-19 infections and deaths in nursing homes from mid-March to mid-May, the analysis shows, even as rates in the wider community continued dropping. More than 10,000 residents and staff members are becoming newly infected each month.

Experts say that limited vaccine uptake among long-term care workers, worker shortages and the recent relaxation of nursing home restrictions might be causing the plateau, although more data and analysis are required.

Since the pandemic hit, COVID-19 has killed more than 184,000 residents and staff of long-term care, which includes nursing homes, assisted living facilities and other residential settings. Those deaths constitute almost a third of America's entire COVID-19 death toll, according to the Kaiser Family Foundation.

In nursing homes, the infection and death rates peaked last winter, when close to 20,000 residents and staff were reported dead from COVID-19 in just four weeks from mid-December to mid-January; 1 in every 51 residents died from the virus.

Then, cases and deaths started to plummet, dropping more than 90 percent by mid-March, with the arrival of vaccines, tougher restrictions from governments, and high levels of natural immunity from months of high infection rates. Though the situation has improved, nursing home advocates say current COVID-19 rates in nursing homes shouldn't be accepted as the new normal.

The federal government asked the country's 15,000-plus nursing homes to loosen visitation restrictions in March. Citing widespread vaccinations of residents, drops in COVID-19 infections among residents and staff, and the tolls of separation and isolation on residents and their families, the federal Centers for Medicare & Medicaid Services (CMS) said facilities should allow indoor visits “regardless of vaccination status of the resident or the visitor."

The resulting uptick in visitors could, in part, be contributing to the halt in COVID-19 declines, according to Jennifer Schrack, an associate professor in the epidemiology of aging at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

"Every visitor is another potential exposure, particularly those who are not vaccinated,” she says. “They have to really consider carefully if they're going to visit their loved one, and if they do, they should wear [personal protective equipment] and be very cautious, even if their loved one is vaccinated. … Low risk doesn't mean no risk.”

Unvaccinated staff, which could represent nearly half of the nursing home and assisting living workforce, may be an even bigger factor.

Source: Emily Paulin, AARP, June 10, 2021 COVID-19 Still Killing 800 a Month in Nursing Homes, AARP Analysis Shows, 

Nursing Home Mortality Rate Soared 32 Percent in 2020

The coronavirus pandemic’s “devastating impact” on nursing homes led to a 32% spike in overall mortality rate among Medicare residents during 2020, according to a new report by the Office of Inspector General. The spike means there were 169,291 more deaths in 2020 than would be expected if the mortality rate had remained the same as in 2019. There were 3.1 million Medicare beneficiaries who resided in nursing homes in 2020. 

Each month of 2020 had a higher mortality rate than the corresponding month a year earlier. In April 2020 alone, a total of 81,484 Medicare beneficiaries in nursing homes died — more than twice the number in April 2019.

Federal investigators added that the data shows the pandemic had “far-reaching implications for all nursing home beneficiaries, beyond those who had or likely had COVID-19.” This blog has previously addressed the higher rate of medical mistakes and errors and neglect that occurred amidst the pandemic as well as the horrific impacts from isolation, loneliness, and lack of psychological care and treatment.

The findings also revealed that more than forty percent of Medicare beneficiaries (1.3 million beneficiaries), in nursing homes had or likely had COVID-19 in 2020. The number of infected beneficiaries swelled dramatically during the spring of 2020, with just over 21,000 diagnosed as having or likely having the disease between January and March. By the end of June, the number was close to 419,000. 

Federal researchers also found about half of Black, Hispanic and Asian beneficiaries in nursing homes had or likely had COVID-19 in 2020. Each group was more likely than their white counterparts to contract the disease. 

Harvard health policy expert David Grabowski, Ph.D., said those who work in the field “knew this was going to be bad” but didn’t think “it was going to be this bad.” “This was not individuals who were going to die anyway,” Grabowski told the Associated Press. “We are talking about a really big number of excess deaths.”

“The COVID-19 pandemic has been devastating for Medicare beneficiaries in nursing homes,” the government watchdog agency wrote. “The toll that the COVID pandemic has taken on Medicare beneficiaries in nursing homes demonstrates the need for increased action to mitigate the effects of the ongoing pandemic and to avert such tragedies from occurring in the future.”  

