En español | Six days a week, for up to 12 hours a day, Sherry Perry cares for elderly residents at a nursing home outside of Nashville, Tennessee. She supports 13 to 18 people per shift, changing their soiled clothes, brushing their teeth, giving them baths.
As nursing homes across the country have become ground zero for the coronavirus epidemic, Perry, 51, is worried.
Nursing aides at her facility, which Perry asked not be identified to protect her job, are provided a single cloth face mask for each shift, she said. They don't wear gowns or the more protective N95 face masks because her facility hasn't confirmed any coronavirus cases. But she knows that a single asymptomatic case of COVID-19, or one that's yet to be diagnosed, could quickly spread to workers and residents.
"We are so up close to the residents, in their faces doing their care,” she said. “They are touching us. How are we going to stop it?"
Across the country, nursing assistants — who are some of the country's lowest-paid health care workers — are asking the same questions. More than 55,000 nursing home residents and staff members have contracted COVID-19; more than 11,000 have died. In some states, more than half of coronavirus deaths have been in nursing homes.
Most of the public attention has been focused on the nation's 1.3 million nursing home residents, who are most vulnerable to the virus and who are thought to represent the vast majority of deaths. But hundreds of thousands of nursing assistants are also in mortal danger every day. It's unclear how many have gotten sick or died, but their facilities are running short of face masks, gowns and other personal protective equipment (PPE). And many nursing assistants complain that low wages, lack of benefits, high turnover and staffing shortages are making them and their facilities even more vulnerable to the coronavirus.
"Care staff are getting sick, but they can't afford to stay home,” said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group. “They take an aspirin and they go to work."
All of which makes nursing home residents more vulnerable, too.
A low priority for coronavirus response
One reason nursing homes are so vulnerable is that they were not the initial focus of the federal coronavirus response, which prioritized hospitals, said Elaine Ryan, vice president of government affairs for state advocacy at AARP. “In many ways, nursing homes were unfairly a second priority for receiving personal protective equipment,” she said. “Federal and state governments did not make them a priority, and that resulted in thousands of people losing their lives."
Sterling Harders, president of SEIU 775, a labor union that represents health care workers in Washington and Montana, said nursing home caregivers are using the same N95 masks for up to a week when taking care of COVID-19 patients. At one facility, Harders said, workers are sterilizing the masks with a disinfectant that causes rashes on their faces. Prior to the outbreak, the reuse of N95 masks would have violated Centers for Disease Control and Prevention guidelines, but those guidelines have been relaxed to conserve supplies during the pandemic.
"Our society is telling these workers, who are mostly women, women of color, and immigrants, that they are essential,” Harders said. “Yet we are not paying a living wage and we are not giving them the basic supplies they need to do their work safely."
Jayne Keller, vice president of senior living at Cappella Living Solutions, which manages 24 nursing homes in seven states, said nursing homes are desperately searching for personal protective equipment. Some facilities in her system have residents who've tested positive for COVID-19, she said, but workers are rationing equipment so they don't run out.
Keller said her company's equipment orders have been “seized, diverted and reallocated” to hospitals, and the company has had to get creative. It's turned to alcohol distilleries for hand sanitizer and is ordering rain ponchos from Amazon for workers to use as gowns.
"We are reusing PPE that we would never reuse in the past,” Keller said.
Less than $15 an hour
Evelyn Liebman, director of advocacy for AARP New Jersey, said the pandemic is highlighting staffing problems that have plagued many nursing homes for years.
"They are short-staffed, and they don't have enough PPE,” Liebman said. “They are just completely overwhelmed.” AARP has asked New Jersey to deploy the National Guard to assist at long-term care facilities, as many other states have done.
Many nursing assistants make less than $15 an hour, and there's high staff turnover. About 700,000 certified nursing assistants (CNAs) work at nursing homes, according to the National Association of Health Care Assistants. They make up the overwhelming majority of care workers at nursing homes. Unlike hospitals, nursing homes are not meant to provide critical care, and registered and licensed practical nurses, who hold higher-level positions, are far outnumbered by low-skilled care workers.
Before the pandemic, nursing homes required certified nursing assistants to have a minimum of 75 hours of training. For now, some of those hours may be waived.
Some academics and advocates accuse nursing home owners of purposely understaffing facilities, and underpaying workers, to maximize profits. The industry blames inadequate funding from Medicaid, which pays the bills for 60 percent of residents, according to the Kaiser Family Foundation.
"I don't believe there is a caregiving shortage,” said Keller at Cappella Living Solutions. “We have often offered CNA classes, but we have had to cancel them because of a lack of interest."
A lack of respect
Others say the industry needs federal help to attract workers to a difficult job that pays barely more than fast-food restaurants.
The American Health Care Association, which represents mostly for-profit nursing homes, said in a statement that it has sounded the alarm for years about an underpaid workforce. “This issue will not be fixed overnight,” it said. “Once we get through this pandemic, we need Congress to support innovative programs that will help recruit, retain, and attract people to work in long term care to ensure our nation can support the needs of our residents and patients."
Lori Porter, executive director of the National Association of Health Care Assistants, said that many workers are single moms and that many work at multiple facilities to make ends meet. Many positions are part time, without benefits. Infected workers have the potential to spread the virus between nursing homes, but because of the lack of testing, asymptomatic workers have no idea that they're spreading the virus.
Other nursing assistants are staying home out of fear, if they can afford to, Porter said. “They are scared to death,” she said. “They are willing to risk their lives, but they don't want to risk their children's lives."
Lisa Sweet, 51, a caregiver in Iowa, has been working in nursing homes since she was 18. The most difficult part of the job, she said, is the lack of respect, which she now feels more keenly than ever. People and businesses that are celebrating the work of doctors and nurses and sending pizzas to hospitals don't think about the role of the nursing assistants who take care of older Americans, she said.
Yet her job has become just as terrifying.
"When you walk into work in the morning, it's like, Oh, gosh,” she said. “Your heart starts pumping. Am I going to get this? It's scary."