A troubled but ordinary nursing home outside Buffalo joined in a nationwide effort over the past few years to cut sharply back on the number of residents sent to hospital emergency rooms whenever anything went wrong.
“Treat in place” was the mantra pushed by federal health agencies, academic researchers and geriatric physicians who argued that hospitals are not friendly environments for the frail and elderly, and that outcomes for those transported to one can include bedsores, dehydration, infections, exhaustion and delirium.
But what thousands of U.S. nursing homes neglected — including Absolut Care of Aurora Park — was the other side of the coin. To treat in place requires having effective means of treatment, staff who know how to deploy that treatment and procedures to stop the spread of infection.
When the novel coronavirus pandemic struck, nursing homes did not swamp hospitals with patients. But neither did they prevent the deaths of more than 30,000 of their residents or, in many cases, even provide decent palliative care.
“These places are not designed for a pandemic,” said John Rowe, a professor of health policy and aging at Columbia University’s Mailman School of Public Health, and the former CEO of Aetna.
The result, said Lori Popejoy, a professor at the Sinclair School of Nursing at the University of Missouri, was “a Stone Age response to this virus, and we thought, ‘It’s better than nothing.’ ”
At Absolut Care of Aurora Park, a big nursing home with 310 beds, 153 residents were found to be infected as the disease swept through one floor after another, and 61 had died as of May 31, according to the Centers for Medicare and Medicaid Services. That figure includes deaths on site and among those taken to hospitals. The owners dispute that number but did not provide their own tally.
“Once it was there it just spread like wildfire,” said Bradley Porter, a registered nurse who quit in anger at the beginning of May. “It was very hectic, chaotic.”
When the coronavirus struck, Absolut was more or less winging it. Administrators there obtained disposable ponchos from the Maid of the Mist — the tourist boat tours at Niagara Falls — as an emergency measure until they could secure enough proper personal protective equipment.
“We had policies and procedures in place before our first covid case,” Jason Newman, a spokesman for Absolut, wrote in an email. “Our policies and procedures changed daily as the new DOH [state Department of Health] directives were given.”
Absolut, in the village of East Aurora, N.Y., already had a couple of strikes against it. Its owners had filed for bankruptcy in September; absences by its low-paid staff made it hard to attend to residents’ needs; and families complained about shortages of adult diapers, toilet paper, towels and decent food.
An investigation two years ago by the Buffalo News termed it “one of western New York’s worst nursing homes.” It currently rates two out of five stars from Medicare’s comparison website.
But Absolut, now under new management, has maintained its certification, and though it differs in degree from more highly rated establishments, its approach is essentially the same as any for-profit nursing home. And that approach has now proved itself to be strikingly inadequate when confronted with a novel virus.
There is another model. Just 15 miles to the west, in the city of Buffalo, is the Terrace View Long-Term Care Facility. It has 390 beds. Four of its residents were infected with the coronavirus. All were transferred to the affiliated Erie County Medical Center. (Both facilities are part of a publicly owned corporation.) One died.
As measured by the CMS, Absolut at Aurora Park provides less care by registered nurses than the national average. Terrace View provides significantly more — more than twice as much per patient as Aurora Park. That may be crucial.
Terrace View, which has a very large percentage of residents on Medicaid, casts itself as part of the health-care system — unlike most nursing homes, which stand apart from it. It had infection protocols in place, designed by experts at the adjoining hospital.
“It’s unfortunate there’s not more integration,” said David Grabowski of Harvard Medical School, who argues that nursing homes do not receive an adequate revenue stream from Medicaid to provide the services they should provide.
A company called VestraCare, based on Long Island, has agreed to buy the bankrupt Absolut chain of six nursing homes. Even while waiting for regulatory approval, it took over the management at Aurora Park on March 1, with ambitious promises to improve the quality of care. Less than two weeks later, New York state ordered nursing homes to lock down as the pandemic erupted. By that time, it was already spreading at Aurora Park.
“That was profoundly and comically bad timing,” said Edward Farbenblum, a co-owner of VestraCare. “It’s really been crisis management since then.”
