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Nursing homes’ unclear death toll has states testing corpses

Elise Young and Keshia Clukey
Bloomberg

Connecticut is swabbing corpses at funeral homes. Maryland is testing all nursing-home residents and staff, symptomatic or not. Coast to coast, governors have intensified efforts to get accurate death counts at the facilities as investigations suggest far more devastation than initially recorded.

In New York and New Jersey, tallies of deaths from the novel coronavirus surged in recent days after the states began disclosing more data on nursing-home residents. On Sunday, New York Governor Andrew Cuomo added a requirement that all positive test results for staff must be reported to the state health department by the next day.

In this April 8, 2020 file photo, health care workers carry personal belongings of a patient to a waiting ambulance as the Magnolia Rehabilitation and Nursing Center in Riverside, Calif., is evacuated.

Nursing homes account for at least a third of the nation’s 76,000 Covid-19 fatalities, and in 14 states they’re more than half the total, according to Kaiser Family Foundation data from Thursday. Those numbers, though, are woefully incomplete because 18 states aren’t disclosing such data and those that are provide varying levels of information. As officials struggle to measure and understand the true toll, the virus continues to victimize the frail and elderly in even the best-run facilities, said Elizabeth Dugan, associate professor of gerontology at the University of Massachusetts in Boston.

“They’re almost like sitting ducks,” said Dugan, whose research team warned of imminent widespread nursing-home infections in early March.

Around the same time, one of the first major U.S. outbreaks of Covid-19 took place at the Life Care Center in Kirkland, Washington. Since then, the number of deaths linked to that facility has more than tripled, to 45 as of Thursday.

Data Mystery

The Centers for Medicare and Medicaid Services on April 19 started requiring long-term care facilities to report Covid-19 cases. And the U.S. Centers for Disease Control and Prevention has said it will penalize nursing facilities that don’t submit weekly infection updates.

Some states have been forced to do their own detective work. Connecticut’s chief medical examiner, Dr. James Gill, sent investigators on the trail of vague death certificates, going so far as to swab the deceased as their bodies awaited cremation. Of 65 dead nursing-home residents his staff tested at funeral homes, 54 were newly found to be positive, he said.

“Acute respiratory failure’ isn’t a cause of death – it means the person’s dead, and you have to answer why they had acute respiratory failure,” Gill said in an interview. As of Wednesday, more than 1,200 Covid-19 deaths were confirmed at Connecticut nursing homes and another 399 were probable.

In California, autopsies detected coronavirus in two individuals who had died at home, pushing back Santa Clara County’s first known cases to February, almost a month earlier than previously reported. On April 30, the CDC made recommendations specifically for coronavirus testing during postmortem exams.

In New York, a tally of nursing- and adult-care home deaths jumped to 5,215 as of Wednesday with both confirmed and presumed cases being counted. That’s up from a total of 3,653 deaths the state had reported as of April 28. New Jersey on April 30 reported 458 deaths, its biggest daily tally, which added earlier fatalities newly ruled as virus-related. Officials said the new figure included nursing-home residents, but they didn’t know how many.

Both states are conducting broad inquiries amid reports of improperly stored bodies, scarce personal protective-equipment and poor communication with families and officials.

Private Operators

About 70% of the nation’s more than 15,000 nursing homes are run by companies, including Life Care Centers of America Inc. and HCR Manorcare, which each operate more than 200; and publicly traded Genesis HealthCare, which has more than 300, and whose founder died in April after a long-term illness and Covid-19 complications.

All of the homes are regulated by federal and state laws, while care is funded by a mix of Medicaid, Medicare, private insurance and individuals. Though President Donald Trump’s administration previously had worked to ease government regulation of the nursing-home industry, it said after the first virus outbreaks in U.S. facilities that its inspections oversight would emphasize infection control.

The American Health Care Association and National Center for Assisted Living, representing most of the nation’s long-term homes, acknowledges that not all coronavirus deaths have been counted, and says its members “are being as responsive as they can with the resources they have been given.”

“Without additional testing, our nation’s providers have no way of knowing who has or may have succumbed to the virus, especially those who are asymptomatic,” Cristina Crawford, a spokesperson for the groups, said in an email. “Therefore, non-reporting is not necessarily due to a lack of willingness, but a lack of accessibility to tests.”

