Nursing Homes Found Guilty in Criminal Understaffing Case= Individual Defendants Acquitted

In a rare case in which a nursing home business faced criminal charges over staffing misconduct, two Pennsylvania facilities owned by Comprehensive Healthcare Management Services were recently found guilty of healthcare fraud and other crimes.

Prosecutors alleged two different schemes to enrich the nursing homes’ operations. In the first, leaders were accused of falsifying payroll documents to make it appear the nursing homes were meeting required staffing levels, including having non-working direct care staff clock in for shifts they never intended to work. In the second, administrators were accused of changing assessments to make it appear patients were clinically depressed or needed more therapy as a means of delaying discharge and driving Medicare or Medicaid reimbursements.  

Both schemes appear to be occasional, if not common, practice of some nursing homes.  The Trump Administration, for example, began demanding payroll records of nursing homes, because CMS found that some nursing homes misrepresented staffing levels on routine reports. Moreover, the financial incentive of these institutions to misrepresent a patient's condition or need for treatment, underlies many of the ongoing battles to ensure better quality of care for patients.  

After five weeks of testimony in the complicated case involving Brighton Rehabilitation and Wellness Center and Mt. Lebanon Rehabilitation and Wellness Center, the jury returned verdicts against the institutions charged. The US Attorney’s Office for the Western District of Pennsylvania also prosecuted five company and facility leaders for their roles in a scheme that led to overbilling; the jury found all five not guilty.

Brighton Rehab itself was found guilty of healthcare fraud and five counts of falsification of records in a federal investigation, while Mt. Lebanon was found guilty of one count of falsification of records related to healthcare matters and three counts of falsification of records in a federal investigation. The nursing home defendants are scheduled to be sentenced in May before US District Judge Robert J. Colville.

According to Kimberly Marselas, reporting for McKnights' Long Term Care News, neither prosecutors nor defense attorneys offered a solid explanation why the jury reserved its convictions for the corporate defendants. US Attorney Eric Olshan, nonetheless, assured told McKnight’s Long-Term Care News that his office would pursue similar cases in the future, if warranted:

“Our legal system entrusts the jury with making determinations of guilt, and as in all cases, we respect the jury’s verdict. Today, the jury held the two corporate defendants criminally liable for a total of 10 counts of making false statements and obstructing CMS’s critically important work of ensuring that nursing facilities comply with the law.  This office and our law enforcement partners will continue to seek accountability for any individual or business that pursues profit through deceit and does so at the expense of vulnerable members of our community.”

Several counts in the indictment carried up to $250,000 in fines, or jail times in the case of individuals. In a press release issued by the US Attorney’s Office , prosecutors said the companies faced a maximum of five years probation, $500,000 in fines, or both, on the counts for which they were convicted.

According to McKnights, 

"Brighton, with 589 beds, is one of the state’s largest nursing homes and was plagued by problems during the pandemic. The facility was hit with at least  $62,000 in fines for infection control deficiencies, and the state later selected a temporary manager to come in and clean up operations. 

The 121-bed Mt. Lebanon facility also has had its share of problems, including a 2-star overall rating and an abuse citation noted on the Care Compare site.

Both facilities are managed by Comprehensive Healthcare Management Services, an entity affiliated with Ephram “Mordy” Lahasky. He has a 10% direct ownership stake in Brighton, while Halper has a 12% ownership stake.

Attorneys for the individual defendants framed the case as one of sloppy record keeping and government malfeasance, rather than intentional fraud, TribLive reported.  The Pittsburgh Tribune-Review reported that attorneys also attacked the credibility of 20 former nursing home employees as each having an axe to grind: some were fired, others quit, and some were offered immunity in exchange for their testimony.

Attorney Kirk Ogrosky represented Sam Halper, Brighton’s CEO and 12% owner and an officer at Mt. Lebanon. Orgosky argued there was no evidence Halper was involved in ordering or completing incorrect staffing records but instead told the jury that a handful of staff members came up with a scheme to cheat the buildings’ corporate owners.

“Throughout this case, all defendants cooperated with the US Department of Justice in every way possible. Yet, DOJ pursued individuals without regard for the truth,” Halper said in a statement shared with TribLive. “Thankfully, the jurors were able to hear the evidence and find that the facts did not support DOJ’s claims.”

