Did patient movement boost virus?
Critics: Transfers from hospitals to nursing homes increase risk
Tony Vershousky was feeling unusually lethargic after a routine dialysis treatment in March, leading to a short stay at Easton Hospital.
He was admitted March 12, six days after Pennsylvania recorded its first coronavirus case. After a short hospital stay, Vershousky, of Palmer Township, was discharged for rehabilitation at a nearby nursing home.
His wife, Joanne, had expected him home in about a month, but that turned into three months after Tony Vershousky contracted the coronavirus in April, with a positive test result April 20, she said. All the while, she was unable to see him because the home was shut to visitors.
Exactly how or where Vershousky, 81, contracted the virus remains unclear. But his situation highlights an issue that could partially explain how the coronavirus spread through Pennsylvania nursing homes, where deaths due to the virus account for nearly 70% of the state’s total.
Even as nursing homes closed their doors to visitors, they kept them open to hospital discharges, including those needing short-term stays like Vershousky. Under state and federal guidelines on admissions, nursing homes accepted new residents and those returning to homes after being hospitalized with COVID-19.
Critics charge that the practice put other residents and staff at risk. As of last week, more than 17,000 long-term care residents and more than 3,000 staff members have been infected by the virus, which has killed more than 4,500 residents in those facilities.
Chief among those critics is U.S. Rep. Steve Scalise, R-Louisiana, a ranking member of a subcommittee investigating why the coronavirus has been so deadly in nursing homes. He recently sent letters to Democratic governors, including Pennsylvania’s Tom Wolf, demanding they justify nursing home admission policies that he believes contributed to the
spread of the illness.
“The decision of several governors to essentially mandate COVID-positive patients go back to their nursing homes ended up being a death sentence,” Scalise has said.
Pennsylvania’s admission policy is in line with what the Centers for Disease Control and Prevention and Center for Medicare Services recommend, said Nade Wardle, a Health Department spokesperson.
The policy, as spelled out by the Pennsylvania Health Care Association, has stated: “Nursing care facilities must continue to accept new admissions and receive readmissions for current residents who have been discharged from the hospital who are stable to alleviate the increasing burden in the acute care settings. This may include stable patients who have had the COVID-19 virus.”
‘This was best for patients’
The pandemic was expected to burden acute care settings and did so in some parts of New York. Critics question whether hospitals sent nursing home residents with COVID-19 back to their facilities too quickly as a caution against an anticipated problem that never materialized locally. Lehigh Valley and most Pennsylvania hospitals were not overrun with coronavirus cases.
Wardle said the readmission policy typically has applied to nursing home residents who contracted COVID-19, were sent to the hospital for treatment, then were returned to the nursing home where they contracted the virus in the first place. He said those transfers would depend on a facility’s ability to care for the person while protecting others. He pointed to Health Department guidance that nursing homes test all residents discharged from hospitals to long-term care facilities, even if they weren’t hospitalized for COVID-19. Those who test positive would be isolated, he said.
“Facilities were instructed they should only receive patients if they could properly isolate and care for them,” he said. “In addition, most of the people who were in the hospital with COVID-19 and returning to a long-term care facility were returning to their homes, where they had contracted COVID-19 in the first place.”
In a June 21 op-ed in The Morning Call, state Health Secretary Dr. Rachel Levine said people discharged from nursing homes to hospitals mostly did not introduce the virus to nursing facilities upon readmission. The virus was already in the facilities, as that tended to be where residents contracted it, she said.
Recovered patients were returned to their nursing homes because “this was the best for these patients, as studies show people get better when they are home,” she wrote.
Following state and federal guidelines, New Eastwood Rehabilitation & Healthcare Center, where Tony Vershousky was staying, continued to take in residents who transferred from hospitals, said Lauren Everett, its administrator, declining to get into specifics regarding Vershousky’s situation due to privacy laws. In accordance with those guidelines, infected patients were isolated, she said.
“Even in the midst of this global pandemic, hospitals must discharge patients to nursing homes,” Everett said. “The American Health Care Association encourages facilities like ours to make rooms available and admit these patients.”
Discharge planning is a crucial part of COVID-19 treatment, said Rachel Moore, a spokesperson with the Hospital and Healthsystem Association of Pennsylvania, which represents about 250 hospitals and other stakeholders. Individual patient needs vary, she said, depending on the level of care and where they are being discharged to.
Not every patient who tests positive for COVID-19 needs hospital-level care throughout their illness, Moore said. For many, a long-term care facility with appropriate safety precautions, including personal protective equipment and staffing, is the clinically appropriate place for a patient to recover.
“State agencies, hospitals and longterm care facilities are making extensive efforts to meet the needs of their patients in a COVID-19 world,” Moore said.
Irresponsible or not?
But relatives of nursing home residents have expressed fear that their loved ones may be exposed to newly released hospital patients who bring the coronavirus with them.
Brad Konstas, of Mahoning Valley, realized that fear when the Lehighton nursing home where his mother lives admitted a person who tested positive for the virus. Until that point, the facility had no COVID-19 cases, he said.
The situation didn’t sit well with Konstas.
“Common sense says when you have a facility that’s COVID-free and how hard the nurses and the staff have worked, and then you reward them by admitting this person,” he said. “That just seemed irresponsible to me.”
The issue for nursing homes hasn’t been with readmissions but with infection controls, said Rachel M. Werner, a University of Pennsylvania professor of medicine and executive director of the Leonard Davis Institute of Health Economics.
It’s been hard for them to get adequate personal protective equipment for staff and to isolate residents with the virus, she said, key measures in stemming the spread.
According to an analysis by the U.S. Government Accountability Office of more than 16,000 inspections, more than 4 in 5 nursing homes were cited for infection control problems from 2013-17.
Infection control issues also turned up in a review by Toby Edelman, an attorney and consultant for the Center for Medicare Advocacy, of 171 deficiency surveys from facilities nationwide. The surveys were conducted amid the coronavirus pandemic, from late March to late April, and they turned up such issues as staff members failing to wash hands, change gloves, disinfect equipment used with multiple residents, and keep track of who’s infected.
Industry experts, advocates and workers point to infection control and other longstanding problems that made nursing homes vulnerable to the virus, including staff shortages, lack of PPE and other resources, and lax enforcement by regulatory agencies.
Those problems have been widespread for decades, according to experts and others.
“Nursing home residents have died from the coronavirus in states governed by Republicans and Democrats, in big cities and in small towns, in rural and urban communities,” said U.S. Rep. James Clyburn, D-South Carolina, a member of the coronavirus subcommittee Scalise is on.
Last weekend, the Pennsylvania Health Department issued a three-step process to reopening nursing homes to visitors. The main measures involve regular testing of staff and residents, infection controls that keep the virus from flaring, and screening protocols for those eventual visitors. Facilities must be coronavirus-free for 14 days before they can lift restrictions, and a fresh case would put a facility again in lockdown — with the reopening process starting over.
The nursing home industry has accepted that the coronavirus will be a challenge for many more months. And families have come to realize that their worries won’t go away until an effective vaccine is developed.
For Vershousky, what started with a routine dialysis treatment in March has yet to end. After New Eastwood, he went back to Easton Hospital and after three months — including six weeks in isolation — was sent home to Palmer Township on June 25, still weak from the coronavirus.
The next day, he was admitted to St. Luke’s Hospital-Anderson Campus in Bethlehem Township.
He survived the virus, but is struggling on the road to recovery, with Joanne Vershousky saying recently that doctors were checking him for numerous things.