The report is the first in a three-part series focusing on the impact of COVID-19 in nursing homes. Upcoming analyses are expected to focus on strategies nursing homes have used to combat the pandemic. 

Source: D. Brown, "Nursing home death rate soared 32 percent in 2020," McKnight's Longterm Care News (June 23, 2021).

Nursing Home Residents May Have Lower Vaccine Immune Response

A COVID-19 vaccine administered to nursing home residents in northeast Ohio was less effective in creating an antibody response in them than in a control group of health care workers, according to a Case Western Reserve-led study.

Some residents responded "reasonably well," but a portion responded "poorly to very poorly," concluded university researchers. What's not yet clear is why, or what the threshold for protection is when measured in terms of antibodies.

"We urgently need better longitudinal evidence on vaccine effectiveness" to inform best practices for nursing home infection control measures, outbreak prevention and potential indication for a vaccine boost, stated the study. Its co-principal investigators include David Canaday, MD, a professor in the School of Medicine’s Division of Infectious Disease, and Mark Cameron, PhD, an associate professor in the school’s Department of Population and Quantitative Health Sciences.

Once COVID-19 reached the United States, nursing homes became hotspots, with a rapid rise of infections and deaths; when vaccines became available, nursing home residents were among the first to receive them.  The study focused on the antibody immune response in residents by comparing a blood sample taken before the first vaccination, with another taken about two weeks after the second one.  It included 149 residents and a younger control group of 110 health care workers. All participants received the Pfizer vaccine.

Researchers examined three measures of antibodies; in all cases, residents had lower levels. For example, residents had a quarter of the anti-virus antibodies as the control group.

Canaday said the study's results can’t be compared to Pfizer’s vaccine efficacy rate of 95% because the Pfizer clinical trial focused on the number of adults of any age who got COVID-19, not the quantity of antibodies in the blood.

"The vaccine does make an immune response in almost every nursing home resident, although the magnitude is lower than in the younger age," Canaday said.

The study was the first outcome from a $2.3 million National Institutes of Health grant focused on COVID-19's spread in nursing homes awarded to Canaday, Cameron and fellow co-principal investigator Stefan Gravenstein, MD, a geriatrician and professor at Brown University.

They are now exploring varying responses to COVID-19 in nursing home residents and what level of antibodies is protective.

"There are so many questions to be answered surrounding the role of one's immune system in determining whether an infected individual has a mild, moderate or very severe form of COVID-19," Cameron said, "especially in people who are older or have underlying health issues that put them more at risk for poor outcomes."

Nearly 40% of SNF's Reported No 2020 COVID-19 Deaths; SNF Risk of Death Still Ten Times Higher than Independent Living

In rare good news regarding health outcomes in nursing homes, particularly during the pandemic, a recent study found that nearly 40% of nursing homes reported no COVID-19 deaths during 2020.  The new study was conducted by NORC at the University of Chicago.  The analysis, which was funded by the National Investment Center for Seniors Housing & Care, estimated 2020 COVID mortality rates in seniors housing by level of care and compared the rates to seniors who lived in non-congregate settings. Findings were based on data from five states.

Thirty-nine percent of skilled nursing facilities experienced no COVID-related deaths during the year, while about two-thirds of independent living, 64% of assisted living and 61% of memory care prosperities experienced no related deaths.   The analysis also found that COVID-19 deaths across senior housing correlated with how ill the average resident was and the amount of care they needed: 

“The facts include that COVID-19 transmission is more likely with close person-to-person contact and mortality increases with age and comorbidities. This study shows senior housing isn’t homogeneous, and mortality was higher in property types whose residents, on average, are sicker and require higher levels of care,”

Brian Jurutka, NIC’s president and CEO, said in a statement. 

SNFs and memory care had the highest adjusted mortality rates from COVID-19 with 59.6 and 50.4 deaths per 1,000 residents, respectively.