Regardless, the case is representative of just how complicated is the challenge to ensure care quality,  and just how difficult it can be for the government, even when properly motivated, to protect the vulnerable by holding third parties responsible.  Individuals and institutions pursuing their own self interest at the expense of senior residents and patients is a common theme in cases like the one reported.  

Of course, the case does not ask or resolve the question of whether a health care system devised and regulated by a government bureaucracy overly concerned with reducing costs at the expense of quality can ever attain a high quality of care for patients.  Aging in Place is a discreet goal of a well-crafted estate plan because a person with family and loved ones can often better control the circumstances of their care at home or at less institutional alternatives.

White House Announces Measures to Improve Nursing Home Care Quality

The Biden administration on February 28th announced a round of new measures for nursing homes aimed at ensuring adequate care for seniors. 

Citing how the pandemic "highlighted the tragic impact of substandard conditions at nursing homes," the White House announced it would be issuing new requirements through the Department of Health and Human Services (HHS) to improve the "quality and safety" of nursing homes.  Through the Centers for Medicare and Medicaid Services (CMS), the administration will be proposing new minimum standards of care to be unveiled within the next year following a study to determine the level of care and staffing needed.  That means, practically, that it is intended that the new minimum standards would be in place before January 1st, 2024.

While the Administration's highlighting quality of care issues in nursing homes is welcome and commendable, it is hard to see the move as anything but a political device giving President Biden subject matter for his upcoming and first State of the Union address.  President Biden is "set to talk further on these proposed plans," among other topics, on Tuesday evening during the address.

The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) and LeadingAge, while grateful the Biden administration seems to be prioritizing long-term care, questioned how these policies would be implemented and enforced without adequate funding and investments.

Mark Parkinson, president and CEO of The American Health Care Association and National Center for Assisted Living (AHCA/NCAL), said in a statement to Skilled Nursing News that additional oversight without necessary assistance will not improve resident care.  In a longer written statement, he wrote: 

“Those who continue to criticize the nursing home sector are the same people who refuse to prioritize our residents and staff for resources that will help save and improve lives. Additional oversight without corresponding assistance will not improve resident care. To make real improvements, we need policymakers to prioritize investing in this chronically underfunded health care sector and support providers’ improvement on the metrics that matter for residents.  

“Long term care was already dealing with a workforce shortage prior to COVID, and the pandemic exacerbated the crisis. We would love to hire more nurses and nurse aides to support the increasing needs of our residents. However, we cannot meet additional staffing requirements when we can’t find people to fill the open positions nor when we don’t have the resources to compete against other employers.  

“It’s time to stop blaming nursing homes for a once-in-a-century pandemic that uniquely targeted our residents and vilifying the heroic caregivers who did everything they could to protect the residents they have come to know as family. Together, we should focus on meaningful solutions that can attract and retain the frontline heroes we need and strengthen delivering the quality of care and services that our nation’s seniors deserve. Providers are dedicated to learning from this pandemic, renewing our commitment to our seniors, and offering solutions that will improve the quality of care in our nation’s nursing homes. With the proper resources and support, we can transform our nation’s nursing homes.”

On February 22nd,  Mr. Parkinson sent a letter on behalf of AHCA/NCAL to Congressional leadership thanking them for their continued support of long term care residents and staff but urging them to take additional steps to ensure the safety and protection of America’s most vulnerable.  In the letter,  he outlined the association’s specific requests of Congress that would provide nursing homes and assisted living communities with the resources necessary to combat COVID-19 and address critical challenges brought on by the ongoing pandemic. Specifically, in the upcoming appropriations bills, AHCA/NCAL is calling for replenishment of the Provider Relief Fund with $20 billion allocated to long-term care, as well as an extension to the current delay of Medicare sequestration cuts and the recoupment of Medicare Accelerated and Advance payments. 

He wrote that

“[n]ursing homes and assisted living communities are facing the worst job losses among all health care professions, and the shortage is impacting seniors’ access to care. More than half of nursing homes were limiting new admissions in recent months—at a time when overwhelmed hospitals needed our assistance to free up precious beds due to the Omicron surge.

 .           .          . 

Long term care residents and staff have been among the hardest hit by the pandemic, as the virus uniquely targeted older adults with chronic conditions and exposed long-standing issues within the industry. Chronic government underfunding coupled with workforce recruitment challenges were exacerbated by the global crisis. The number of long term care facilities forced to limit admissions or close altogether because of staffing shortages and financial concerns continues to grow." 

