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Government actions, guidance fail to keep pace with health crisis in nursing homes

Operators struggle to fend off virus, unintended consequences of state moves

Members of the Massachusetts National Guard removed their hazmat suits after leaving Alliance Health at Marina Bay in Quincy this month. The National Guard was deployed to assist nursing homes with COVID-19 testing.
Members of the Massachusetts National Guard removed their hazmat suits after leaving Alliance Health at Marina Bay in Quincy this month. The National Guard was deployed to assist nursing homes with COVID-19 testing.Stan Grossfeld/ Globe Staff

Earlier this month, Governor Charlie Baker activated a dozen National Guard teams to test for COVID-19 at hard-hit nursing homes across Massachusetts in an effort to help them contain the deadly outbreak.

Yet soon after the Guard completed its testing, managers of the homes noticed a disturbing trend: Large numbers of front-line employees stopped coming to work, leaving their beleaguered facilities severely understaffed.

“The National Guard has been wonderful, but when staff sees them come in their hazmat suits, that puts the fear of the virus in everyone,” said Zo Long, regional division vice president for Life Care Centers of America, which has lost 75 employees at its Nashoba Valley nursing home alone because they are either ill or worried about getting the virus. “You have people quitting on the spot or calling in sick.”

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The unintended consequences of the Baker administration’s mobile testing program were just one more blow to embattled nursing home operators, who say the state and federal response has failed to keep pace with the crisis. Public health guidance, they say, has been well-meaning but constantly changing — often coming late, not matching the scope of the problem, or not working as intended.

Frank Romano, chief executive of Essex Group, which owns eight nursing and assisted living homes in the state, likened it to his experience in war, when orders that came from the distant high command made no sense to those in the field.

“I tell everyone, this is like when I was in Vietnam,” Romano said. “Some of the directives were absolutely ridiculous. You have to let the people in the field make the best decisions because they are dealing with it. Not a bunch of bureaucrats who mean well and think they are doing the right thing.”

Romano and his peers have been scrambling to access desperately needed testing, staff, and equipment to fight the pandemic, which has killed 810 residents of long-term care facilities in Massachusetts — accounting for 52 percent of the state’s coronavirus deaths.

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In interviews last week, nursing home operators — some speaking openly and others on condition of anonymity to avoid offending families of residents and public officials — described the pandemic as the most devastating crisis of their careers, as they seek to comfort distraught residents and families while bucking up nervous staffers.

Families and public officials have blamed nursing home operators for lax infection control, poor communications, and initially failing to require staff to wear masks and other protective gear. But many operators say they’ve done their best, and public officials have failed to provide meaningful help.

“What we hear from the state officials sounds great, but it’s hard to bring it down to where we’re operating," said Rich Bane, president of Braintree-based BaneCare Management, which runs a dozen nursing homes in the state.

Last week, for instance, the state announced a new digital long-term care portal to help short-staffed facilities recruit registered nurses, licensed practical nurses, and other workers to care for patients through the ongoing crisis.

But some operators advertising for jobs on the site said it proved useless in helping them identify candidates to fill the 40 percent of nursing home jobs that are now vacant. “We put in dozens of jobs, and got zero inquiries,” said Bane.

For weeks, nursing home operators contended that state guidance on testing, which followed federal guidelines set by the US Centers for Disease Control and Prevention, was too little, too late; they struggled to get patients tested so they could contain the virus’s spread. Even when the Baker administration last week finally promised a one-time “baseline” testing for all residents and workers, critics insisted only repeated testing will identify who has been infected.

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On a recent phone call with nursing home operators, state officials lauded the National Guard testing program. But some operators on the call told them it took two days to get National Guard technicians in their buildings and another two days to get results. In a life-or-death situation, that was time they didn’t have.

Health officials “seemed to be unaware that the whole system had broken down,” said Dr. Larissa Lucas, of the North Shore Physicians Group, who serves as medical director for nursing homes in Peabody, Lynn, and Marblehead.

Even steps sought by operators have gone awry. Some told state officials last week that a move intended to help nursing homes fill jobs by lifting a cap on wages for temporary employees prompted temp agencies to try to lure away the homes’ already depleted full-time staffers with higher pay. Earlier, some homes abandoned a state-orchestrated plan to relocate residents and turn their facilities into recovery centers for hospital patients after infections cropped up at the sites before the moves.

In an interview, Marylou Sudders, the Massachusetts health and human services secretary, defended the state’s actions and guidance. But she said health officials in Massachusetts and elsewhere are adapting constantly as they learn more about how the virus is spreading and who it’s impacting.

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“It’s an extraordinarily stressful time for the long-term care industry,” Sudders said. “We’re trying to do everything possible, as the pandemic evolves, to be responsive." The administration’s message to the nursing homes is, she said, “We’re working for you, and we’re in this with you.”

