Health Care (Archived)

How NY nursing homes became death traps

Limited staff, insufficient training and a lack of funding.

New York nursing homes have become COVID-19 hotbeds.

New York nursing homes have become COVID-19 hotbeds. Tommy Larey/Shutterstock

Due to staffing shortages, low Medicaid payment rates and a questionable policy from the state Department of Health, nursing home deaths have skyrocketed since COVID-19 touched down in New York. On Tuesday, the state reported an additional 1,700 more nursing home deaths. About 4,813 New Yorkers have died from the coronavirus at nursing homes throughout the state since March 1, according to the state, including those who were suspected to have the virus but were not tested. That’s nearly one-fifth of the total of 25,028 New Yorkers who have succumbed to the disease.

As with deaths overall, New York has had more nursing home deaths caused by the coronavirus than any other state thus far. But it’s unclear exactly how many have actually occurred. Severalreportshave suggestedthat some nursing homes may be underrepresenting their COVID-19 deaths for fear of bad publicity

But how did New York allow its most vulnerable residents to be so widely exposed? Isn’t the state supposed to only grant operating licenses to facilities that ensure their residents’ safety? The state’s lack of a minimum staffing requirement at long-term care facilities, insufficient Medicaid funding and the state Department of Health’s decision to allow sick residents back into nursing homes all helped to create the perfect storm.

Nursing homes have always been conducive to the spread of disease. They’re known to have crowded quarters, overworked and underpaid employees performing tasks requiring them to come into close contact with residents, such as changing diapers and bathing and feeding residents. And the elderly and individuals with pre-existing conditions are especially susceptible to contracting diseases and are more likely to die from viruses. These factors combined with the state’s faulty response, already understaffed facilities, insufficient infection control and prevention, and a lack of funding helped turn the state’s nursing homes into death traps. 

The state Department of Health has been criticized for instating a policy on March 25 that forced nursing homes to accept COVID-19 infected residents back into their facility after being in the hospital. This affected nursing homes’ ability to safely isolate their sick residents from healthy residents. 

While the state has insisted that these facilities should only welcome sick patients back if they have the means to care for them, the department of health’s protocol clearly states that nursing home residents cannot be denied re-entry if they have COVID-19. “No resident shall be denied readmission or admission to the (nursing home) solely based on a confirmed or suspected diagnosis of COVID-19,” Newsday reported.

One might wonder why the Cuomo administration thought these nursing homes would be able to prevent COVID-19 from spreading, when there was already evidence that they lacked proper infection protections such as personal protective equipment and access to coronavirus testing. More than half of the nursing homes that were most ravaged by the outbreak were repeatedly warned by federal inspectors, over the past three years, that they were not meeting the state’s infection-control regulations, designed to prevent viral outbreaks. In 2016, the Society for Post-Acute and Long-Term Care Medicine published a report on infection control programs in nursing homes across the country and found that about 61% of the people they spoke to in charge of infection control and prevention at nursing homes had no training regarding infection control or prevention. Many personal care aides and certified nursing assistants that work in nursing homes in the U.S. are vastly under-trained and most don’t even need to obtain associate’s degrees in order to work at long-term care facilities, let alone a bachelor’s in nursing. About 36% of the nursing home facilities they looked at had received citations for not meeting infection control standards. While the report did not disclose which standards were violated, possible infractions could include failing to properly sanitize equipment or failing to report an infectious disease outbreak.The study concluded that most American nursing home staff are not properly trained to control or prevent infection. 

Nursing homes in New York have regulations regarding infection control practices. However, understaffing can lead to an increased risk of infection, even if workers are well-trained, as employees are more likely to make careless errors rushing from resident to resident during their shifts.

State Sen. Rachel May, Chair of the Committee on Aging, told City & State that one of the primary reasons why things escalated so quickly at nursing homes had a lot to do with “chronic” staffing shortages. The state doesn’t have any minimum staffing requirements for long-term care facilities. And as nursing home workers contracted the virus, facilities became more strained. Nursing home employees are low-paid and attracting adequate staff is difficult. “It's been hard to get anybody to do long-term care jobs for quite a while because at this point people can make more money working in fast food or something like that,” May said. “It's been really hard to recruit people into what is a very difficult job.” 

