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COVID Deaths Spiral Higher in Nursing Homes; 20,000 Dead in 4 Weeks

More than 200,000 new COVID cases in that time, AARP analysis shows

American nursing homes last month reported their highest COVID-19 death rate since they began submitting data to the U.S. government, a new AARP analysis of federal data shows. Over four weeks, from late November to late December, 19,386 residents and 184 staff died from the virus.

As deaths spiraled — adding to the nation’s long-term care death total of roughly 133,000 residents and staff, which represents 37 percent of all deaths from COVID-19 in the U.S. — more than 200,000 residents and staff tested positive for COVID-19 during those four weeks, placing many more lives in danger.

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The figures represent startling jumps in COVID-19 deaths and infections in nursing homes nationwide since AARP began its monthly analysis of federal coronavirus data in September. The resident death rate quadrupled from 0.48 per 100 residents – around one death per 200 residents – for the Aug. 24 to Sept. 20 reporting period to 1.88 per 100 residents — nearly one death per 50 residents — for the most recent reporting period, which ran from Nov. 23 to Dec. 20.

The new figures mark the highest COVID-19 death rate since nursing homes began submitting data to the government last May.

New resident cases have increased fourfold since AARP launched its monthly analysis, jumping from 2.6 to 10.8 per 100 residents for the same reporting periods, with new staff cases rising from 2.5 to 9.3 per 100 residents.

“The numbers speak for themselves,” says AARP’s Elaine Ryan, vice president of state advocacy and strategy integration. “It’s just a devastating failure on the part of the federal and state governments to protect lives.”

For months, she says, “it’s been the same story: raging infections and tragic deaths that could have been prevented.”

“Now occurring everywhere”

The analysis also shows that no region of the country, except for Hawaii, is immune from the COVID crisis ravaging nursing homes. While in previous analyses, national trends have been largely driven by a series of intense regional outbreaks, the new analysis shows that the virus is now out of control in almost every state.

“We saw outbreaks in the Northeast in the early stages of the pandemic, then across the Sunbelt over summer, then more recently in the Midwest,” says AARP’s Ari Houser, a senior methods adviser and coauthor of the new analysis. “But the new data shows severe impacts are now occurring everywhere.”

Since the four-week reporting period ending Sept. 20, the rate of new resident cases has increased in every state except Hawaii and Florida, while the rate of resident deaths has increased in every state except Hawaii, Florida and South Carolina. It is notable that Florida and South Carolina were experiencing surges in August and September, but while they managed to ease off in early fall, both deaths and cases have risen in the latest reporting period.

And every state except Hawaii has seen an increase in the rate of new staff cases. Nursing home staff, who because of low wages often work in multiple facilities, unwittingly but commonly introduce the coronavirus into nursing homes, especially when the rate of community transmission is so high.

COVID is not only rampant in nearly every state, “it’s inside or knocking on the door of nearly every nursing home in those states,” says Houser. In the four weeks ending Dec. 20, 87 percent of nursing homes had at least one confirmed staff case. Over the same period, 59 percent had at least one confirmed resident case.

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Since the beginning of 2020, 90 percent of nursing homes in America have reported a resident with COVID-19.

spinner image a funeral director standing next to an empty stretcher waits outside a nursing home door
Tim Tai/The Philadelphia Inquirer via AP

Infection-control failures

The supply of personal protective equipment (PPE) to nursing homes has improved over the course of the pandemic, the analysis found.

From June 1 to June 28, the earliest period AARP’s analysis captures, 29 percent of nursing homes reported insufficient PPE, defined as having less than a one-week supply of N95 respirators, surgical masks, eye protection, gowns and gloves. From Nov. 23 to Dec. 20, 18 percent reported shortages. 

But Ryan says the analysis shows that improving PPE supply alone “is not working.” Infection-control deficiencies, a longstanding issue at nursing homes that pre-dates the pandemic, persist.

That’s largely because the training of nursing home staff in COVID-19 prevention practices has been subpar, according Toby Edelman, an attorney at the Center for Medicare Advocacy. She says the decision made by the Centers for Medicare & Medicaid Services (CMS) at the beginning of the pandemic to require nursing aides to complete only eight hours of online training for certification — instead of the previously required 75 — has had severe consequences.

“It’s complicated,” she says of proper PPE use. “You don’t just pick it up and throw it on. You have to put it on and take it off in a certain order, and you need to be trained in how to do that.

“You need to know how often to wash your hands, how often and when exactly to change gloves,” says Edelman. “There are a lot of things they need to know, so if they’re only getting eight hours of training, I don’t see how they’re getting through enough infection control.”  

Although CMS released a training program to help nursing home staff combat the spread of COVID-19, only around 125,000 workers — approximately 12.5 percent of the nation’s one million nursing home staff — had completed the program as of Nov. 17.

Staffing shortages are also driving poor infection-control practices, according to Charlene Harrington, professor emerita and a nursing home researcher at the University of California, San Francisco.

“When you’re short-staffed, workers are just running from patient to patient — trying to feed them, take them to the toilet, the basic things,” she says, “and things like handwashing go out the window.”

With so many staff infected with the virus, more temporary workers are entering nursing homes. “If the staff don’t know the residents, the routines, the facility’s procedures, that can be really bad for infection control,” Harrington says.

Vaccines slow to arrive 

Although almost all states have followed the CDC’s guidance by moving nursing home residents and staff to the very front of their vaccine line, slow distribution, poor uptake among staff, and issues with the federal program charged with vaccinating America’s long-term care community have delayed the effort.

“While the COVID vaccine holds great promise for everyone, the thought the most vulnerable cannot get that vaccine in real time is outrageous,” says AARP’s Ryan.

It will be well into February before nursing home residents and staff are actually protected from the virus by vaccines, says Sondra Norder, president and CEO of St. Paul Elder Services in Wisconsin. For assisted living residents and staff, that date is even further away. 

“We really need the community to understand that the continued risk to facilities like ours is really serious, especially now with cases surging across the country,” Norder says, as more than a quarter-million new cases and near or above 4,000 deaths across the U.S. have been reported on recent days, setting records for the pandemic.

“Even though there’s light at the end of the tunnel there, the lights are all still blinking red for us.”

The analysis, conducted by the AARP Public Policy Institute and the Scripps Gerontology Center at Miami University in Ohio, draws primarily on data acquired from the Nursing Home COVID-19 Public File by CMS. Nursing homes are federally certified and are required to submit data to the government each week. The analysis groups data into the following reporting periods: June 1 to June 28, June 29 to July 25, July 26 to Aug. 23, Aug. 24 to Sept. 20, Sept. 21 to Oct. 18, Oct. 19 to Nov. 15, Nov. 16 to Dec. 6 (a Thanksgiving Special Report) and Nov. 23 to Dec. 20. Around 93 percent of the nation’s 15,000-plus nursing homes submitted data for each reporting period.

The analysis focuses on five key categories of COVID-19 impacts — resident cases, resident deaths, supply of PPE, staff cases and staff shortages — and captures data only from federally certified nursing homes, not all long-term facilities (such as assisted living, independent living, memory care and others), as some other tallies do. This is the fourth in a series of monthly AARP analyses. An updated analysis will be released next month, as new federal data becomes available.

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