Months after it became painfully clear that older people were the most likely to die from COVID-19, poor infection control resulted in multiple, sustained outbreaks at the overwhelming majority of the nation’s nursing homes, according to reports from the U.S. Government Accountability Office.
Of the 50 states and District of Columbia, California ranked 19th worst for sustained COVID-19 outbreaks lasting more than five weeks from May 2020 to January 2021.
But nowhere was safe: A stunning 99.5% of America’s nursing homes overseen by the Centers for Medicare & Medicaid Services (CMS) had at least one outbreak, and 74% had three or more outbreaks, in the time frame examined.
“The congregate nature of nursing homes, with staff caring for multiple residents and residents sharing rooms and other communal spaces, as well as high incidence rates in the surrounding community, can increase the risk that COVID-19 will enter the home (for example, through staff) and easily spread,” the GAO said.
“Asymptomatic transmission can further complicate a nursing home’s efforts to prevent and control the spread, as it allows the virus to continue to transmit in the home undetected. A growing body of evidence shows that asymptomatic transmission may be a contributing factor to nursing home COVID-19 outbreaks.”
A lack of personal protective equipment can increase the risk as well, and staffing issues — frequent turnover, and manpower shortages due to illness, became acute during the pandemic — make it harder to stick to infection-control practices, nursing home officials said.
In a series of probes over the past year, the GAO also has found that many nursing home staffers have been hesitant to get COVID-19 vaccines, which can complicate infection-control efforts, and that consumers can’t easily look up how many residents and staffers have been vaccinated at each nursing home.
“This has been striking, that so many staff have had cases of COVID-19,” said John Dicken, a director on GAO’s health care team. “We recommended that CMS report vaccination rates for staff and residents of homes, so consumers, families and CMS itself will be able to better understand which facilities may be more apt to have outbreaks.”
CMS is working on that recommendation. It’s responsible for making sure the nation’s 15,500 Medicare- and Medicaid-certified nursing homes — which house 1.4 million elderly and fragile people — meet federal quality standards. But the agency has appeared loathe to crack down on homes after finding infection-control problems, the GAO found.
Whether nursing homes were for-profit or nonprofit didn’t seem to make a difference in the severity and number of COVID-19 outbreaks they suffered, but the sheer size of the facilities did.
Nursing homes with outbreaks that dragged on and on were more likely to have a larger number of beds than did homes with short-duration outbreaks, the GAO found.
Once COVID-19 entered a home — more likely when community transmission was high — the home’s ability to quickly test, identify and separate infected residents and staff before they infected others was critically important to stopping the spread, nursing home officials said. Asymptomatic infections, however, made that more difficult.
In California, nearly three-quarters of COVID-19 deaths were among people 65 or older, according to state data.
“This analysis highlights the challenges most nursing homes faced when responding to the COVID-19 pandemic — responding to repeated outbreaks, many with weeks of continued spread and marked by high numbers of cases and deaths,” the GAO said.
But even before the pandemic, California’s nursing homes had the worst track record in the nation when it came to problems with preventing infections, according to a different study by the GAO.
As federal surveyors watched, a certified nursing assistant at a California nursing home was coughing and looking ill. She had been sick for at least two days with fever, diarrhea, cough and a runny nose, she told the federal surveyors. Yet she was at work with frail and elderly people.
Another nursing assistant at the same facility failed to properly clean her hands while caring for an incontinent patient, creating the potential to spread disease and infection. Seven other employees had not been screened for tuberculosis before they were hired. Others who had not been vaccinated for flu weren’t wearing face masks.
Despite these problems, and despite the facility’s “pattern of behavior,” no enforcement actions were launched against this nursing home by federal authorities, the GAO found.
In California, 1,174 nursing homes were surveyed, and an overwhelming 60.6% of them had been cited for deficiencies in infection prevention and control in a single year. That was the worst in the nation, far above the national average of 39.6%, and Rhode Island’s 3.8%.
But it’s not just a matter of big state vs. small state. Other big states performed far better than did California: In New York, just 21.2% of nursing homes had been cited for infection prevention in the time period studied. In Texas, it was 48.2%; in Florida, 43%; Pennsylvania, 45.9%.
Most nursing homes had infection-control deficiencies prior to the pandemic, the GAO said — and half had persistent problems. Despite that, 99% of these deficiencies were classified as “not severe” and enforcement actions were exceedingly rare: just 1%.
“A small minority ended up having enforcement actions and sometimes that may be valid — the homes may have taken steps to improve things — but in many cases there were real lapses of oversight,” Dicken said.
The GAO is looking more deeply at California — and three other states — to understand precisely why nursing homes had greater-than-average issues. Are there understatements or inconsistencies in data collection between states? Do inspection processes differ? That probe is underway and will be released later this year.