Katie Smith Sloan, LeadingAge president and CEO, called on officials to keep in mind Medicaid’s insufficiencies when it comes to covering the cost of service:

“We know that transparency, quality improvement, and workforce investments are critical to building better nursing homes for America’s older adults and families,” Smith Sloan said in the statement. “Yet Medicaid, the dominant payer of long-term care services, doesn’t fully cover nursing homes’ cost of quality care. Regulations and enforcement, even with the best intentions, just can’t change that math.” 

On the other hand, the Long Term Care Community Coalition (LTCCC) likened the proposed changes to “the biggest and most positive news for nursing home residents in the 35 years since Ronald Reagan signed the Nursing Home Reform Act.”

CMA Senior Policy Attorney Toby S. Edelman said the federal government’s agenda tackles issues that have “plagued” the nursing home industry for decades.

“For years, we have watched as an increasingly sophisticated and corporatized industry has, too often, cut back on staffing and essential services to maximize profits,” Richard Mollot, executive director of the Long Term Care Community Coalition (LTCCC) said in a statement. “We are profoundly grateful to the [p]resident for taking this bold stand for vulnerable residents, their families, and American taxpayers, who foot the bill for most nursing home care.”

Mollott’s comments about a “corporatized industry” echo the White House’s criticism of private equity ownership of nursing homes and practices that make it difficult for consumers and watchdogs to track corporate ownership of facilities. The Biden administration is seeking to address these issues with provisions related to greater transparency, heightened penalties and standards related to “corporate competency.”

President Biden's remarks in the SOTU address:

 And as Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up.  

That ends on my watch. 

Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect. 

We’ll also cut costs and keep the economy going strong by giving workers a fair shot, provide more training and apprenticeships, hire them based on their skills not degrees. 

 

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). 

Deaths from Nursing Home Neglect Surged Amid the Pandemic

As more than 180,000 of the nation’s long-term care residents and staff died of COVID-19 in a pandemic that has pushed staffs to the limit, advocates for the elderly say a tandem wave of death separate from the virus has quietly claimed untold tens of thousands more.  The most common causes included neglect occasioned by overburdened workers unable to provide necessary care.

Matt Sedensky and Bernard Condon, writing for the Associated Press (AP), told the soul wrenching story of David Wallace: 

"When COVID-19 tore through Donald Wallace’s nursing home, he was one of the lucky few to avoid infection. He died a horrible death anyway."

Hale, hearty, and reportedly happy before the pandemic, the 75-year-old retired Alabama truck driver became so malnourished and dehydrated that he dropped to 98 pounds.  His son reported that he looked like he’d "been in a concentration camp."  No wonder: septic shock suggested an untreated urinary infection, E. coli in his body from his own feces hinted at poor hygiene, and aspiration pneumonia suggested that  Wallace, who required assistance with meals, had  choked on his own food.  All of these conditions developed while Wallace was under the control, custody, and care of a nursing home.  

Kevin Amerson, Walace's son indicted the institution:

“He couldn’t even hold his head up straight because he had gotten so weak. They stopped taking care of him. They abandoned him.”

According to the AP, as nursing homes were opening up to family visitations nursing home watchdogs were being flooded with reports of residents kept in soiled diapers so long their skin peeled off, left with bedsores that cut to the bone, and allowed to wither away in starvation or thirst.

Beyond that, AP interviews with dozens of people across the country reveal swelling numbers of less clear-cut deaths that doctors believe have been fueled not by neglect but by isolation.  The AP described a common mental state plunged residents into despair as a result of prolonged isolation.  The AP noted that many residents cause of death as reported on death certificates was simply “failure to thrive.”

A nursing home expert who analyzed data from the country’s 15,000 facilities for the APs investigation reportedly estimated that for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes. Those “excess deaths” beyond the normal rate of fatalities in nursing homes could total more than 40,000 just since between last March and November.

The industry's record was not stellar prior to the pandemic; studies have indicated that one 

These extra deaths are roughly 15% more than you’d expect at nursing homes already facing tens of thousands of deaths each month in a normal year.

“The healthcare system operates kind of on the edge, just on the margin, so that if there’s a crisis, we can’t cope,” Stephen Kaye, a professor at the Institute on Health and Aging at the University of California, San Francisco, who conducted the analysis, told the AP. “There are not enough people to look after the nursing home residents,” he admitted.

Comparing mortality rates at homes struck by COVID-19 with ones that were spared, Kaye also found that the more the virus spread through a home, the greater the number of deaths recorded for other reasons. In homes where at least 3 in 10 residents had the virus, for example, the rate of death for reasons besides the virus was double what would be expected without a pandemic.