Lawsuit Shields

At least 15 states have enacted shields against coronavirus-related lawsuits involving long-term care facilities, and the organization was urging more to do the same.

“It is critical that states provide the necessary liability protection staff and providers need to provide care during this difficult time without fear of reprisal,” Crawford said.

Nursing homes and adult-care facilities account for more than 25% of the 21,000 deaths in New York, the hardest-hit state. As more information comes in, he said, the numbers will change, Governor Andrew Cuomo said Wednesday at a press briefing.

Clearer Reports

Some nursing homes previously were combining presumed deaths with confirmed, according to Cuomo adviser Jim Malatras.

“Now we’re putting up both categories so people can clearly see, because some of the facilities were reporting both together and it was difficult to tease out,” Malatras said. “So we’ve asked them to report clearly that line of confirmed and presumed.”

Cuomo on April 23 announced state health department and attorney general investigations to ensure nursing homes are complying with guidelines. The inquiry includes whether the facilities have notified residents and their families within 24 hours of discovering virus cases or deaths. On Sunday, the governor added measures to protect the state’s 100,000 nursing-home residents, including requiring all workers to be tested for Covid-19 twice a week

State Detectives

In New Jersey, Attorney General Gurbir Grewal has been investigating some long-term homes since April 16, after reports of unusually high fatalities and shortages of equipment and staffing.

“For many of these facilities, this was the equivalent of a 500-year flood – but that doesn’t mean that we shouldn’t examine how folks responded when those floodwaters started rising,” he said at a news conference on May 5, when he asked anyone with knowledge of missteps to contact investigators at covid19.nj.gov/LTC.

A day later, Governor Phil Murphy said the state had hired two outside experts to examine “incredibly uneven performance” among nursing homes. Of the state’s 9,255 coronavirus deaths as of May 10, more than half were long-term care residents. Several cases turned up after the state ordered better reporting.

“Was it just a delay in reporting versus willful? I think that’s why the attorney general is involved with a task force looking at this,” Murphy said. “I hope it is: We were late. We were overwhelmed. It was a 500-year flood,’ as opposed to anything willful.”

Makeshift Morgue

Murphy also assigned 120 National Guard personnel to perform non-medical tasks to boost staffing at such homes, including the state’s largest, in Andover, where authorities removed 17 bodies from a makeshift morgue in mid-April.

“The performance by the operators has been extremely disappointing,” Murphy said at his Saturday virus press briefing. “Not in every case, but in too many cases. Uneven, disappointing, lacking in communication, lacking in some basic blocking and tackling.”

The Centers for Medicare and Medicaid Services on May 6 fined that facility, Andover Subacute and Rehabilitation Center II, more than $220,000, citing non-compliance that put residents in “immediate jeopardy.” At least 94 residents and staff have died of coronavirus, according to the report, which cited missing temperature logs and symptomatic patients who weren’t tested.

Chaim Scheinbaum, the home’s owner and operator, wasn’t available to comment on Friday, according to the home’s staff. He didn’t respond to a voicemail left on an administrative line.

Offensive Move

In Maryland, Governor Larry Hogan on April 29 ordered testing of all nursing-home residents and staff, “regardless of whether they’re symptomatic or not.” States including Massachusetts, Wisconsin, South Carolina and West Virginia have done the same.

Minnesota is expanding testing of residents and staff, stockpiling personal-protective equipment and relying more on local health specialists. The facilities house less than 1% of Minnesotans, but account for 80% of the state’s Covid-19 fatalities, according to Jan Malcolm, the state health commissioner.

“We have to be ready for it to continue to spread, and that’s where I think we need to get less reactive and more proactive,” Malcolm said.

In Colorado, Governor Jared Polis, a Democrat, criticized the federal government for not providing enough tests early on to check asymptomatic workers and keep down infections in nursing homes, where there have been at least 342 fatalities.

Inspectors since March 22 have issued 137 citations after infection-control reviews of about 20% of the state’s 1,081 long-term homes, officials said on Wednesday.

“We want to find out if there are nursing home and senior centers that are trying to cut corners, and make sure they’re penalized appropriately,” Polis said.