Sudders acknowledged some state moves, such as a recommendation that nursing homes adopt a no-visits policy, came after federal regulators had already acted. But she said the state has expanded its mobile testing capabilities, through the National Guard, private labs, and emergency services, and is now getting faster results. Many operators “appreciated the National Guard coming in,“ Sudders said, but the state is also sending couriers with test kits to other sites.

She said the state has taken a number of steps to help nursing homes find workers during the crisis, boosting MassHealth reimbursements to increase the pay of front-line staffers, and offering hiring bonuses to recruits who work a certain number of hours. While some operators are still struggling to find workers, Sudders said the new jobs portal has already referred hundreds of job candidates to nursing facilities. She said the state is also using an emergency call-up system, MA Responds, to direct volunteers, including doctors and nurses, to long-term care facilities.

But it’s not just the state public health officials who’ve failed them, operators say: It’s the federal government. They wonder how much of the virus’s spread could be traced to an early recommendation from the CDC that allowed nursing home employees who were exposed to the virus but did not exhibit symptoms to continue to work as long as they wore masks.

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Romano,, the Essex Group chief executive, said he ignored another CDC recommendation to keep sick and healthy roommates together, rather than separating them, saying it “was just not making common sense.” He estimated that among his eight facilities, there are 25 positive cases and about two deaths.

A CDC spokeswoman pointed to recently changed agency guidance on nursing homes. The CDC now recommends that a resident with known or suspected COVID-19 be isolated in their own room with their own bathroom, or in a special COVID-19 unit, and cared for by dedicated staff. If the person had a roommate, that person should not be given another roommate for 14 days.

The lack of universal rapid testing has aggravated two daunting challenges nursing homes face — staff and supply shortages — further diminishing their ability to fight the novel coronavirus.

Widespread testing was initially unavailable at nursing homes, whose residents are most at risk of contracting and dying from COVID-19. They were also hobbled by an inability to get results quickly enough to isolate sick residents in a timely way and contain the disease.

Mirroring federal recommendations, guidance from the state Department of Public Health initially called for testing only residents and staff with specific COVID-19 symptoms, such as a cough or fever. But that excluded many who may have been infected but were asymptomatic and potential spreaders of the disease.

Some operators said they began pressing their outside labs to test more residents, even when state guidance still called for limited testing. “We did respectfully depart from the guidance we were given at the moment,” said Adam Berman, president of Chelsea Jewish Lifecare, which runs three nursing homes and three assisted living facilities in the Boston area.

Despite such measures, coronavirus outbreaks have brought infections and deaths to Chelsea Jewish facilities and nearly 250 other nursing homes across the state in recent weeks.

As operators clamored for more testing, state health officials expanded the criteria to a wider range of symptoms. Belatedly, they enlisted more technicians and labs, enabling some nursing homes to begin testing everyone, even those who didn’t show symptoms. Under a new program, some nursing homes will begin testing repeatedly at pilot sites this week. But the new “surveillance” testing may be too late and too limited in scope to rein in the fast-moving virus in many facilities.

The slow rollout of testing has also aggravated staffing shortages; anxious workers couldn’t be sure who had the virus, which fed their anxiety and led to waves of departures.

Early testing lapses also worsened shortages of personal protective equipment, the masks, gowns, and gloves caregivers are required to wear in the rooms of patients with confirmed or presumed cases of the virus. Because only some patients could be tested at first, and it could take five to 10 days to get results, all coughing residents were listed as “precautionary,” meaning staff would have to change their protective gear before entering and after leaving their rooms.

“Once you have it, you just burn through PPE," said Tom Lavallee, chief operating officer of Alliance Health & Human Services in Southborough, which runs eight skilled nursing facilities and a rest home in Massachusetts. “If people have symptoms of any kind, you treat them as though they have the virus and put them on precaution while you wait for the tests.”

If the homes had been able to test all residents, not just those who were symptomatic, they could have isolated COVID-positive residents in dedicated units, allowing them to conserve protective equipment, operators said.

When their usual suppliers were unable to fill mounting orders for protective gear, nursing home operators began scrambling to obtain equipment wherever they could find it. Some in Massachusetts joined a consortium called the COVID-19 Policy Alliance, started by a pair of MIT professors, that helped them place bulk orders of equipment from China.

At senior housing sites that have so far kept the virus out, operators continue a daily struggle to protect their residents amid state and federal directives that change constantly, with little time to work through the complexities.

“You can have something that sounds like it makes perfect sense on paper," said Bill Bogdanovich, chief executive of Broad Reach Healthcare, which runs a nursing home and assisted living facility in Chatham. “But at the front lines there are people who have to carry it out and there are people who it impacts, and it’s not as simple as changing a light from red to green.”

Some might call this flying blind. Bogdanovich said it’s worse than that.

“With the different directions from which the guidance is coming, it’s almost [flying] with a cloud swirling around that you can’t even make a decision about which one to go with,” he said.



Robert Weisman can be reached at robert.weisman@globe.com. Follow him on Twitter @GlobeRobW. Laura Krantz can be reached at laura.krantz@globe.com. Follow her on Twitter @laurakrantz.