That suggests the care of those who didn’t contract the virus  suffered, possibly  as healthcare workers were consumed attending to residents ill from COVID-19 or were left short-handed as the pandemic infected employees themselves.

Chronic understaffing at nursing homes has been one of the hallmarks of the pandemic, with a few homes even forced to evacuate because so many workers either tested positive or called in sick. In 20 states where virus cases are now surging, federal data shows nearly 1 in 4 nursing homes reported staff shortages.

The nursing home trade group American Health Care Association disputed that there has been a widespread inability of staff to care for residents and dismissed estimates of tens-of-thousands of non-COVID-19 deaths as “speculation.”

Dr. David Gifford, the group’s chief medical officer, said the pandemic created “challenges” in staffing, particularly in states like New York and New Jersey hit hard by COVID-19, but added that, if anything, staffing levels have improved because of a drop in new admissions that has lightened the patient load.

“There have been some really sad and disturbing stories that have come out,” Gifford said, “but we’ve not seen that widespread.”

Another industry group, LeadingAge, which represents not-for-profit long-term care facilities, said staffing challenges are real, and that care homes are struggling in the face of federal inaction to provide additional stimulus money to help pay for more workers.

“These incidents, stemming from the challenges being faced by too many committed and caring nursing home providers during this pandemic, are horrific and heartbreaking,” said Katie Smith Sloan, LeadingAge’s president. “I hope that these tragedies will wake up politicians and the public.”

When facilities sealed off across the country in March, advocates and inspectors were routinely kept out too, all while concerning reports trickled in, not only of serious injuries from falls or major medical declines, but of seemingly banal problems that posed serious health issues for the vulnerable.

Mairead Painter, Connecticut’s long-term care ombudsman, said with dentists shut out, ill-fitting dentures went unfixed, a factor in mounting accounts of malnutrition, and with podiatrists gone, toenails went untrimmed, posing the possibility of painful conditions in diabetes patients.

Even more widespread, as loved ones lost access to homes, was critical help with residents’ feeding, bathing, dressing and other tasks. The burden fell on aides already working tough shifts for little pay.

“I don’t think anyone really understood how much time friends and family, volunteers and other people spent in the nursing home and supplemented that hands-on care,” Painter said.

Strict rules barring in-person visitation persisted in many homes, but as families and advocates have inched back inside, they’ve frequently been stunned by what they found.

The AP shared the  story of June Linnertz, who, when she returned to her father’s room at Cherrywood Pointe in Plymouth, Minnesota, for the first time in three months, she was struck by a blast of heat and a wall thermometer that hit 85 degrees. His sheets were soaked in sweat, his hair was plastered to his head and he was covered in bruises.  Linnertz would learn these bruises came from at least a half-dozen falls. His nails had been uncut so long, they curled over his fingertips and his eyes crusted over so badly he couldn’t get them open.  

Linnertz father, 78-year-old James Gill, was found screaming, thinking he had gone blind, and Linnertz grabbed an aide in a panic. She snipped off his diaper, revealing genitals that were deep red with skin sloughing off.

Two days later, Gill died from Lewy Body Dementia, according to a copy of the death certificate provided the AP. Linnertz told the AP that she always expected her father to die of the condition, which causes progressive memory and movement loss, but she never thought he would end his days in so much needless and avoidable pain and suffering.

“What the pandemic did was uncover what was really going on in these facilities. It was bad before, but it got exponentially worse because you had the squeeze of the pandemic,” Linnertz said. “If we weren’t in a pandemic, I would have been in there... This wouldn’t have happened.”

The assisted living facility’s parent company, Ebenezer, told the AP: “We strongly deny the allegations made about the care of this resident,” adding that it follows “strict regulatory staffing levels” required by law.

Cheryl Hennen, Minnesota’s long-term care ombudsman, said dozens of complaints have poured in of bedsores, dehydration and weight loss, and other examples of neglect at various facilities, including a report of a man who choked to death while he went unsupervised during mealtime. She fears many more stories of abuse and neglect will emerge as her staff and families are able to return to homes.

“If we can’t get in there, how do we know what’s really happening?” she said. “We don’t know what we can’t see.”

The nagging guilt of unnecessary death is one Barbara Leak-Watkins understands. It was just in February that her 87-year-old father, Alex Leak, went for a check-up and got lab work that made Leak-Watkins think the Army veteran, contractor and farmer would be with her for a long time to come.

