Kentucky nursing homes failed at basic infection control for years. Then COVID-19 hit.

Public records show that many Kentucky nursing homes failed at infection prevention and control even before the novel coronavirus blazed through them over the last two months, infecting more than 1,000 of their residents and staff as of Friday and killing more than 120.

Among the places cited for errors as routine as a lack of hand-washing are seven of the 10 long-term care facilities now hardest hit by COVID-19, such as Rivers Edge Nursing and Rehabilitation Center in Jefferson County, Signature HealthCARE at Summit Manor in Adair County and Signature HealthCARE at Jackson Manor in Jackson County.

“Yes, we are amazed at how simple some of the infection control practices are that are continually violated,” Sherry Culp, executive director of the Nursing Home Ombudsman Agency of the Bluegrass in Lexington, said this week.

However, state regulators almost never issued a serious penalty for infection control violations, so they seldom resulted in fines or affected the federal government’s five-star rating system that the public uses to compare the quality of nursing homes, according to a Herald-Leader review of the 333 infection control citations issued to Kentucky nursing homes from April 2016 to December 2019.

It’s the same story across the country, said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy, which lobbies for better care for the elderly and disabled. Infection control citations are among the most commonly issued to nursing homes, as well as among the least penalized, Edelman said.

“We have a lot of nursing homes that get cited for infection control deficiencies year after year, and for really basic stuff like nursing aides not washing their hands between rooms. But our regulatory system is pretty toothless, so we haven’t been solving the problem,” Edelman said.

“Unfortunately, at a time like this, during a pandemic, we’re all seeing the results,” she said.

The Kentucky Cabinet for Health and Family Services nearly always determined there was “minimal harm” as nursing home employees failed to wash their hands, change gloves and disinfect equipment and supplies while walking from room to room among elderly and ailing residents, even when they handled urine and feces and cared for infectious patients in isolation, according to its own citations.

At various Kentucky nursing homes over the last three years, aides passed out food, drinks and pills to residents with their unwashed bare hands while also touching their own faces, hair and communal objects such as light switches and refrigerator door handles, according to inspection reports. Feces-stained bed sheets were put on residents’ bed tables where personal items were kept. Residents’ surgical wounds were not properly cleaned and dressed.

At Landmark of River City, a Louisville nursing home with 33 resident infections from COVID-19 and six resident deaths, a resident was placed in isolation in August 2017 with an infectious condition — Clostridium difficile — that causes symptoms ranging from diarrhea to life-threatening colon inflammation.

State inspectors watched the director of nursing and a maintenance technician enter the resident’s isolation room, touch his bed and various other objects and then leave for different rooms in the facility without ever donning gloves or gown or washing their hands, all in violation of infection control rules.

When the dietary supervisor delivered a meal tray to the isolation room, he did put on the requisite gown and gloves. Unfortunately, rather than remove the gear and toss it in the trash just inside the door, as he was supposed to, he walked down the hall to the nurses station, stripped next to a medication cart used for other residents and then, with his unwashed hands, delivered another resident’s meal tray.

“Minimal harm,” state inspectors concluded in their report.

‘Minimal harm’ or ‘immediate jeopardy’?

Time and again over the previous three years, the nursing home employees made these mistakes as state inspectors stood nearby, clearly monitoring them, according to the reports. In their subsequent interviews with inspectors, the employees sometimes said they had not received adequate infection control training, or their facilities were so under-staffed that they felt rushed in their jobs.

But only three of the cabinet’s 333 infection control citations since 2016 were classified as the most serious kind — “immediate jeopardy” — as compared to the less serious “minimal harm.”

One of the three immediate jeopardy citations was issued in March 2019 to Treyton Oak Towers in Louisville, which has seen 35 residents sickened and 15 more residents killed since the coronavirus pandemic began. In that case, state inspectors said Treyton Oak failed to clean a small blood-testing device carried from room to room, including isolation rooms that held infectious patients. Employees told inspectors they had not been taught how to properly clean the device. Treyton Oak paid a $11,278 penalty.