‘It was just cross-contamination everywhere’
Patient No. 1 at Absolut was a woman who had returned from a hospital stay some weeks before. “The staff were the ones who brought it in,” Porter said, though management suggested the woman may have contracted the virus in the hospital. She fell ill, “and sat there sick a couple of days, and the staff was spreading it around. And then she was tested and it was like, ‘Oh, crap.’ ”
She was eventually housed in an isolated section that was to become an ever-expanding “red zone” at Aurora Park.
“Obviously, staff go home, they shop, they worship and interact with other people all over our region for the 16 hours a day they are outside of Absolut,” Newman wrote. “There’s no way of telling where any staff contracted the virus. None, arguably, could have caught it at Absolut. No one knows, or can say for sure, because the county and state provided inadequate tracking.”
Some employees work second jobs to augment their low pay. Some drive to work; some take the bus out from Buffalo. Health records show that 46 staff members had tested positive for the virus as of May 24. At the time of the bankruptcy filing last fall, the center had 331 employees.
Workers and family members interviewed by The Washington Post say that some of those sent home after testing positive were pressured to come back early. Farbenblum and Newman insist that the nursing home was following the original seven-day isolation rule, later extended to 14 days, dating from the first positive test even if later tests were also positive.
“I literally barricaded my office door,” said one employee who was told to come back to work, and who spoke on the condition of anonymity out of fear of retribution. But this employee was still feeling ill from covid-19, and eventually went home sick again.
Another went back to work, notwithstanding a persistent cough.
As the disease started to spread, residents were at first locked down in their rooms. But then staffers cleared a floor in one of the wings to create an enlarged red zone. They trundled all the positive patients to rooms on that one floor — without taking sufficient care, employees and residents say, to protect other residents from infection as they passed by.
“They weren’t handling it very well,” Porter said. “It was just cross-contamination everywhere throughout the building.”
Farbenblum points to an infection control survey by the New York State Department of Health on May 4 that found no deficiencies.
Porter had worked at Absolut for about a year and was directed to take charge of a covid-19 floor once the disease was widespread. He had two nurses and three aides working for him, taking care of 56 people, he said.
“I couldn’t be one RN for 56 people. There should be two or three of me.” He said he was never tested for the coronavirus and was told that as long as he took his clothes off when he got home, his family — he has two young children — should be fine.
“Not if I have it in my body,” he said.
Porter said he has heard from other employees that Aurora Park by now “has settled in” and the sense of crisis has passed.
“As you know before very recent weeks there was a tremendous shortage of testing supplies,” Newman wrote in an email. “We have been asking for tests from every governmental agency as well as labs; additionally the testing mandate for staff was not issued until May 10 with an effective date” the end of the following week.
“Regarding patients being moved to the red zone,” he said, “as is best practices and as advised by the DOH epidemiologists, we aggressively and rapidly moved patients to the red from wherever they were when they met the criteria.”
Richard Smith, a 47-year-old quadriplegic after a motorcycle accident, has been at Aurora Park just over two years. He has tested negative. It infuriates him that he’s forced to stay inside while he can see employees lounging and smoking in the parking lot on their break. If they can come and go, he asks, why can’t he?
He is supposed to get a shower three times a week. “But lately, I haven’t been getting them because they’re short-staffed, or they say they don’t have linen. I don’t know, it ain’t bad. I’m supposed to be turned every two hours, but that hardly ever happens.”
Newman wrote that privacy concerns prevent the nursing home from commenting on individual patients. “However, like every skilled facility during the covid crisis we were balancing staffing constraints specifically as we are located in [New York state], the ground zero for the global pandemic,” he said. “Lastly, at no point was there a linen or any supply shortage.”
Barbara Godios said her 88-year-old mother, who has dementia, walked into Aurora Park two months ago, and was infected with the coronavirus but remained asymptomatic, but has nevertheless gone rapidly downhill; she has lost 25 pounds and is now in a wheelchair.
“She’s so feeble and fragile now,” said Godios, who asked that her mother not be identified.