Resident deaths in independent living settings were statistically comparable to the rates of death for older adults living in non-congregate settings in the same geographic area. Independent living had average adjusted mortality rates of 5.9 per 1,000. That’s compared to the 6.7 per 1,000 found for seniors living in the same counties. For Aging in Place Planning purposes, that means that independent and non-congregant settings showed no higher mortality rate. 

The analysis included data from 3,817 senior housing properties across 113 counties in five states: Colorado, Connecticut, Florida, Georgia, and Pennsylvania.

Source: D. Brown, "39 percent of nursing homes had no COVID deaths: report,"  McKnight's Long-term Care News (June 3, 2021) (last accessed 6/3/2021). 

Guardian Lawfully Refused Family's Request to Remove Ward from Nursing Home Amidst Pandemic

COVID-19 may have revealed with horrific and heart-breaking clarity just how deeply is the bias for institutional care in our legal and health care systems.  A recent Maryland case, arising from pandemic decision-making, may provide an object lesson regarding this bias, and is another in a string of cases revealing the dangers of guardianship. 

Mary Boone suffered from dementia and lived in a nursing home. Due to discord between Ms. Boone’s two daughters, the court appointed an independent guardian for Ms. Boone. In April 2020, one of Ms. Boone’s daughters, Sherry Feggins, filed an emergency motion to remove her mother from the nursing home and relocate her to Ms. Feggins’ house due to concerns about COVID-19 in the nursing home.

The guardian opposed the motion, arguing that Maryland’s governor had ordered people to shelter in place. She also noted that Ms. Feggins did not provide a care plan for Ms. Boone at her house. Ms. Boone’s doctor submitted a statement that moving Ms. Boone would worsen her dementia and put her and the facility at risk for COVID-19. Ms. Feggins argued, additionally, that her mother had suffered abuse at the facility. The court denied Ms. Feggins’ motion, and Ms. Feggins appealed.

The Maryland Special Court of Appeals affirmed, holding that it was in Ms. Boone’s best interest to remain at the facility. 

The court ruled that “it is the welfare of the ward that is of chief concern -- not the wishes of the relatives nor the convenience of the guardian.” The Court determined that Ms. Feggins did not provide sufficient proof that changing Ms. Boone’s residence would be in her best interest.  In the Matter of Boone (Md. Ct. Spec. App., No. 432, May 13, 2021).

An Aging in Place Plan with a clear appointment of a primary decision-maker,  providing for a succession of decision-makers, and conferring authority to implement aging in place plans and preferences, may have prevented this case and controversy.   

CMS Requires LTC Providers Report Weekly COVID Vaccine Data; Data Made Public

Long-term care facilities are required to report weekly data on COVID-19 vaccination status for both residents and staff under a new interim final rule, putting more pressure on providers to remain transparent with their efforts. 

The Centers for Medicare & Medicaid Services (CMS) announced the new regulation, which apply to long-term care facilities and intermediate care facilities for individuals with intellectual disabilities.  Enforcement begins June 14. 

As data becomes available, CMS will post facility-specific vaccination status information so that it can be seen openly by the public on CMS’ COVID-19 Nursing Home Data website, the agency said.

CMS added that the new mandate is designed to assist in monitoring uptake among residents and staff, and aid in identifying facilities that may be in need of additional resources to respond to the COVID-19 pandemic.

LTC facilities are already required to report COVID-19 testing, case and mortality data to the National Healthcare Safety Network for residents and staff, but they have not been required to report vaccination data.

“These new requirements reinforce CMS’ commitment of ensuring equitable vaccine access for Medicare and Medicaid beneficiaries,” Lee Fleisher, MD, CMS’ Chief Medical Officer and director of the Center for Clinical Standards and Quality, said in a statement. 

“Today’s announcement directly aids nursing home residents and people with intellectual or developmental disabilities who have been disproportionately affected by COVID-19. Our goal is to increase COVID-19 vaccine confidence and acceptance among these individuals and the staff who serve them,” he added. 

Some states had already been collecting and monitoring such data, and Maryland last week said it would require its providers to feed information to a public-facing dashboard.

