In October 1966, three weeks of rain poured onto a mountain of discarded coal shale that rose a hundred feet over the mining town of Aberfan, Wales. At 9:15 a.m. Oct. 26, one side of the pile collapsed and sent a tidal wave of rock crashing through a school and into town, killing 28 adults and 116 children.
The cause of that carnage was not the rain. It was the fact that the unstable rock pile couldn’t handle the rain.
Maryland’s nursing home system finds itself in the midst of a similar disaster. As of last Wednesday, the state reported a total of 42,323 COVID-19 cases, of which 8,458 were related to nursing homes.
Jurisdictions in the Washington, D.C., area have been hit particularly hard, and Montgomery County nursing home residents and staff are suffering disproportionately. While 57% of Maryland’s COVID-19 deaths are related to nursing homes, that number jumps to 72% in Montgomery County. Nationally, The New York Times estimates that one-third of all deaths are nursing home residents and staff.
One facility in Rockville demonstrates just how dire the situation is.
The Collingswood Rehabilitation and Healthcare Center has reported 100 resident cases and 32 resident deaths, meaning the virus is killing a third of those who contract it. Among the staff, 36 have tested positive and one has perished on the front line of this pandemic.
Soon after the coronavirus took hold in Montgomery County, state Sen. Cheryl Kagan began receiving pleas from constituents who had loved ones at Collingswood. “They were telling me stories about staff coming to work sick, insufficient medical care and inadequate oversight,” Kagan told us. So she arranged for an unannounced inspection to assess what was happening inside Collingswood.
Last Wednesday the inspectors issued their report, and now Kagan is working to ensure that its findings are addressed immediately. “What we’re seeing during this pandemic is that nursing homes are petri dishes for the spread of this disease,” Kagan says.
Years ago Medicare created an online guide, Nursing Home Compare, designed to give families the information they need to assess a facility’s quality of care. It uses a five-star rating system, with one indicating “poor” and five indicating “much above average.” The ratings are based on three categories: health inspections, staffing, and quality measures, which are individually rated, and an overall rating is given based on those metrics.
One might guess that nursing homes with a higher overall rating would be better equipped to protect residents and staff from the spread of this virus, but the data shows no correlation between the two.
However, looking at staffing ratings alone, it becomes clear that Montgomery County nursing homes with a lower score in that category are more likely to have higher rates of infection. In other words, it appears that a nursing home’s staffing rating is more important than its overall rating.
Collingswood, for instance, holds an overall rating of five stars, but only scores a three on staffing.
Brian Lee is not surprised by this correlation. As the executive director of the national nursing home advocacy group Families for Better Care, he has been advocating for higher staffing ratios in nursing homes for years.
“Our nation’s nursing homes were ill-equipped to handle this pandemic because of underlying staffing issues,” Lee says. “Historically we’ve seen that when staffing levels are improved, there’s a corresponding increase in quality measures and a decrease in regulatory deficiencies and lawsuits.”
In its 2019 Nursing Home Report Card, Lee’s group gave Maryland a D and ranked it 33rd in the nation. That score was driven by the fact that Maryland’s direct care staffing level dropped 50% since the organization’s last report card in 2014 (in which Maryland also earned a D).
A scarcity of personal protective equipment also left Maryland’s nursing homes more vulnerable when the pandemic arrived. And failure to use the available PPE properly, consistently and universally has significantly undermined its effectiveness.
“Workers in one facility were issued rain ponchos and rain bonnets,” says Ricarra Jones, political director for Service Employees Union Local 1199, which represents nursing home support staff throughout Maryland. “At another site, management hung one gown outside each room, and staff members were supposed to put it on before entering and hang back up when they left.”
At many nursing homes, the union’s members are still struggling with PPE. “They’ll be in a resident’s room delivering a meal, standing right next to a nurse with full PPE, while they work unprotected in some cases,” Jones says. This practice, Jones notes, increases the risk of spread among the residents, the staff and their family members.
Every day, Jones and her fellow SEIU 1199 representatives get on a conference call to check in with members who work in nursing homes. She can’t put into words the fear, uncertainty and loss that her members are experiencing day after day. She hopes the general public will begin to comprehend the degree of suffering that is likely occurring inside the nursing home right down the street.
“People see what’s happening in the news,” Jones says. “But they don’t see the faces, they don’t know the stories. They just see numbers and don’t understand that it’s people.”
— LEAH HAWORTH AND BRIAN H. KILDEE
The writers are, respectively, a research nurse consultant in Massanutten, Virginia, and a communications consultant in Silver Spring.
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