‘Implausible.’ As COVID-19 battered KY nursing homes, inspectors cited few infection problems
State inspectors say they have found almost no infection control deficiencies in Kentucky nursing homes even as COVID-19 spread through 162 of them, killing 330 people as of Thursday and infecting more than 2,300, according to a Herald-Leader review of published inspection reports.
COVID-19 has reached at least 57 percent of Kentucky’s 285 nursing homes. But by Tuesday, the Kentucky Health and Family Services Cabinet identified deficiencies in only 3 percent of the 202 inspection reports it had released.
Critics say such a low number is hard to believe.
“How could it be that everyone is doing such an excellent job that we can’t find deficiencies, and yet all of these residents are getting COVID and dying?” asked Toby Edelman, senior policy attorney for the Center for Medicare Advocacy in Washington, which lobbies for better care for the elderly and disabled.
“Is the virus just spreading by magic?” Edelman asked. “Or do we in fact have some infection control problems that we’re consistently failing to detect?”
Ridgewood Terrace Nursing Home in Hopkins County lost 24 of its 100 residents to the novel coronavirus over the last three months. Gov. Andy Beshear publicly mourned two of them in April: Doug and Freda Jones, grandparents who were married for 63 years and died within days of each other.
“The coronavirus has done something unthinkable to this family,” Beshear said in a choked voice at his April 21 news conference. “This is not supposed to happen. I cannot imagine their pain.”
Like nearly one-fourth of Kentucky nursing homes, Ridgewood Terrace entered the pandemic rated “much below average” in its quality of care by the U.S. Centers for Medicare and Medicaid Services. State inspectors cited it over the last three years for poor infection control, resident abuse, failure to report abuse and inadequate staffing. It paid nearly $75,000 in civil fines in 2018.
But on April 7, following an infection control survey, the Office of the Inspector General at the health cabinet published a short, tersely worded report finding “no deficient practice identified” at Ridgewood Terrace.
Having a quarter of the resident population die from an infectious disease does not violate infection control regulations, the cabinet says.
“Facilities with a large number of deaths or a large number of positive cases cannot be cited on the grounds of an outbreak,” said cabinet spokeswoman Susan Dunlap in a prepared statement.
Ridgewood Terrace referred questions to its corporate owner, Concord Health Systems of Madisonville, which did not respond to requests seeking comment.
Until COVID-19 arrived, 41 percent of Kentucky nursing homes received infection control deficiencies in multiple consecutive years, often for violations as basic as employees failing to wash their hands, properly use protective equipment, disinfect supplies or isolate infected residents, according to a federal report released in May.
“The fact is, infection control is the No. 1 deficiency in our nation’s nursing homes,” Edelman said. “Except suddenly we’re told it’s not happening anymore, right in the middle of a pandemic where thousands and thousands of nursing home residents are dying of infection.”
Kentucky’s numbers are close to the national average, Edelman said. Her group published a study last week finding that only 2.83 percent of infection control surveys of nursing homes nationwide have identified deficiencies during the pandemic.
“I find that to be implausible,” Edelman said.
Edelman isn’t the only one concerned.
The watchdog agency at the U.S. Department of Health and Human Services has announced that it will investigate how well the federal and state governments are overseeing nursing homes during the pandemic, given the staggering death toll among residents. The agency called state inspections a “fundamental safeguard.”
Many nursing homes already were struggling to provide care with too few qualified employees, and they collapsed into chaos once a highly infectious virus breached their walls, a certified nursing assistant from Chicago told the U.S. House Select Committee on the Coronavirus on June 11.
“When you have one CNA who is working and they have 15 residents and they are given seven towels and seven diapers, there is no way for them to do everything that needs to be done,” Chris Brown testified to the committee. “These things were going on before COVID. The only thing COVID did was blast the doors open.”
Kentucky Health Secretary Eric Friedlander and Inspector General Adam Mather did not respond to requests to be interviewed for this story.
Before he was hired by Beshear last winter to regulate nursing homes, Mather was the regional vice president of operations at Signature HealthCare, a Louisville-based nursing home chain that is dealing with its own COVID-19 tragedies. Thirty residents and two employees at Signature facilities in Jackson and Adair counties have died after contracting the coronavirus.
Betsy Johnson, president of the Kentucky Association of Health Care Facilities, which lobbies for nursing homes in Frankfort, declined to comment about the findings of state inspections during the pandemic.
“I can’t really talk about this, I’m sorry,” Johnson said before hanging up the phone this week.
The nursing home industry protested during the early days of the viral outbreak that it was last in line for personal protective equipment and COVID-19 tests, getting less attention than hospitals and local health departments. More recently, the industry has said the Medicaid reimbursement rate paid to nursing homes doesn’t cover the expense of responding to the coronavirus, including the need for additional staff, equipment and cleaning.