The state department of health’s Division of Nursing Homes and Intermediate Care Facilities for Individuals with Intellectual Disabilities Surveillance oversees New York’s nursing home conditions. The division also acts as a proxy for the federal government, making sure that nursing homes abide by federal and state regulations. Health inspections conducted by Medicare and Medicaid and any facility that violates any state or federal procedures is subject to citations and fees.

The state launched a probe into nursing home deaths across the state on April 23, after 3,500 nursing home residents died from the coronavirus and it was reported that nursing homes were without personal protective equipment and were not following safety protocols properly. Failure to comply with the state Department of Health regulations may result in a $10,000 fine for each violation or the revocation of a nursing home’s operating license. 

“We've said from the start that protecting our most vulnerable populations including people in nursing homes is our top priority and that's why the State acted quickly and aggressively to issue guidance specifically for these facilities on testing, infection control, environmental cleaning, staffing, visitation, admission, readmission, and outreach to residents and families,” the state’s health department said in a statement sent to City & State. “Our efforts are consistent with CDC and CMS guidance here and here and adopted in multiple other states including New Jersey, Connecticut, Massachusetts, Michigan, Illinois and California. The Department will continue to work with administrators of private and county nursing homes to do everything possible to protect the health, well-being and privacy of the residents who call these facilities home.” 

May has been working to create new initiatives to incentivize more people to work at nursing homes and other long-term care facilities by offering things like free childcare and student loan forgiveness – which many registered nurses already receive – and creating career ladders that ensure better pay in the future. Retaining employees at nursing homes is a nationwide problem. Most nursing assistant salaries are typically very low. In 2017, the average annual salary for a nursing assistant was $28,000. This often forces nursing assistants to work at multiple facilities. And the work can be grueling, often involving changing diapers and bathing people. May hopes that if the state provides these benefits it will give more people the impetus to work in nursing homes. 

But many nursing homes also cut back on staff in an effort to save money, since the state has no minimum staffing requirements. “You cut the staff because you can,” Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, told City Limits in 2019. “You cut it to the bone, and then what we end up seeing is terrible, terrible understaffing.”

The state senator also wants to create a tax credit for people that are caring for an elderly family member at home, in an effort to prevent them from putting them into nursing homes when they don’t need to be there, which puts more pressure on understaffed nursing homes. “We should be rewarding that work (taking care of a family member) and recognizing that work and making it easier for people to do that work, so that people don't have to go into nursing homes who don't want to,” May said. 

May has also said that another big reason why the state’s nursing homes were hit so hard by the outbreak stemmed from a lack of Medicaid funding. “(The state’s nursing homes) have gone 12 years without a cost-of-living rate increase for Medicaid recipients,” May said. “That means, in skilled nursing homes, they're spending a lot more money per day on care for their residents than they are receiving back from Medicaid. And that has led to a financial crisis and cuts to funding numerous times. The state has also cut some capital funding to nursing homes so they weren't able to expand or create safer spaces (for their residents during the onset of the outbreak).” 

The American Association of Retired Persons isn’t concerned with pointing fingers or placing blame on anyone for the state’s massive outbreak – yet. Its first priority is ensuring that Cuomo makes a concerted effort to coordinate relief for the state’s nursing homes, like he did with the state’s hospitals, and getting a task force set up to contend with nursing home-related issues amid the coronavirus crisis. The nonprofit wrote a letter addressed to the state on April 29, asking for it to do just that. “The governor did a great job organizing all of the hospitals in the state of New York, particularly down in New York City and Long Island to respond to the pandemic,” Bill Ferris, legislative director of AARP in Albany, told City & State over the phone. “But AARP is saying, now, today, that the government needs to have that same response to the long-term care system.”

The organization also wants the state’s nursing homes to better communicate with their residents’ loved ones, as many families statewide have complained that long-term care facilities failed to tell them when a resident contracted the coronavirus. Nursing homes in New York are legally required to notify a resident’s family of any COVID-19 cases at their facility within 24 hours, once they discover a resident is sick. Ferris suggests that Cuomo invoke an executive order to facilitate better communication between nursing homes and their residents’ families.

The state currently has a long-term care Ombudsman Program which is in charge of investigating any complaints regarding long-term care facilities, such as nursing homes. However, according to May, the program is underfunded and has seen a progressive decline in the number of volunteers it uses to sift through the complaints and assess what nursing homes need to be investigated. May said she fought hard to get more money for the program included into this year’s state budget but was unsuccessful. “In terms of there being people out there to find out what's going wrong in nursing homes, that also was not functioning at the level it should,” she said.