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Long-Term Care in the COVID Era : Mandates for Change , Opportunities for Improvement Driving the Way Forward
By Kelly M . Pyrek
Nowhere else in healthcare might you find a more challenging segment than long-term care ( LTC ), where approximately 1.3 million residents live in about 15,505 nursing homes in the United States ( Fulmer , et al ., 2020 ). Of these individuals , more than one-third experience dementia , and most have significant disabilities . They are primarily cared for by a low-paid , poorly trained workforce that must address a great heterogeneity of need and escalating acuity levels among long-term care residents .
Experts point out that even prior to COVID-19 , the quality of nursing home care has long been a critical issue . In 1998 , the Centers for Medicare and Medicaid Services ( CMS ) initiated the Nursing Home Compare website designed to help the public monitor clinical quality of nursing homes by providing long-term care facility performance measures , and which currently uses a five-star rating system . As of 2015 , approximately 39 percent of U . S . nursing homes had overall low ratings of only one or two stars .
At the onset and then height of the COVID-19 pandemic , hard-hit U . S . nursing homes experienced high rates of morbidity and mortality , operating in full lockdown mode and fear of the coronavirus driving staff shortages that exacerbated other shortfalls in personal protective equipment ( PPE ) and resources to keep residents and caregivers safe .
Sharing what she has seen in nursing homes firsthand , Nancy Tuders , RN , IP-BC , GERO-BC , CDONA , a regional nurse consultant and regulatory specialist with Monarch Healthcare Management , recounts , “ I would say we have very few residents prior to COVID-19 who were on droplet precautions ; perhaps someone once in a while , but it was not routine . We also donned and doffed PPE in a different order than we normally practiced with other infectious diseases . That required ongoing return-demonstration education for all staff . Staff members were scared . So much was unknown and there was so much media coverage of people in ICUs dying from COVID-19 . Staff were afraid they were going to die or bring it home to their families . Some staff quit their jobs . Residents were quarantined to their rooms . They ate their meals in their rooms . Their families were not allowed to visit . The hallways , common areas , and dining rooms were empty except for staff . That in and of itself was eerie . No matter how hard we tried , we could not stop COVID-19 from coming in . We had residents hospitalized and some died there . Others died at our facilities . Some staff became infected . Luckily , no staff who were diagnosed with COVID-19 were hospitalized . We had staff working double shifts regularly due to other staff being out sick . It was a daunting time . A sad and scary time . An exhausting time .”
Tuders alludes to the moving goal posts of evidence-based guidelines being issued by public health authorities during the pandemic . “ The guidance for care changed weekly , sometimes twice a week ,” she confirms . “ That was extremely frustrating , but it was no one ’ s fault . The WHO , CDC and CMS were trying to stay up to date but so much was unknown and changing regularly . We all were learning as we went along . I felt the media coverage was minimal in LTC unless you had several cases or deaths from COVID-19 ; then it was spun to appear you must be doing something wrong . In Minnesota where I work , we were so fortunate to have such great guidance and support from the different divisions of the Minnesota Department of Health ( MDH ). It immediately started – and still has – weekly calls to keep all providers updated on the latest recommendations and mandates . MDH was key in assisting facilities to make sure there was enough PPE at the peak of COVID-19 . There were some lapses , and we did have to preserve at times , but MDH was diligent in trying to get needed supplies to us . The one exception was N95 masks , as they were all being used in the hospitals last year . LTC staff had to wear double masks or a mask and a face shield . That has recently changed , and we now have access to N95 masks , and they are used when providing care for a COVID-19 resident or suspected resident .”
As Werner , et al . ( 2020 ) confirm , “ U . S . nursing homes were unstable even before COVID-19 hit . They were like tinderboxes , ready to go up in flames with just a spark . The tragedy unfolding in nursing homes is the result of decades of neglect of long-term
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