The New York Times - 12.09.2019

K THE NEW YORK TIMES NATIONALTHURSDAY, SEPTEMBER 12, 2019 N A21

cilities, particularly those with
ventilated patients, but not Palm
Gardens specifically.
Such nursing homes are play-
ing a key role in the spread in New
York, where 396 people are known
to be infected and another 496 are
carrying the germ without show-
ing symptoms, according to public
health officials. In Chicago, half of
patients living on dedicated venti-
lator floors in the city’s skilled
nursing homes are infected with
or harboring C. auris on their bod-
ies, said Dr. Allison Arwady, the
acting commissioner of the city’s
Department of Public Health.
Much of the blame for the rise of
drug-resistant infections like C.
auris, as well as efforts to combat
them, has focused on the overuse
of antibiotics in humans and live-
stock, and on hospital-acquired in-
fections. But public health experts
say that nursing facilities, and
long-term hospitals, are a danger-
ously weak link in the health care
system, often understaffed and ill-
equipped to enforce rigorous in-
fection control, yet continuously
cycling infected patients, or those
who carry the germ, into hospitals
and back again.
“They are caldrons that are con-
stantly seeding and reseeding
hospitals with increasingly dan-
gerous bacteria,” said Betsy Mc-
Caughey, who leads the nonprofit
Committee to Reduce Infection
Deaths. “You’ll never protect hos-
pital patients until the nursing
homes are forced to clean up.”
The story is far bigger than one
nursing home or one germ. Drug-
resistant germs of all types thrive
in such settings where severely ill
and ventilated patients like Ms.
Davila are prone to infection and
often take multiple antibiotics,
which can spur drug resistance.
Resistant germs can then move
from bed to bed, or from patient to
family or staff, and then to hospi-
tals and the public because of lax
hygiene and poor staffing.
These issues have also vexed
long-term, acute-care hospitals,
where patients may stay for a
month or less before going to a
skilled nursing home or a different
facility.
A recent inquiry by the New
York State Department of Health
found that some long-term hospi-
tals grappling with C. auris were
failing to take basic measures,
such as using disposable gowns
and latex gloves, or to post warn-
ing signs outside the rooms of in-
fected patients. At one unnamed
facility, it said, “hand sanitizers
were completely absent.”
Officials at the 240-bed Palm
Gardens did not respond to re-
peated requests for comment.
Over the past year, the number of
patients who were infected with
or were carrying C. auris there
grew to 38 from six, according to a
nurse there and public health offi-
cials. The tally has now fallen into
the high 20s after some patients
died or moved elsewhere.
The New York health depart-
ment issued a statement in re-
sponse to queries from The New
York Times: “The Department of
Health has made controlling the
spread of C. auris a high priority
and has conducted extensive
training and education on infec-
tion control policies and pro-
cedures for Palm Gardens and
other nursing home providers
throughout this region. The health
and well being of nursing home
residents is our primary concern
and we take complaints regarding
quality of care very seriously.”
Scientific research on nursing
homes and drug resistance is
sparse, but some recent studies
offer evidence of the problem. A
study published in June in the
Journal of Clinical Infectious Dis-
eases found that patients and resi-
dents in long-term care settings
have alarmingly high rates of
drug-resistant colonization,
which means they carry the
germs on their skin or in their bod-
ies, usually without knowing it,
and can pass them invisibly to
staff members, relatives or other
patients. Elderly or severely ill
people with weakened immune
systems who carry the germ are
at high risk of becoming infected.
(Health officials in New York state
said 14 percent of those now in-
fected started out carrying it and
then developed symptoms).
The study, which focused on
Southern California, found that 65
percent of nursing home residents
in that region harbored a drug-re-
sistant germ, as did 80 percent of
residents of long-term acute-care
hospitals, where their “status is
frequently unknown to the facili-
ty.” By comparison, only 10 to 15
percent of hospital patients car-
ried such germs, the study found.
The phenomenon is global. A
study published in 2017 found that
elderly residents of long-term
care facilities in Britain were four
times as likely to be infected with
drug-resistant urinary tract infec-
tions as those living at home.
Soaring levels of resistance were
found in long-term care facilities
in Italy, a 2018 paper found. And a
2019 study found that long-term
care facilities in Israel are “a ma-
jor reservoir” of carbapenem-re-
sistant Enterobacteriaceae, or
CRE — a major family of drug-re-
sistant germs — contributing to

“rapid regional dissemination.”