“We are at a point where difficult decisions have to be made on how to survive,” Signature HealthCare chief executive officer Joe Steier said June 10, announcing that his company was cutting 100 positions.
Few complaints substantiated
The Herald-Leader reviewed 202 nursing home inspection reports produced by the inspector general’s office since March 10, the day Beshear closed the state’s nursing homes to the public because of the infection threat posed by the coronavirus. (These reports cover 186 facilities, some of which were inspected more than once.)
During this period, the states have been ordered by the Centers for Medicare and Medicaid Services to halt their traditionally expansive inspections of nursing homes. Instead, states are supposed to focus narrowly on infection control and “immediate jeopardy” issues, such as abuse and neglect, that could threaten residents’ lives.
Of those 202 so-called “COVID surveys,” seven reported finding deficiencies. The deficiencies included:
▪ failure by staff to wear masks inside the facility (Rockcastle Health and Rehabilitation, Rockcastle County; Signature HealthCare at Summit Manor, Adair County);
▪ improper donning of personal protective equipment (Bluegrass Care and Rehabilitation, Fayette County);
▪ failure to provide necessary care (Landmark of Elkhorn City Rehabilitation and Nursing, Pike County);
▪ and infection control and failure to provide necessary care (Christian Health Center, Hopkins County).
Two reports said deficiencies were found in nursing homes but did not identify the problems. (Those nursing homes were Princeton Nursing and Rehabilitation in Caldwell County and Signature HealthCare of Bowling Green in Warren County.) The cabinet refused to comply with an Open Records Act request by the Herald-Leader to provide copies of all deficiencies issued since March 1.
The reports did not identify any fines issued for the deficiencies.
One or more complaints had been made against nursing homes before 50 of those inspections, according to the reports. But inspectors said they only could substantiate complaints in two cases, resulting in the two deficiencies in the Caldwell and Warren county nursing homes.
The reports do not reveal anything about the complaints, such as who made them, what they alleged or how it was determined they could not be supported.
The cabinet also refused to comply with an Open Records Act request by the Herald-Leader for information about the complaints. Dunlap, the cabinet spokeswoman, only would say that “residents, family members, caregivers or others” can file complaints about nursing homes with the inspector general.
‘Problems being lost’
Why are state inspectors unable to find infection control problems in most nursing homes despite roughly 2,300 known coronavirus infections in three months?
One big difference is how closely inspectors are looking.
Until the pandemic, teams of inspectors on a traditional survey would spend several days inside a nursing home — wandering through rooms, watching the staff interact with residents, studying the physical condition of the facility and asking people questions.
Inspectors sometimes caught serious mistakes because, after sticking around for a couple of days, they were able to witness routine lapses in care firsthand.
In January, for example, state inspectors spent three days on a traditional survey inside Signature HealthCare at Jackson Manor in Jackson County. They wrote a 34-page report detailing a variety of problems, often because the facility did not have enough employees on duty. By speaking to many people throughout the nursing home, the inspectors heard about long delays in bedside assistance when there were just two or three overworked aides trying to manage the entire building during the overnight shift.
For COVID surveys, though, the pace has quickened. CMS issued a July 31 deadline for states to inspect all of their nursing homes at least once or else risk losing a portion of their federal CARES Act funds. Kentucky has 285 nursing homes across 120 counties.
And rather than allow extended tours by a survey team, CMS has limited COVID inspections to one or two people filling in boxes on a “streamlined review checklist” of questions, such as: Do employees wear masks properly? Do they wash their hands and have easy access to disinfectant? Has the facility ended communal dining and other group activities?
Instead of face-to-face conversations throughout the facility, inspectors are encouraged to follow up with phone interviews with managers to reduce the amount of time they spend in nursing homes, which otherwise are closed to visitors to prevent the spread of COVID-19.
“It’s different and abbreviated,” said Sherry Culp, the Kentucky State Long Term Care Ombudsman.
Culp’s independent, nonprofit watchdog agency, which in ordinary times is a constant presence in Kentucky nursing homes, chatting with residents, has not been allowed inside the facilities during the pandemic.
“I do think there are problems being lost or missed,” Culp said. “Their focus now is so much smaller. It’s narrower. They’re not spending days walking around the facility and talking to a lot of different people as they do with an annual survey, when you really learn what’s going on.”
“Just moving quickly through a facility and checking off boxes, asking if the regulations are being followed on the day that you’re there — I don’t think you’re going to catch what you used to, or need to,” she said.
Back at Jackson Manor, the coronavirus devastated the nursing home a few months after its critical inspection in January. Fifteen of its residents have died after testing positive for COVID-19 while 63 residents and staff have been infected.
State inspectors returned to Jackson Manor during this crisis for a COVID survey and wrote a three-paragraph report. There had been a complaint against the facility that the report does not identify, but inspectors said they could not substantiate it.
As for infection control: “No deficient practice was identified.”
This story was originally published June 19, 2020 at 11:26 AM.