Since mid-March, under state orders, family members have not been allowed to visit nursing homes. Godios has FaceTimed with her mother and did a “window visit” recently. She says some of the certified nursing assistants have been uncaring, even at times negligent. The staff is stretched too thin, she believes, to ensure that patients who need help at meal times reliably get it.
“If I was able,” she says, “I would just love to get her out of there. But she’s [tested] positive.”
Dorothy Carlone, whose story was first published in the Buffalo News, says she pleaded with Aurora to let her in despite the state order so that she could feed her mother, Maxine Schwartz, who had dementia and was refusing to take food from staff. She had not tested positive. But Carlone’s sister, who was their mother’s health proxy, did not agree. On March 27, Schwartz, 92, died of cardiac arrest. In Carlone’s view, she is a collateral victim of the pandemic.
Cheryl Darling’s mother, Nancy, has tested positive but is asymptomatic. She hasn’t seen her for three months. She has a camera in her mother’s room, which she watches relentlessly. She caught temporary nursing assistants taunting her mother; they were let go after she complained.
She has seen employees going into her mother’s room without gloves, or without a hair bonnet, she said. Some have had their PPE gowns “half hanging off.”
“I’m like, ‘You don’t think that’s why it’s spreading through the nursing home?’ ” she said. “The aides that normally take care of her are just amazing. I don’t blame the staff. I blame the nursing home.”
Newman said all staff members receive proper training. “All employees and agency staff have been trained and competencies given on proper application and removal of PPE.”
Darling, like Carlone, used to visit almost daily to help feed her mother. “I know the staff doesn’t have the time.”
Their experiences illustrate an important but unappreciated truth about American nursing homes: Family members provide a significant amount of the care for many residents. Nursing homes rely on them.
“They’re a strong complement to the staff, and another set of hands,” Grabowski, of Harvard, said. Now, because of the lockdowns, “there aren’t a lot of eyes on the care.”
Amy Vogelsmeier is a colleague of Popejoy’s at the University of Missouri, and together they are running a program called the Missouri Quality Initiative at 40 nursing homes, designed to improve the quality of care while still reducing avoidable hospitalizations. Families, she said, can often see changes in a resident before the staff notices; they have a “partner role.”
But beyond that, she said, every nursing home in America needs a registered nurse working full time on infection control — permanently. In their project, each nursing home has an advanced practice registered nurse full time. An APRN, she said, “is just an absolutely critical person.”
At Terrace View, “infection preventionists” began monitoring staff and residents on March 2 (the day after VestraCare took control of Absolut). Staff training on infection control began. Screening of staff and visitors started March 11.
“It was a combination of education and awareness,” said Thomas Quatroche, president and CEO of the Erie County Medical Center. Administrators, he said, forcefully emphasized to employees that they should stay home if they tested positive or became ill.
“Infection control is the most important,” he said. “But at the end of the day, some of that is chance.”
Terrace View has the advantage of a partnership with a hospital. (It currently has an abuse citation stemming from the alleged sexual assault of one resident by another.) Most nursing homes, including Absolut, can’t match that. Farbenblum said he aims to provide Aurora Park with wireless telemetry monitoring, RN staffing at night, 24-hour IV capability and a telemedicine platform for consultations with a physician. He has also just hired the former head of Terrace View as executive vice president for business operations.
Could deaths have been prevented if more nursing home residents had been taken to emergency rooms this spring?
In some areas, the strain on ambulance services presented an obstacle. Death from covid-19 sometimes came on quickly, especially among already frail people, even as short staffs were unable to keep close tabs on everyone. A significant number of nursing home residents have do-not-hospitalize orders. And some nursing homes apparently transported patients only as they drew close to death.
“This is not advanced care,” said Rowe, of Columbia University. “It’s last rites.”
Yet the coronavirus has exposed the deep inadequacies of a nursing home system that relies overwhelmingly on low-level aides.
“So underpaid and undertrained. So much stress,” said Rowe. “And they are the ones who are stepping up.”
The burden shouldn’t fall on them — or on the residents, Rowe said. “If I had good enough nursing staff, I could take care of nearly everyone in a nursing home.” That’s what it would take to treat in place.