Experts said the problem is pro-

nounced in the United States, giv-

en changing economics that push

high-risk patients out of hospitals

and into skilled nursing homes.

The facilities are reimbursed at a

higher rate to care for these pa-

tients, they said.

C. auris, which is resistant to

major antifungal medications,

was first identified in 2009 in Ja-

pan and, as of July 31, had infected

796 people in the United States,

largely in New York, Chicago and

New Jersey, since its arrival here

in 2015, according to the C.D.C.

Another 1,540 people have been

identified as carrying the germ on

their skin or in their bodies with-

out showing symptoms.

C. Auris Up Close

On Palm Gardens’ second floor,

where Ms. Davila and other venti-

lated patients reside, signs posted

outside nearly every room warn

visitors and staff members to

wear gloves, gowns and masks —

a state requirement for those in-

fected with C. auris.

But during two recent visits to

Palm Gardens by a Times report-

er, accompanying Ms. Davila’s

husband as his guest, orderlies

and nurses moved in and out of

her room without the required

protection.

“The nurses and janitors are

just spreading this thing from

room to room,” her husband, An-

thony Hernandez, said on a visit in

August, shortly after a nurse, who

was wearing gloves but no mask

or gown, poured liquid nourish-

ment into his wife’s feeding tube.

During a brief interview in the

lobby, Pamela Delacuadra, the

center’s director of nursing, said

employees had initially struggled

with the protocols for C. auris.

“It was overwhelming at first

but with help from the health de-

partment, we’ve gotten much bet-

ter,” she said.

Ms. Davila’s medical records,

reviewed by The Times, do not

identify the specific date when she

got C. auris, but a chart written by

a Palm Gardens doctor in Decem-

ber 2018 includes a note listing her

as a carrier of the fungus. She was

put in isolation for C. auris pa-

tients, and her records subse-

quently referred to her as taking

medications for the infection.

Palm Gardens occupies a sev-

en-story brick building in central

Brooklyn. Magenta banners pro-

mote its dialysis center and adult

day care services, as well as a

“respiratory pavilion” for patients

on mechanical life support.

A high-level official from a local

hospital that has seen a number of

C. auris patients from nursing

homes said Palm Gardens was a

major source. He declined to be

named because his employer had

not authorized any comment.

Palm Gardens received two

stars, a below-average rating for

staffing and overall care, from the

Centers for Medicare and Medic-

aid Services, an agency that ranks

nursing home care on a scale from

one star to five. In 2018, the

agency investigated the deaths of

two ventilator patients at Palm

Gardens, finding that employees

had failed to turn their ventilators

back on after performing mechan-

ical checks. The patients died

within minutes of each other, the

report said.

C.M.S. declined to comment on

Palm Gardens.

Ownership of Palm Gardens is

controlled by someone identified

as Shimon Lefkowitz, according to

public filings.

Mr. Lefkowitz did not respond

to efforts to reach him through

Palm Gardens. Calls to several

law firms that represent Palm

Gardens in lawsuits were not re-

turned.

Not all Palm Gardens residents

with C. auris contracted the germ

there, and it is not clear how many

did. One patient who died was in-

fected at Maimonides Medical

Center in Brooklyn, according to

the man’s family.

A Changing Role

Skilled nursing homes and long-

term care facilities have been

playing an increasingly important

role in caring for seriously ill pa-

tients who used to stay longer in

hospitals.

Advances in technology have

made it possible to prolong the

lives of desperately ill patients,

while changes in Medicare reim-

bursement rates created incen-

tive for the expansion of such fa-

cilities, said Neale Mahoney, an

economist at the University of

Chicago who studies the indus-

try’s growth. There are now about

400 long-term care hospitals

across the country, up from about

40 in the early 1980s, he said.

Since 2012, the number of

skilled nursing homes with venti-

lator units rose to 436 from 367 —

a significant jump but still a frac-

tion of the nation’s 15,000 nursing

homes — according to C.M.S.