You’re going to outlive all of us,” Leak-Watkins remembered the doctor saying.

As nursing home outbreaks of COVID-19 proliferated, Leak-Watkins prayed that he be spared. The prayer was answered, but Leak was nonetheless found unresponsive on the floor at Brookdale Northwest in Greensboro, North Carolina, his eyes rolled back and his tongue sticking out.

After he arrived at the hospital, a doctor there called Leak-Watkins with word: Her father had gone so long without water his potassium levels rocketed and his kidneys were failing. He died two weeks later of lactic acidosis, according to his death certificate, a fatal buildup of acid in the body when the kidneys stop working. For a man whose military service so drilled the need for hydration into him that he always had a bottle of water at hand, his daughter had never considered he could go thirsty.

“The facility is short-staffed...underpaid and overworked,” Leak-Watkins said. If they “can’t provide you with liquids and fluids to hydrate yourself, there’s something wrong.”

The daughter is considering filing a lawsuit but a North Carolina law granting long-term care facilities broad immunity from suits claiming negligence in injuries or death during the pandemic could stymie her efforts. Similar laws and executive orders have been enacted in more than two dozen states.  Critics say the laws are a free pass for neglect.

The owner of the father’s facility, Brookdale Senior Living, said it couldn’t comment on individual cases but that “the health, happiness and wellbeing of each of our residents will always be our priority.”

Around the country, the heartache repeats, not only among families who have already buried a member, but also those who feel they are watching a slow-moving disaster.

In Hendersonville, Tennessee, Tara Thompson was able to see her mother for the first time in more than six months when she was hospitalized in October. The 79-year-old had dropped about 20 pounds, her eyes sunken and her legs looking more like forearms. Doctors at the hospital said she was malnourished and wasting muscle. There were bedsores on her backside and a gash on her forehead from a fall at the home. Her vocabulary had shrunk to nearly nothing and she’d taken to pulling the blankets over her head.

The facility Thompson’s mother lived in had been engulfed in virus outbreaks, with more than half its residents testing positive and dozens of employees infected, too. She never caught it, but shaken by the lack of care, Thompson transferred her mother to a new home.

“It has nothing to do with the virus. She’s declined because she’s had absolutely no contact with anybody who cares about her,” she said. “The only thing they have to live for are their families and, at the end of their life, you’re taking away the only thing that matters to them.”

“Failure to thrive” was among the causes listed for Maxine Schwartz, a 92-year-old former cake decorator whose family had been encouraged prior to the lockdown by how well she’d adjusted to her nursing home, Absolut Care of Aurora Park, in upstate New York. Her daughter, Dorothy Ann Carlone, would coax her to eat in the dining room each day and they’d sing songs and have brownies back in her room. Several times a week, Schwartz walked the length of the hallway for exercise.

When the lockdown began March 13, Carlone feared what would happen without her there. She pleaded to staff: “If you don’t let me in to feed her, she won’t eat, she will starve.”

On March 25, when a staffer at the home sent a photo of Schwartz, Carlone was shocked how thin she was. Carlone was told her mother hadn’t been eating, even passing up her favorite brownies.

Two days later, Carlone got an urgent call and when she arrived at the home, her mother’s skin was mottled, she was gasping for breath and her face was so drawn she was nearly unrecognizable. An hour later, she died.

Dawn Harsch, a spokeswoman for the company that owns Absolut Care, noted a state investigation found no wrongdoing and that “the natural progression of a patient like Mrs. Schwartz experiencing advanced dementia is a refusal to eat.”

Carlone is unconvinced.

“She was doing so good before they locked us out,” Carlone said. “What did she think when I wasn’t showing up? That I didn’t love her anymore? That I abandoned her? That I was dead?”

Before the lockdown, Carlone’s mother would wait by an elevator for her to arrive each day. She thinks of her mother waiting there when her visits stopped and knows the pain of the isolation must have played a role in her death.

“I think she gave up,” she said.

You should never give up.  Plan to age in place.  Learn what aging in place planning entails, develop a plan, and then implement the plan. If you won't for yourself, do it for those whom you love, who may be ravaged by the consequence of there being no plan when it is needed.    

Source: Sedenski and Condon, "Not just COVID: Nursing home neglect deaths surge in shadows," AP NEWS (November 19, 2020) (last accessed 4/15/2021).