“Unfortunately, that’s typical,” Edelman said. “I’ve never understood why it’s not considered seriously harmful to have violations that could spread infection through a long-term care facility. And the problem is, unless it’s an immediate jeopardy citation with a serious financial penalty, neither the facility or the state is going to go back and make sure the problem is fixed for good.”

A spokeswoman for the Health and Family Services Cabinet this week declined to say whether the state did enough in the past to enforce infection control at nursing homes or whether it would take more aggressive steps in the future.

Instead, cabinet spokeswoman Susan Dunlap issued a written statement deferring to the U.S. Centers for Disease Control and Prevention.

“With respect to nursing homes, the cabinet has followed CDC-recommended protocols for infection prevention and control,” Dunlap wrote. “These guidelines are continuing to be followed in the face of the COVID-19 pandemic. Awareness of confirmed cases of COVID-19 in our commonwealth and in long-term care settings has resulted in the escalation of safety and infection control protocols and expanded emergency-scenario planning.

“Long-term care facilities are anticipating changes to CDC guidelines with respect to safety and infection prevention based on new learnings from combating the novel coronavirus. When these are issued, CHFS will follow them,” Dunlap wrote.

The cabinet official in charge of nursing home inspections is Inspector General Adam Mather, appointed by Beshear last December. Previously, Mather was regional vice president of operations for Signature HealthCARE, a Louisville-based chain of nursing homes that includes several of those hardest-hit by the coronavirus.

‘Room for improvement’

Even in normal times, up to three million infections occur every year in American nursing homes, killing an estimated 380,000 people, according to the U.S. Centers for Disease Control and Prevention.

Given this background, it’s no surprise the highly infectious coronavirus spread so quickly through nursing homes once it gained entrance, probably through an asymptomatic employee who was not showing a fever or cough, experts said this week. Kentucky Gov. Andy Beshear ordered the state’s nursing homes closed to visitors on March 10, but employees come and go with every shift.

After the pandemic began in early March, the U.S. Centers for Medicare & Medicaid Services sent a team of inspectors to the country’s hardest-hit nursing homes. They found that in 36 percent of the facilities, staff were not following proper hand-washing guidelines, and in 25 percent, staff failed to properly use personal protective equipment, such as masks, gloves and gowns, even when they had it.

“We are hyper-focused on infection control right now,” CMS Administrator Seema Verma told reporters at that time.

“Our role in this is to say, ‘Were there some breaches in protocol? Was this facility following the guidelines that are in place? Was there hand-washing? Were they changing gloves? Were they doing laundry appropriately? Was food handled appropriately?’” Verma asked.

Nursing homes often have certain limitations compared to hospitals when it comes to infection control, said Betsy Johnson, president of the Kentucky Association of Health Care Facilities. Johnson’s group lobbies for the nursing home industry in Frankfort and also offers infection control seminars for its members throughout the year.

“I’m not saying there isn’t room for improvement. There is,” Johnson said.

“But we’re dealing with a different kind of health care provider,” she said. “We’re not dealing with people who went to medical school for the most part. We’re depending on certified nurse aides. They’re just that — certified. They’re not licensed, they didn’t go to college.”

Also, Johnson said, some of Kentucky’s nursing homes are old, dating back to the 1960s when the federal Medicare and Medicaid programs began. Being outdated, their buildings make it harder for staff to comply with modern standards, she said.

“We don’t have the fancy hospital systems that you see in downtown Louisville or in Lexington and elsewhere throughout the state,” Johnson said. “You might have a room that doesn’t have a sink in it. It might not even have a private bathroom. And so, to do infection control, before you have a CNA or a nurse or somebody helping a resident, they would have to walk all the way down the hallway to wash their hands.”

“You know, they need to do that, I’m not saying they shouldn’t,” she added. “But our rooms can look very different from a hospital room. I’ve never been in a hospital room that didn’t have its own sink and bathroom.”