Covid-19: Resident Safety in Nursing Homes

Additional Recommendations 6

These recommendations are not explicitly linked to specific findings.

• R4
  – When requested by the facility, Solano County Division of Public Health establish and continue to provide more stringent screening protocols of all staff .
• R30-39
  years 2x higher 4x higher
• R40-49
  years 3x higher 10x higher
• R50-64
  years 4x higher 30x higher
• R65-74
  years 5x higher 90x higher
• R75-84
  years 8x higher 220x higher Source of information: CDC Website Nine licensed nursing homes are located in Solano County. These skilled nursing facilities (SNF) provide ongoing and extended nursing care to its residents. The residents of these homes are typically elderly and vulnerable to infectious diseases due to underlying chronic medical conditions. The high number of deaths in the Windsor Vallejo Care Center sounded the alarm that the elderly in nursing care facilities were at higher risk than the rest of the county’s population. Solano County Division of Public Health administrators expressed their surprise that the mortality rate wasn’t significantly higher. They specifically cited the lack of infection control procedures, lack of training, staff turnover and lack of use or lack of proper use of PPE as contributing factors to the outbreak. In the fall of 2020, Parkrose Gardens of Fairfield and Magnolia Court in Vacaville experienced a rise in deaths due to COVID-19. Although they are congregate living facilities, not skilled nursing home facilities, the deaths do point to the fragility of our older populations living in group settings. The primary concern was determining how COVID-19 was introduced into the facilities. Early on, little was known about the transmission of the disease so protocols such as social distancing and use of PPE were not in place. Once case investigation and contact tracing was implemented, it was determined that the staff was introducing COVID-19 into the nursing homes. Prior to Covid-19, staff members were not required to use PPE on a regular basis. As a result, staff may not have been trained on proper use or may have been complacent since PPE protocols were not part of their regular routine. The COVID-19 pandemic created an environment where PPE use is required at all times to mitigate the spread of disease. Inexperience in the use of PPE and lack of training in proper usage were significant issues. Consequently, on May 11, 2020, the California Department of Public Health (CDPH) began requiring skilled nursing homes to implement strong infection prevention and control programs to protect the residents and healthcare personnel. One of the primary challenges for nursing homes has been adequate staffing for patient care. CDPH requires 3.5 direct nursing care service hours each day for each patient in SNFs. Several issues came to light as Solano County nursing homes tried to implement the health safety guidelines set forth by the California Department of Public Health. The unexpected COVID regulations overwhelmed some of the care centers as they strived to provide personnel with the necessary PPE. Once they obtained the proper equipment, it became apparent that many of the staff did not know how to use the PPE appropriately. High turnover rates did not allow time for proper training and evaluating skill sets of employees. Staff in skilled care facilities are underpaid so retaining trained employees has been difficult and has led to a shortage of experienced personnel. As of January 1, 2021, Assembly Bill (AB) 2644 requires all SNFs to: • have a plan in place for infection prevention quality control • ensure all healthcare professionals (HCPs) receive infection prevention and control training on an annual basis • have a full-time Infection Preventionist (IP) on staff to make recommendations and implement policies within the facility for infection control CDPH will maintain oversight powers of the implementation of the Bill. Lockdowns in SNFs pose a risk to the residents. According to the Centers for Disease Control and Prevention, social isolation and loneliness significantly increase the risk of premature death. According to the American Association of Retired Persons (AARP), “there has been a thirty-two percent increase in the risk of stroke, and a nearly fourfold increased risk of death among heart failure patients” due to social isolation. This risk is on par with smoking, obesity, and physical inactivity. Social isolation is also associated with a 50 percent increased risk of dementia. Depression plays a large part in the mental well-being of these patients. Residents are losing whole support systems including their friends with whom they sit in the dining hall or see in activities. There are limited entertainment opportunities since such activities would not allow social distancing nor would it allow outsiders into the facilities. In addition, families have not been allowed to visit. It is not unusual to see news stories relating incidences in which families were not able to be at the bedside of their loved ones as they pass away because of the mandated lockdown precautions. The CDPH licenses all skilled nursing facilities in the state of California. It provides regulatory oversight of “licensed health care facilities and health care professionals” to ensure patient safety and quality care. During the COVID-19 pandemic, CDPH has provided guidelines for isolating infected patients, isolating new patients and establishing quarantine protocols for improving patients. The