Updated at 5 p.m., March 31 with latest number of cases at Frontier Health and Rehabilitation
When dozens of nursing home residents in a Seattle suburb tested positive for COVID-19, people in St. Louis grew worried about their loved ones.
Michael Allen immediately thought of his aunt, who has schizophrenia and a heart condition, and lives at Frontier Health and Rehabilitation in St. Charles. Allen grew more worried when her nursing home reported that residents there had tested positive.
Nursing homes across the country blocked access to visitors, began screening staff and residents multiple times a day, and are trying to follow guidelines from federal and local authorities.
Older people who are frail and have chronic diseases are among the most likely to become very sick from the coronavirus.
“My aunt doesn’t have a cellphone, so the only way she can call us is to get out to use the telephone down the hall, and they’re trying to keep people from leaving their rooms,” he said. “I’m very worried because they’re not testing everyone.”
But even though facilities are taking action to prevent infection, they’re operating with reduced staff and the social distancing measures will take a toll on residents’ mental health. Families of residents are struggling with anxiety, since they cannot visit to check on their loved ones. It’s been hard for Allen’s father to reach Frontier Health, especially after the COVID-19 cases were found, he said.
Working harder to fight infection, but with fewer workers
The Missouri Department of Health and Senior Services expanded the criteria for COVID-19 testing on March 22 to include people who live in long-term care facilities. Since then, 18 people living at Frontier Health in St. Charles, Life Care Center of St. Louis, Anthology of Town and Country and a veterans home in north St. Louis County have tested positive for the disease.
States are directing nursing homes to follow guidelines from the Centers for Medicare and Medicaid Services to restrict access to visitors and volunteers and increase screenings for symptoms. But such measures won’t completely stop the virus from getting into nursing homes, said Chien Hung, program director at VOYCE, a group that advocates for better quality care in long-term care facilities.
“The problem is the workers have their own personal lives, and one worker could work in three or five nursing homes,” Hung said.
A Kaiser Health News analysis this month found that nursing homes that have more staff are more likely to follow infection prevention protocols. But Frontier Health and Life Care Center of St. Louis already had inadequate staffing, according to Medicare. Missouri and Illinois nursing homes are understaffed compared to the national average, the St. Louis Post-Dispatch reported.
That’s due to lack of funding, said Dr. John Morley, former medical director of NHC Healthcare Maryland Heights, a nursing home in north St. Louis County.
“There is just not enough money in nursing homes to staff,” Morley said. “Payment for most staff is at the low end of normal.”
Nursing homes this month also have lost volunteers, contract workers who provided mental health and physical therapy services, and some staff due to the pandemic, said Bill Bates, CEO of LeadingAge’s Missouri chapter. The nonprofit serves 55 nursing homes in the state.
“We’re losing staff to their symptoms; we’re losing staff to child care issues. Many staff have lots of leave and they’re scared to go to work, so they’re using their leave,” Bates said.
Dr. Charles Crecelius, a geriatric medical specialist at Barnes-Jewish Hospital, expects that nursing homes with residents who test positive for COVID-19 soon won’t have enough employees. Unfortunately, he said, there’s noplace to borrow workers from.
“Hospitals are going to be overwhelmed, so we can pretty much cross that off,” Crecelius said. “It really comes down to people working a lot of overtime.”
The pandemic has also created new challenges that guidelines from CMS and the Centers for Disease Control and Prevention could not sufficiently address, Crecelius said. For example, the guidelines do not say that a nursing home resident who’s been hospitalized needs to test negative for COVID-19 before returning to a facility.
“A patient who’s had a stroke may come back to the nursing home, and I can’t guarantee they won’t develop an infection a week later,” Crecelius said.
Nursing home employees also became concerned about visiting hospice workers, since they have to work in multiple nursing homes. State health officials informed hospice agencies and long-term care centers on March 20 that hospice care workers would be allowed to enter facilities on a case-by-case basis.
Social distancing fosters isolation among residents
Because of restricted access, many families are worried about the well-being of their loved ones. VOYCE has received 30 to 40 calls daily since the restrictions began, and most of them are from concerned relatives, Hung said.
“[They say], ‘You know, we were already not satisfied with the care, now you don’t let us visit at all?' How do we know if they feed Mom? How do we know if they change Mom’s diapers?” he said. “They are not going to take the nursing home’s word for it.”
But nursing homes may not be able to describe how they are being treated, said Cheryl Kinney, senior director of client services for the Alzheimer’s Association's Missouri chapter.
The federal guidelines call for suspending communal dining and canceling social activities. Keeping residents isolated so they don’t catch the virus has made it difficult for nursing home personnel to care for them, Crecelius said.
“For patients with dementia, you want socialization, mental and physical stimulation,” he said. “That’s difficult to accomplish when you’re under isolation procedures. The longer this goes on, the more I anticipate having to treat depression more actively.”
Many facilities are helping with Skype, FaceTime and other communication technologies to connect residents with their families. Some family members have also tried talking to their relatives through windows.
But some residents have neurodegenerative diseases, so these tactics may not work, said Kinney, whose own father is experiencing the early stages of Alzheimer’s disease.
“I’m regularly getting calls from my dad, who is not really understanding, like, ‘Why is this all going on? Why can’t you see me? Why can’t I get a haircut?'” she said. “It’s hard for everybody because we weren’t prepared for this.”
When Kinney’s brother stood outside their father’s window, the elder Kinney did not understand and merely peeked at his son through the blinds as they talked on the phone.
Some families don’t have the option of speaking to their loved ones. St. Louis resident Anne Bannister has a father whose Alzheimer’s disease is so advanced that he does not know how to use the phone anymore.
“The phone would ring, and he didn’t know what the noise was, so we didn’t get him a phone,” Bannister said. “I’ve been trying to mail him cards and letters every week because he loves to get mail.”
Bannister hoped initially that his facility, Laclede Groves, would restrict access for just a couple of weeks. But when she realized the pandemic could last for much longer, it made her sad, since her father had only moved to his memory care facility in January and was still adjusting to living away from home.
“The last card I sent him, I said: ‘Guess what? We’re all locked in right now. You know, I’m not in a different situation. I’m in my house, and people can’t come and see me. And as soon as they tell us it’s safe, I promise I will be there,’” Bannister said.
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