As vaccinations increase and COVID-19 infection rates in nursing homes plummet, it’s easy to forget just how bad things got in many of them and how ill-equipped many were in the the early months of the pandemic to provide humane and effective care.
The following excerpt is from our March Reflections essay, “Right Under Our Noses: Nursing Homes and COVID-19,” which was written by a California nursing professor who volunteered to join a California Medical Assistance Team. The mission of her team was to bring aid to a skilled nursing facility where the coronavirus was rapidly infecting both patients and staff, a facility with little PPE available and many staff members refusing to come to work out of fear of infection.
The conditions I saw were shocking, even to an experienced nurse. I saw soggy diapers on the floor at the heads of many beds on most mornings. One day a bedbound patient needed the bedpan. I searched every closet and drawer but there were no supplies. I filled a basin with warm water and cut up a PPE gown to make washcloths to clean the patient. On the second day of my deployment I realized that many of the patients were dehydrated. They had no access to water. A patient with dementia was sipping juice from a cup. I glanced in the cup and saw floating fly carcasses.
On the next block, behind closed doors.
The author makes the powerful point that intense suffering often happens behind closed doors, right under our noses. While not every facility had conditions so dire—and we should be clear that desperate and overburdened staff were not to blame for the breakdown in care resulting from systemic neglect and individual management decisions—a similar story played out in many settings and resulted in untold deaths.
The media has shown COVID-19 patients in clean hospital settings, not in the conditions I witnessed—conditions hidden from view only blocks from the homes of a very wealthy community. In the last two weeks of May 2020 I saw, firsthand, the inequality of the U.S. health care system.
The author describes her efforts to help formulate a plan to improve conditions, and her sense of the ethical quandary she faced in knowing it couldn’t possibly be enough. Most powerfully, she calls for a harder look in the coming months and years at how such care was allowed to happen, as well as the underlying inequalities that have been more fully exposed by these events.
A big problem is that federal and state regulations (or lack of them) have allowed the de-nursing of nursing homes. They are now called rehab or long term care facilities. In Florida in 2002, the CNAs of then SEIU Local 1199 worked, then slept on 10 hour bus rides to Tallahassee, lobbied and fought for the landmark “2.9” bills that assured an average of 2.9 hours of CNA care plus 1 hour of RN or LPN care per resident per day. At the time the average care hours were 1.4 to 1.6 hours/day. The bills became law which was not fully funded until 2008. The increase in staffing improved the quality of care in Florida’s nursing homes dramatically. The law came with a compromise of tort reform, making it more difficult for lawsuits against the facilities under the philosophy of it is better to prevent malpractice than to sue over it.
Every year since the full funding, the original bipartisan bill has come under attack from the Republican leadership, chipping away at the hours – now .3.5 hours/day of combined care. Most homes have also reduced RN positions to the federal minimum of one beside RN caregiver for 8 hours per day in the facility and 16 hours RN available by phone or radio. LPNs have filled the RN void.
During the pandemic some homes did well with infection control and isolation, but many issued one surgical mask for a week, no N95s and did not even notify the staff that they were caring for COVID-19 positive patients under the excuse of HiIPAA violation. Staff infection rates and resident rates as well as deaths from COVID were high resulting in lack of staff. Bad conditions resulted in increased resignations.
As an emergency response to this crisis, the Florida Agency for Health Care Administration (ACHA) which oversees nursing homes, allowed a new level of caregiver, the PCA or patient care assistant to fill in for CNAs and count in the 3.5 hour minimum. These workers are considered under the Nurse Practice Act as UAPs- unlicensed assistant personnel, who work under the license of the RN or LPN, but have no requirement for education, training, or limit of scope of practice other than the RN or LPN limit. As an emergency staffing source they were better than nothing,
The CNAs knew better what was about to happen. As the facilities get priority vaccinations, and COVID-19 rates decline, the Florida Legislature currently is moving bills to make the PCAs permanent and count in the 3.5 hours, threatening again the quality and safety of care given to nursing home residents.
Gross misconduct in protecting nursing home workers in the pandemic was addressed ultimately in our 1199SEIU UHWE Florida represented facilities by member leaders speaking out to management, then AHCA, then OSHA, and in some cases the press and the communities served by the facilities. Former Governor, now Senator, Rick Scott gutted the Ombudsmen independent oversight program and changed the burden of notification of problems on residents’ filing complaints, rather than regular inspections.
I cannot imagine the quality control problems in non-union worker represented nursing homes given the inconsistent responses from AHCA and OSHA, and now the ability to replace CNAs who make complaints or demand adequate PPE, training and isolation equipment, policy and staffing enforcement, with untrained, non-accountable PCAs.
As resident and patient acuity of nursing homes has increased over the years, the answer is to increase the minimal RN and certified caregiver minimums nationally by CMS and HHS. Let’s put the nurses back in nursing homes and allow no caregiver less educated than CNAs, which by the Nurse Practice Act have a defined limited scope of practice and have accountability by their certification, not just someone who is working under a nurse’s license and is minimally trained, supervised and non-accountable for any standards.
For those in Florida, please call your state senator and representative and tell them you oppose HB 485/SB 1132 Patient Care Assistants.
I am proud of our union member leaders who stood up for the quality of care for their residents and for standards for protection of the workers. They still do not make a minimum wage of $15/hour nor have affordable healthcare as the Florida Republican-majority governors and party leadership have steadfastly refused Medicaid Expansion, despite many Republican State Senators voting for and introducing similar versions of ME.
Elections have consequences.
Governors and legislators work for us, We must hold them accountable for the safety of the residents and caregivers.