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This is the second of two stories about COVID-19 deaths of West Virginia nursing home residents. Read the first story here.
When West Virginia’s first nursing home residents tested positive for COVID-19 in March at Sundale Nursing Home in Morgantown, the facility became the site of the first designated coronavirus outbreak in the state.
Although five residents died at Sundale, leadership at the home was able to control the spread and prevent the death toll from getting worse.
But across the state, the count has continued to rise.
As of Sept. 22, at least 140 of West Virginia’s 317 reported COVID-19 deaths were nursing home residents who contracted coronavirus at the facilities where they lived. The majority of West Virginia’s nursing home outbreaks have taken place since the state began its reopening.
By early May, Eldercare Nursing and Rehabilitation in Jackson County had lost 15 residents to the virus. Princeton Health Care Center in Mercer County had 24 residents die after contracting the virus in August. That’s the deadliest known single site COVID-19 outbreak in West Virginia to date.
Many factors make nursing homes particularly susceptible to the spread of coronavirus, including low staffing levels, communal living, and residents with weakened immune systems, experts say. Despite early warning signs of trouble ahead, state and federal officials still largely failed to take proactive steps to keep some of the most vulnerable West Virginians safe.
Nursing homes in West Virginia were also easy marks for the coronavirus pandemic, in part, because of a long-broken safety system for the nation’s long-term care homes.
“The virus is new, but the systemic challenges nursing homes face are not,” said Dr. Rachel Werner, a professor of health care management at the University of Pennsylvania. “Should we have seen this coming? Yes, absolutely.”
State officials did not respond to multiple interview requests on the topic, but Department of Health and Human Resources spokeswoman Allison Adler responded to a list of written questions and said that the state has followed guidance provided by CMS and CDC to protect nursing home residents.
Too Little, Too Late
When Gov. Jim Justice mandated testing of all state nursing home residents and staff on April 17, West Virginia became the first state in the country to make such a move. Officials touted it as an unparalleled action to protect West Virginia’s most susceptible residents.
But that action followed weeks of inaction and, most importantly, a general absence of virus testing across the state.
Geography and culture gave West Virginia some protections from communicable spread. The population is less dense and spends less time in close contact on public transportation than those in major metropolitan areas.
Still, nursing homes had been identified as vulnerable spots from the beginning.
West Virginia nursing homes have a history of being cited by federal regulators for substandard practices that fail to prevent the spread of infections.
DHHR said in its written response that infection citations are the most frequent citation issued nationally.
But West Virginia’s nursing homes have been cited at one of the highest rates in the country. 89% of West Virginia’s nursing homes have been cited for at least one infection-related deficiency in the last three years. Only four other states in the country fared worse during that period.
Eldercare Health and Rehabilitation in Jackson County, where the 15 residents died, was cited on two separate occasions for failing to “establish and maintain an infection control policy” to prevent the spread of disease. The most recent citation was for the failure to report an unidentified respiratory outbreak to the local health department in August 2019.
Neither Eldercare nor its owner, Vanguard Healthcare Services, responded to multiple interview requests.
In mid-April, Justice said the state would respond aggressively to any positive tests at nursing homes. “We have told our people point blank … to run to the fire and test everybody there,” the governor said.
But it wasn’t until the outbreak at Eldercare that Justice mandated testing at all homes. For nursing homes where residents had already been exposed to the virus, the governor’s order came too late.
The problems faced by West Virginia’s nursing homes didn’t end in April. Outbreaks have continued in facilities throughout the state. And the death count has kept rising.
DHHR said that during the pandemic, citations have been reviewed for facilities with outbreaks, and “…past citations for infection control were not always a factor or correlation for facilities with COVID-19 outbreaks, including large outbreaks.”
But in mid-August, DHHR had reported 30 nursing homes in the state with at least one positive case of COVID-19. All 30 of those homes had been cited for at least one infection-related deficiency during the last three years.
The governor was also late to take other actions that could have helped slow the pandemic.
As early as April, experts advised that wearing masks could drastically reduce the spread of the virus. But Justice waited until July 6, after COVID-19 cases were rapidly rising in West Virginia to announce a statewide indoor face-covering requirement. He left businesses responsible for enforcing his mandate.
Additionally, many positive COVID-19 cases across the state have been linked to West Virginians traveling to and then returning from Myrtle Beach with the virus. Although Justice originally ordered a 14-day quarantine for West Virginians returning from out-of-state travel, the governor lifted that order in May.
DHHR said that all but one of West Virginia’s nursing home outbreaks with a known source of origin “were spread by staff contracting COVID-19 while traveling out of state or attending a community event.”
