Each passing day brings news of another outbreak of COVID-19 at a nursing home or assisted living facility in Massachusetts. On April 4, The Boston Globe reported that state health officials had found outbreaks in at least 94 senior facilities; by April 20 there were 214 such facilities with multiple cases of infection. As of this writing, 1,059 residents of long-term care facilities in Massachusetts have died from the virus, a shocking 54 percent of the 1,961 total deaths statewide.
These figures will continue to rise, because although the virus can affect anyone, the residents of long-term care facilities are particularly susceptible to COVID-19, given dynamics such as age, underlying illnesses, and their proximity to one another (including shared rooms and bathrooms) and to their caregivers. But these commonly accepted factors are not the only reason COVID-19 is proliferating in our nursing homes: The poverty wages paid to caregivers and the understaffing of our long-term care facilities are also to blame.
The national median wage of Certified Nursing Assistants, who make up the bulk of the nursing home workforce, is $14.25 per hour — or $29,640 per year with a 40-hour work week. Although wages are somewhat higher locally, they are nowhere close to a living wage. Many who work in these facilities hold multiple jobs — in another nursing home or home care agency, for example — in order to pay rent and put food on the table. Given how COVID-19 is transmitted by asymptomatic individuals, when an outbreak begins in one facility, it is unlikely to be contained there for very long.
In an outbreak across several nursing homes in Washington state beginning in February, investigators from the Centers for Disease Control and Prevention found that in part “staff members working in multiple facilities contributed to intra- and interfacility spread.” If we ever get a full accounting, the same will surely prove to be true here in Massachusetts and across the country.
Many nursing homes were already woefully understaffed before COVID-19, despite efforts to appear properly staffed to government regulators and accreditation commissions. A report in 2019 compared the staffing data nursing homes reported to the Centers for Medicare and Medicaid Services (CMS) to facilities’ actual payroll records, and found that a majority of those studied “met the expected staffing level less than 20% of the time,” and that staffing levels “increased before and during the times of the annual [CMS] surveys and dropped off after.” As the growing footprint of private equity firms and publicly traded corporations (and their tangled networks of related entities) in the long-term care field shows, there is a lot of money to be made by understaffing nursing homes and underpaying workers.
From a care-delivery perspective, the low wages that prevail in the industry create staff recruitment and retention challenges, and high turnover and short staffing undermine infection control training and practice. Even before COVID-19, an analysis from Kaiser Health News found infection control deficiencies in 63 percent of US nursing homes, with higher violation rates “at homes with fewer nurses and aides than at facilities with higher staffing levels.” In Massachusetts, the Globe revealed that prior to the outbreak, almost “two-thirds of nursing homes … were cited at least once within the past three years for a deficiency in infection control.”
Before the current crisis, nursing home work was already harried and backbreaking. Now, when the virus arrives in a home and begins to sicken residents and sideline staff, conditions can rapidly deteriorate, as in the case of one facility where, according to the Globe, “staff said residents have been left naked in bed or on sheets soiled with urine and feces; workers without appropriate training have been asked to bathe patients.” These levels of human tragedy and suffering, not to mention death, may become more common as the pandemic continues, but we should never grow accustomed to the idea that they are inevitable or acceptable.
Nursing home residents, their families, and their caregivers are justifiably scared, frustrated, and outraged. Like grocery store workers, public transit employees, delivery drivers, and so many others, health care workers are risking themselves and their own families in order to care for us, often lacking the proper protective equipment or adequate resources or staffing to get the job done correctly and safely. Immediate steps must be taken now to fix these issues — along with providing hazard pay to those who are in the trenches saving and supporting others in the battle against the virus.
Long term, to best prepare for the wave of baby boomers who will need care over the next few decades, we must also change the conditions that allowed COVID-19 to spread so quickly through our long-term care facilities in the first place. High on the list needs to be a restructuring of a care delivery model built on low wages and short staffing which, by compelling caregivers to work multiple jobs just to survive, has intensified the COVID-19 outbreaks across our nursing homes.
Ultimately, a worldview that puts profits before patients and that devalues our caregivers — often women, people of color, and immigrants — might prove to be the biggest hazard of all.