Bloomberg Businessweek - USA (2020-11-09)

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November 9, 2020

haveerredwhentheysoughttofree

uphospitalspacebyrequiringnursing

homestoaccept Covidpatientswho

weremedicallystable.“Mosthomes

weren’t prepared to manage these

patients,”saysMichaelWasserman,a

geriatricianand,untilrecently,pres­

identoftheCaliforniaAssociationof

LongTermCareMedicine.It’snotclear

whetherinfectedstaffandresidents,

orthesenewpatients,manyofwhom

werelikelynolongercontagious,were

themainvectorfortransmissioninside

thestate’snursinghomes.

Evenso,PresidentTrumpjumped

toblamethescaleoftheoutbreakson

misstepsby Democratic governors.

“11,000peoplealonediedinNursing

Homesbecauseof[Cuomo’s]incompe­

tence!”hetweetedonSept.3.Around

thesametime,theU.S.Department

ofJusticeannounceditwasconsid­

ering investigationsinto New York

andthreeotherDemocratic­ledstates

thatissuedsimilardirectives.(Cuomo

rescindedNewYork’sorderinMay.)

Amid the political scrum, nursing

homeshavelargelyevadedresponsi­

bility.Infact,atleast 26 states,includ­

ingTennessee,havegrantednursing

homessomelevelofimmunityfrom

Covid­relatedlawsuits.

Buttherearestrongindicationsthat

nursinghomes aren’tjustblameless

victimsandthattheindustryhas,by

lobbying against stricter federal rules

and cutting staff sizes, likely helped

accelerate outbreaks. Last

year,attheurgingofindustry

groups,theWhiteHousepro­

posedeasingrulesenactedby

PresidentObamathatwould

haverequiredeachfacilityto

hirea dedicatedinfectionpre­

ventionexpert.Trump’spro­

posal received praise from

the American Health Care

Association,themainindustry

tradegroupthatarguedforit,

andsomehomespostponedhir­

ingtheseexpertsuntiltherules

werefinalized.“Failuretohave

thispositionfullyimplemented

hasproventobea costlymis­

take,”saysDebraFey,aninfec­

tionpreventionnurseandconsultantfor

thelong­term­careindustry.

Moreover,since Grabowski’sini­

tialresearchwaspublished,fourmore

papershavefoundthatcertainqual­

itymetrics domatter inoutbreaks.

YueLi,a professorattheUniversityof

RochesterMedicalCenter,forinstance,

examineddata fromnursing home

infectionsinConnecticutthroughmid­

April and compared the homes’ rate of

infections to the number of registered

nurses they employed. The industry

tracks nursing staffing in terms of min­

utes worked by RNs, per resident per

day. Li found that among homes with at

least one infection, every 20 minutes of

additional RN staffing time was associ­

ated with a 22% decrease in Covid cases.

Charlene Harrington, of the University

of California at San Francisco, found

a similar link for homes in California.

RNs are “the only ones really trained in

infection control,” she says.

Of course, nurses are expensive, and

CareRite, like many other large opera­

tors, has financial incentives to employ

fewer of them. The company’s four

facilities in Tennessee with more than

100  infections apiece averaged only

22 minutes of RN time per resident each

day, about half the national average of

41 minutes, according to data compiled

by the U.S. government for the fourth

quarter of 2019. CareRite’s five other

Tennesseefacilitiesfaredsomewhatbet­

ter,averaging 38 minutesofRNtimeand

rangingfrom 25 to 61 infections each.

Meanwhile, nursing aides at CareRite

facilities spent 14% fewer hours per res­

ident per day, compared with other

facilities in the country. That statistic

could also be seen as troubling. A paper

published by University of Chicago

researchers in August found that higher

numbers of hours worked by aides, who

areresponsibleforchanging,bathing,

andfeedingresidents,correlatedwith

a lowerprobability ofanoutbreak.

“Havingenoughnurseaidestoimple­

mentviruscontainmentwillbecrucial

if deathsaretobeaverted,”theywrote.

Grabowski, the Harvard profes­

sorwhoseresearchwastoutedbythe

industry,sayshebelievesthenewfind­

ings.Althoughhemaintainsthatloca­

tionis stillthestrongestpredictorofan

outbreak,“staffingdoeslimitthesizeof

anoutbreakandthenumberofdeaths.”

Headdsthatthoughallnursinghomes

aresusceptibletothevirus,theindus­

tryglommed onto only certain parts of

his initial findings. “Nothing we wrote

saidthatnursinghomesshouldn’tbe

accountable,”hesays.“Nooneshould

geta get­out­of­jail­free card.”

Before CareRite came along, Trevecca

and the nearby Bethany Center for

Rehabilitation & Healing were owned

by Emily Whitcomb, whose family had

operated the two nursing homes since

1994. Whitcomb moved her own parents
      into Trevecca when they became too
      old to care for themselves. Her motto
      was “happy residents, happy employ­
      ees, and stay in the black,” according
      to a former Trevecca manager who
      worked for both owners. “She believed
      PREVIOUS SPREAD: COURTESY CLIFF MCGILL. DATA: BLOOMBERG ANALYSIS OF TENNESSEE DEPARTMENT OF HEALTH DATASETS AS OF 10/7/20 that if you provided good patient

“Nothing we wrote said that nursing homes

shouldn’t be accountable. No one should get

a get-out-of-jail-free card”

Tika Johnson