State officials have since said that the outbreak at Princeton Health Care Center in Mercer County, the site of the deadliest coronavirus outbreak in West Virginia, likely began when somebody carried the virus into the nursing home after returning from Myrtle Beach. That’s two months after initial outbreaks in the state were linked to travel to and from that destination.
Despite a spike in cases and deaths over the summer, the governor has not reinstated the quarantine order for travel back to West Virginia from coronavirus hotspots.
The System Regulating Nursing Homes is Flawed
Past inspection reports could have served as warning signs for some of West Virginia’s nursing homes. But that system of inspections, built around checking for compliance with federal guidelines, is itself flawed, experts say.
When a new nursing home opens in West Virginia, state inspectors conduct a preliminary inspection of the home before issuing a license. Then, health inspections are conducted once every nine to 15 months.
The inspections, which are supposed to be unannounced, are meant to verify that nursing homes meet federal standards.
Inspectors look for anything from abuse and neglect to unsanitary food preparation or laundry delivery practices. If an inspector sees a violation, like a nurse reaching into a pill bottle with dirty gloves or a patient falling because they were left unattended, they issue a citation. If the violation is severe enough, the home might be required to pay a fine.
In response to the citation, the home submits a written report called a plan of correction, explaining how they will fix the problem. That’s typically where the process ends.
Dr. Morgan Katz, a nursing home and infectious disease expert at Johns Hopkins University, said the system used to regulate nursing homes in the United States is flawed. Katz said the system should focus more on helping facilities fix problems, not just identify them.
“When you go in and do a survey, don’t just cite the facility for using their gowns wrong or not washing their hands and then write them a letter seven days later and tell them that was wrong,” said Katz.
Katz and other experts cite a variety of other problems that the system doesn’t adequately address, including high staff turnover, poor pay and a shortage of training.
Lack of preparation hurt us
For years, experts have known that nursing homes would be difficult places to protect during a pandemic.
“With millions of elderly, infirmed, and other at-risk individuals living in thousands of nursing and residential care facilities across the nation, ensuring their well-being during a pandemic will be a challenge,” concluded a 2007 report put together for the White House by government officials and business executives, and recently unearthed by ProPublica.
But a lack of leadership at the federal level left health care providers ill-prepared for the COVID-19 pandemic, said Werner, the health care management professor at the University of Pennsylvania. Most homes didn’t have the personal protection equipment necessary for infection control, or access to testing. When people were tested, delays in the turnaround of test results often undermined the purpose of the test, Werner said.
In fact, much of the defense by state officials for their actions is built on the idea that they were just following federal standards. And failures of the system meant to protect nursing home residents were not unique to West Virginia.
“States are the ones that regulate nursing homes for historical reasons, so I don’t want to give them a pass, but I think they were put in a hard position because of the absence of clear federal guidance,” Werner said.
Werner also said that initial assumptions about how COVID-19 was transmitted led to an ineffective approach to infection prevention. That was largely due to the false assumption that people who showed no symptoms couldn’t spread the virus.
“There was a lot of emphasis on keeping the virus out and less acknowledgement that it was going to get in and we needed to prevent it from spreading once inside the homes,” said Werner.
Dr. Carl Shrader, medical director of Sundale Nursing Home in Morgantown, said that widespread testing enabled his staff to respond adequately to the outbreak. Although five Sundale residents died after contracting the virus, Shrader said things could have been much worse had the home not quickly secured testing for all residents and staff.
Shrader said that through mass-testing, he learned that 55% of residents and staff tested who were positive at the nursing home were asymptomatic carriers.
“We wouldn’t have known to isolate them without those test results,” said Shrader. “They could have very well passed the virus on to somebody else.”
On July 5, West Virginia expanded testing guidelines for nursing homes to mandate the testing of all residents and staff after a case of COVID-19 is present in the home. Following the detection of a positive case, subsequent weekly testing is performed until 14 days pass without a new case. That’s in accordance with CDC guidelines.
But as testing has increased across the country, delays in the return of test results have been a problem.
After the nursing home outbreaks in West Virginia in August, Justice said during a press conference that there was likely a need to do another round of universal testing at nursing homes. But the governor doubted the capacity of the state’s labs.
And to add to that, the CDC recently issued new guidelines that seem to discourage an increase in testing across the general population. A CNN investigation revealed that changes to language were the result of orders made by White House officials.
Still, Werner said that one round of universal testing, like what was conducted in West Virginia, is not enough. Staff and residents need to be tested with some frequency to identify and contain potential outbreaks.
“The resources just weren’t there,” said Werner.