“Ventilator units are the poster

child, the best example of a place

that has challenges,” said Dr. Al-

exander Kallen, an outbreak ex-

pert at the C.D.C.

The federal government reim-

burses facilities for ventilator pa-

tients at significantly higher

rates, according to C.M.S. Venti-

lated patients can bring in $531 a

day compared to $200 for a stand-

ard patient. That’s about $16,000 a

month compared to $6,000.

The reimbursement rates re-

flect the significant care required

for vulnerable patients, and the

cost of equipment.

C.M.S. contends the majority of

skilled nursing homes do well

with staffing and overall care. Yet

roughly 1,400 nursing homes re-

ceived a one-star rating for

staffing in 2018 from the agency.

“It is impossible for them to do a

good job with the way their

staffing is,” said Dr. Mary Hayden,

a professor at Rush Medical Col-

lege who studies the rise of drug-

resistant infections in health care.

She added: “The way they’re set

up, they can’t do it.”

A Patient’s Path

Ms. Davila carried C. auris with

her on her journey through the

health care system.

In early August, after a routine

blood test found her white cell

count plummeting, she was taken

by ambulance to Methodist Hospi-

tal in Brooklyn for a blood transfu-

sion. Doctors discovered an infec-

tion and put her on two different

antibiotics. Heavy use of antibi-

otics, while often necessary, can

kill off the nonresistant infections

and allow resistant ones to thrive.

Her condition stabilized after

two weeks and she returned to

Palm Gardens. It was one of at

least a dozen trips she had taken

to the hospital from the facility.

Her sharp decline began in 2017

after pain from a suspected hernia

sent her to the hospital. A lifelong

smoker, Ms. Davila had emphyse-

ma, which led to complications

and infections, according to a re-

view of her records.

Now she spends her days

frozen in bed, serenaded by a Lat-

in music radio station and the me-

chanical whir of her respirator.

Mr. Hernandez doubts his wife

will recover. “If I can take her

home to die that would be a bless-

ing,” he said.

He pulled the blanket higher,

turned up the radio and told his

wife he loved her. Momentarily

alert, she fixed her eyes on his and

then mouthed: “I love you, too.”

Nursing Homes Foster Spread of a Fungus

HILARY SWIFT FOR THE NEW YORK TIMES

From Page A1

JEENAH MOON FOR THE NEW YORK TIMES

‘If I can take her home to die that would be a blessing.’

ANTHONY HERNANDEZ,whose wife, Maria Davila, tested positive for Candida auris last year.

MELISSA GOLDEN FOR THE NEW YORK TIMES

Palm Gardens Center for

Nursing and Rehabilitation, a

nursing home in Brooklyn, has

had at least 38 patients in-

fected with Candida auris.

What is Candida auris?

Candida auris is a fungus that,

when it gets into the bloodstream,

can cause dangerous infections

that can be life-threatening. Scien-

tists first identified it in 2009 in a

patient in Japan. In recent years, it

has emerged around the world,

largely in hospitals and nursing

homes.

Why is it so dangerous?

C. auris is often resistant to major

antifungal drugs that are typically

used to treat such infections. The

C.D.C. says that more than 90

percent of C. auris infections are

resistant to at least one such drug,

while 30 percent are resistant to

two or more major drugs. Once the

germ is present, it is hard to eradi-

cate from a facility.

Who is at risk?

People with compromised or weak-

ened immune systems are the

most vulnerable. This includes

elderly people, and also people who

are already sick; in at least one

case, newborns were infected at a

neonatal unit. Settings, like hospi-

tals and nursing homes are where

the infection is more prevalent.

Can I protect myself?

The symptoms of C. auris — fever,

aches, fatigue — are not unusual,

so it is hard to recognize the infec-

tion without testing. The good

news is that the threat of becoming

sick with C. auris is very low for

healthy people. If you or a loved

one is in a hospital or nursing

home, you can ask if there have

been cases of Candida auris there.

FORT LAUDERDALE, Fla. —

A Chinese businesswoman who

talked her way into President

Trump’s Mar-a-Lago resort with a

cache of electronics and a story

about wanting to use the pool was

convicted on Wednesday of tres-

passing and lying to federal

agents.