Solano County Division of Public Health serves the community by promoting health. In addition to providing other health-related services, it monitors hazardous health issues and prepares for public health emergencies. Although the Solano County Division of Public Health works with and assists SNFs whenever a communicable disease outbreak occurs, they have no direct jurisdiction over nursing home operations. However, they do have the authority to close facilities to new admissions when disease is suspected. They can also limit admissions if the facility is not in compliance with CDPH guidelines. Solano County Division of Public Health monitors COVID-19 protocols in nursing homes and rehabilitation centers. The County can also provide stricter guidelines than the State if local conditions require which it did at the onset of the pandemic. CDPH guidelines have become stricter and are now in line with Solano County guidelines. There are many unlicensed elder care residences in Solano County. Neither California Department of Public Health nor Solano County Division of Public Health (SCDPH) have oversight of these congregate living sites. The SCDPH can, however, offer assistance if an unlicensed nursing home contacts them. It also has the authority to step in if there is a positive COVID-19 case found. Approximately two dozen unlicensed facilities have sought assistance through the SCDPH directly. The SCDPH holds regularly scheduled virtual meetings with licensed healthcare facilities to provide updated healthcare information. Participation is open to all county facilities including those that are unlicensed. When COVID-19 outbreaks are identified in a congregate setting, including licensed nursing homes, the SCDPH offers testing to residents and staff members. This testing will be ongoing until no new cases are identified over a fourteen-day period. In March of 2020, the Governor declared a state of emergency in California and issued a stay-at- home order. The order precluded any direct contact with the residents of these facilities. CDPH and county health officials were allowed to enter the facilities for testing purposes. The role of the Ombudsman’s Office is to address complaints from residents and the families of residents within licensed long-term care facilities, including skilled nursing homes. During the lockdown, the Ombudsman staff members were prohibited from visiting facilities due to an order from the Centers for Medicare and Medicaid Services. If there were complaints, the office would arrange for virtual visits to address the concerns received. In California complaints for April, May and June dropped 60% compared to January, February and March due to the lack of in- person contact with the Ombudsman representatives. Although the Ombudsman do not serve as inspectors, the Division of Public Health Services informed the Grand Jury that it had the authority to deputize the Ombudsman staff so they would be authorized to enter the SNFs during the pandemic. V. FINDINGS AND RECOMMENDATIONS FINDING 1 – Isolation brought about by COVID-19 lockdowns caused unexpected mental and physical health issues. RECOMMENDATION 1 – In full compliance with CDC protocols, Solano County Division of Public Health be available to assist facilities in putting stringent screening protocols in place to protect residents once visitors are allowed to enter the facilities. FINDING 2 – Registered Nurses, Licensed Vocational Nurses, Certified Nursing Assistants, and other healthcare employees need more training in infection control techniques including personal protection equipment use. RECOMMENDATION 2a – If requested by the facilities, Solano County Division of Public Health provide support for improved staff training as well as on-going mentoring. RECOMMENDATION 2b – If authorized by the State, Solano County Division of Public Health support the state’s efforts to establish a system for monitoring the implementation of California State Assembly Bill 2644. FINDING 3 – Staff members have not been properly trained in implementing proper infectious disease protocols. RECOMMENDATION 3 – Upon request, Health and Social Services work with skilled nursing facilities to ensure that new and existing staff undergo continual training in federal and state prescribed infectious disease safety protocols. FINDINGS 4 – Evidence provided by health professionals indicates staff brought COVID-19 into facilities. RECOMMENDATION 4 – When requested by the facility, Solano County Division of Public Health establish and continue to provide more stringent screening protocols of all staff . FINDING 5 – Ombudsman staff did not visit the Skilled Nursing Facilities in Solano County from March 16, 2020 through August 31, 2020. RECOMMENDATION 5 – The Administration of the Division of Public Health has indicated that the Ombudsman staff can request and receive a waiver during lockdowns to safely enter SNFs. In light of this, Ombudsman staff request a waiver and continue to visit Skilled Nursing Facilities. COMMENTS It is concerning that during a pandemic such as the one we are currently continuing to experience, local county agencies have such limited authority in keeping the vulnerable residents in nursing home facilities safe. It would be advantageous for the county, state and cities to work together to apply the laws and regulations that have been put in place to protect this population. REQUIRED RESPONSES Solano County Division of Public Health Administration Health and Social Service Administration Ombudsman Administration