A growing movement to track

CMS had hinted that a national vaccination reporting requirement could be in the pipeline for providers. The agency put forward a new SNF Quality Reporting Program measure as part of its Skilled Nursing Facility Prospective Payment System proposal for fiscal year 2022. 

The proposed rule would have require skilled nursing facilities to report staff COVID-19 vaccination rates to the Centers for Disease Control and Prevention National Healthcare Safety Network starting Oct. 1. Currently, staff vaccination reporting is voluntary.

The agency on Tuesday added that it’s also seeking comment on expanding the reporting policy to other congregate care settings, such as assisted living facilities, psychiatric residential treatment facilities and group homes.

Regulators said they are specifically interested in comments on “potential barriers facilities may face in meeting the requirements, such as staffing issues or characteristics of the resident or client population, and potential unintended consequences.”

The rule also requires providers to report the use of therapeutics administered to residents for treatment of COVID-19. The agency said reporting their use will help government officials and other stakeholders “monitor the prevalence of these treatments, their impact on reducing the effect of COVID-19 on nursing home residents, and support allocation efforts to ensure that nursing homes have access to supplies to meet their needs.”

Tuesday’s rule would have been more expansive, CMS added, but logistical concerns kept the range limited.

“Because we are not able to guarantee sufficient availability of single dose COVID-19 vaccines at this time, or in the near future, to meet the potential demands of facilities with relatively short stays, we are focusing on facilities that have longer term relationships with patients and are thus also able to administer all doses of and track multi-dose vaccines,” they said in a summary of the interim final rule, scheduled to be published in the Federal Register on Thursday.

Source: D. Brown, "BREAKING: New CMS rule requires LTC providers to report weekly COVID vaccine data, which will be made public," McKnight's Long-term Care News (May 11, 2021) (last accessed 5/11/2021).

Early COVID-19 Vaccinations Reduce Nursing Home Cases

A new study recently found that facilities that started the COVID-19 vaccination process earlier were less likely to have new cases  compared to providers who started inoculations weeks later. 

"Early group" nursing homes had 2.5 fewer COVID-19 infections per 100 at-risk residents after one week when compared to late group facilities. In addition, they had 5.2 fewer cases per 100 after five weeks. 

The study, led by Brown University researchers, was conducted using data from 280 Genesis HealthCare facilities. Nursing homes in the early group conducted their vaccine clinics from Dec. 18, 2020 to Jan. 2, while the late group’s clinics were between Jan. 3 and 18. 

Rates of hospitalizations and deaths were also down for providers who started the vaccination process earlier. Findings showed that after seven weeks earlier vaccinated facilities five fewer hospitalizations and/or deaths per 100 infected residents. 

Brown University biostatistician and co-author Roee Gutman said the findings reveal just how quickly the vaccine starts to work within long-term care facilities. 

“We see that the mRNA vaccine is useful and has a strong protective effect relatively soon after it is being administered,” Gutman told McKnight’s Long-Term Care News.  The full study was published in the Journal of the American Geriatrics Society.

“It is significant because the original Pfizer trial was not performed on this population and it only examined severe COVID cases. Because residents are tested regularly, we can see that the number of infections is lower than those that vaccinated later and a measure of COVID severity is lower. Second, we see that the mRNA vaccine works on this very old and frail population,” he added. 

Researchers said they hope the findings “make it possible for nursing homes to begin controlled efforts to open up to family visitation and alleviate other restrictions, thus reversing the social isolation which has become virtually universal during the pandemic.”  As previously discussed on this blog, isolation has been devastating to this older vulnerable population:

• Seniors Dying from Isolation Amid Pandemic- One Analysis Suggests Tens of Thousands;
• Heartbreaking Study Finds that Contact with Nursing Home Residents Fell by More than Half;
• Survey Suggests 64% of Residents Don't Leave Rooms to Socialize; More Report Profound Loneliness. 

The statistics also provide even more evidence that the vaccination is effective in reducing the spread of the disease. 

Source: D. Brown, "Nursing homes with early COVID vaccinations less likely to have new COVID cases,"  McKnight’s Long-Term Care News April 20, 2021).