The verdict capped an unusual

trial that never answered the

question of whether the woman,

Yujing Zhang, a financial consult-

ant from Shanghai, was a con-

fused tourist or someone who had

a more serious agenda.

Ms. Zhang, 33, said she had

been planning to attend a party

when she showed up at Mr.

Trump’s private club in Palm

Beach, Fla., in late March. She

talked her way past the Secret

Service outside and was allowed

in because her surname — among

the most common in China —

matched that of a club member.

She had no swimsuit but said she

was going to use the pool.

After Ms. Zhang was stopped in

the lobby and questioned further

by the Secret Service, agents

found that she was carrying four

cellphones, a laptop and an exter-

nal hard drive. In her room in a dif-

ferent hotel, they found nine flash

drives, five cellphone SIM cards, a

device used to detect hidden cam-

eras and about $8,000 in cash.

But the three-day trial shed lit-

tle light on the question of

whether Ms. Zhang was a spy

penetrating a place where the

president regularly holds meet-

ings or a tourist on the worst trip

of her life. Some information fed-

eral prosecutors collected in the

case was filed under seal and re-

mains secret.

Jurors took four hours to find

her guilty. Upon hearing the ver-

dict, Ms. Zhang did not react, but

she tried to take her bundle of files

with her to jail. The marshals

made her leave them behind.

She faces up to one year in pris-

on on the trespassing charge, a

misdemeanor, and five years on

the charge of making a false state-

ment to a federal agent, a felony.

The judge set sentencing for Nov.

22.

Against the advice of her public

defenders and the judge, Ms.

Zhang decided to act as her own

lawyer, even though she seemed

unfamiliar with the case against

her, unversed in federal criminal

justice procedures and clearly

struggling to speak English. She

declined opportunities to cross-

examine the prosecution’s nine

witnesses and did not testify in

her own defense.

The trial got off to an unusual

start on Monday, when during

jury selection the judge asked

why Ms. Zhang was appearing in

court in her jail uniform. It was be-

cause she had not been supplied

with any undergarments, she re-

plied — though her standby public

defenders said she had, in fact,

been offered a full set of civilian

clothing.

Her closing argument, the next

day, was brief.

“I do think I did nothing wrong,”

Ms. Zhang told the court. “I did

not lying. I do think I followed in-

structions. I went into the Mar-a-

Lago to have a visit. That’s what I

want to say, so thank you.”

When the prosecutor, Michael

R. Sherwin, proposed entering

into evidence a list of text mes-

sages exchanged between Ms.

Zhang and a contact of hers in Bei-

jing, she objected, saying the texts

were “personal” and “sensitive.”

But the texts showed a clear

business and political thrust be-

hind Ms. Zhang’s trip to the

United States, with no less of an

objective than a meeting with

President Trump at his Palm

Beach club.

Ms. Zhang had paid for a vaca-

tion package that included a ban-

quet at Mar-a-Lago. But the gala

she had paid to attend had been

canceled when news outlets re-

vealed that the Florida woman

who had a role in promoting the

event had once owned a massage

parlor where men, including the

owner of the New England Patri-

ots, Robert K. Kraft, were accused

of paying for sex acts.

Prosecutors said a stream of

text messages showed that Ms.

Zhang knew the event she pur-

portedly was to attend at Mar-a-

Lago had been canceled, which

prosecutors said raised questions

about her motive for making the

trip. Her Beijing contact, she said,

had suggested that she go instead

to an event featuring Bill and Hil-

lary Clinton, or to another with

Warren Buffett.

“You can meet with these fa-

mous people,” the contact wrote,

according to the English transla-

tion of the texts, introduced in

court. “You can stand between

them and have your photo taken.”

Conviction

Ends Trial,

But Leaves

Questions

By NICK MADIGAN

and FRANCES ROBLES

Nick Madigan reported from Fort

Lauderdale, and Frances Robles

from Miami.

Articles in this series explore the

rise in drug-resistant infections,

the causes and possible solutions.

Deadly Germs, Lost Cures

Benjamin Ryan contributed reporting.