Caring for COVID-19 Patients and Staff in Nursing Homes

According to recent data, 40 percent of people in the United States who died from COVID-19 have been long-term care residents. And this is a conservative estimate. Moreover, it is not only nursing home patients who have suffered disproportionately from the pandemic; so too have the medical professionals who care for them. From staffing shortages to isolation, from health risks to mass furloughing, essential healthcare workers have faced unprecedented challenges in the ongoing fight against the disease.

To better understand these challenges and to think through possible changes to make life better for both nursing home patients and staff, I spoke with Keziah Furth, RN, a school nurse in Boston, Mass. As soon as her full-time job went remote, Furth decided to volunteer her talent, time, and energy to care for COVID-19 patients in a local nursing home. Below are excerpts from our interview, which have been edited for clarity.

Elise Amez-Droz: What was it like to work at a nursing home during the peak of the pandemic? What challenges did you face?

Keziah Furth: There were really two main challenges. First, you have simultaneously a sudden increase in the acuity level of patients. I was working in a memory impairment unit whose residents need reasonably high levels of care in normal times. Now, consider that 30 of our patients were COVID positive. While a few were facing major respiratory issues, most of them just experienced a significant increase in their weakness, and therefore their need for care. Residents who might have been able to feed themselves or use the toilet independently needed full assistance.

Second, COVID-19 created staffing shortages. These two challenges together created a perfect bombshell. Some nurses were out because they were sick themselves or had to be home to care for sick family members. Some were out because of their own high-risk medical status. A large number of nursing assistants simply refused to come to work. That high acuity was quite the challenge. Most days I was the only nurse working with as many as 18 to 20 patients. It’s a lot, and it’s scary, and it's really hard to feel like you're doing the job well.

Amez-Droz: Many states waived restrictions to the deployment of telemedicine during the pandemic to help patients access services from their homes during the lockdowns. Was there any use for telemedicine for inpatient care? Did your colleagues and you make use of telemedicine and teleconferencing to care for COVID and non-COVID patients?

Furth: It was never offered as an option during the time that I was there. I think it could have been useful. Staff going in and out of rooms undoubtedly contributed largely to the spread of COVID within the unit. To some extent, that's unavoidable, as staff must feed and bathe people and give them their medications.

But the nurse practitioners and physician assistants who come to the facility for an hour or two to check on patients and then go to a different facility likely contributed to the spread. If we could have cut back on them specifically and done those interactions via telemedicine, it's possible that we would have controlled the spread better. There weren't systems in place, and we didn’t have the equipment for it. We would have needed to conduct training or orientation ahead of the pandemic.

Amez-Droz: Virtually no visitors were allowed in nursing homes during the pandemic, leaving residents alone in their fight against the disease or in their fear of getting ill. Did you come up with creative ways to connect patients to loved ones? If another crisis hits, what will alleviate this problem?

Furth: We frequently brought residents to the window while their families were in the parking lot below, helping them stand up so they could wave and have that distance interaction. We also did a fair amount of phone calls on our personal cell phones. A family would call the front desk and we would say, "Okay, I'm going to go into your mother's room or your grandmother's room, and I'll call you on my cell phone when I get there so that you can speak with your loved one." It was heart-wrenching to be the one facilitating that call when you know that the resident is probably going to pass away in the next 24 hours and family members are saying their goodbyes via a stranger's cell phone, but it was better than nothing.

I think something that would make this much smoother and feel a lot less frightening to staff and to residents and families would be if we could bring in volunteers that would be devoted to that family connection. Because of the staffing shortages and the high acuity level that I mentioned earlier, there simply wasn't enough time to give all of the residents on the floor an opportunity to connect with family. I know that the families were very frustrated and that they were calling frequently, desperate for news about how their loved ones were doing, but we simply couldn't take the time to answer the phone. If your choice is giving someone their breathing treatment versus answering the phone, obviously the nurse is always going to choose the breathing treatment.

HIPAA restrictions prevent nonmedical volunteers from accessing health information. If they were relaxed, we could put one or two volunteers on a floor whose job it is to gather an update on each resident and make calls to the families, organize the window visits and the calls home. Having someone devoted to those tasks is necessary because it's too much to add on to an already overburdened medical staff.

Amez-Droz: Healthcare workers had to work long hours and face unprecedented levels of risk. How did the nursing facility you worked at go about expanding staff, or did it at all?

Furth: The first day that I volunteered at the nursing home, I met the women who were working as nursing assistants and only one of them was actually a nursing assistant. They were bringing up other staff from the facility who were not direct care personnel to help care for patients. The head of human resources, a woman who works in accounting, the supply manager, a couple individuals who work in rehab administration—they all worked full time as nursing assistants for about a month and a half until we got over the hump of the crisis.

The facility also offered a lot of overtime. There were several individuals who were working 60, 70, 80 hours a week. They tried very hard to hire new individuals. The longer I was there, the more new, specifically nursing assistants I met who had been hired with an increased pay scale to encourage them to take the position.

Amez-Droz: What systems, authorizations, or waivers would have helped to expand staffing capacity sooner and more efficiently?

Furth: While there was desperate demand in nursing facilities, hospitals and outpatient clinics were simultaneously furloughing many of their direct care staff because operating rooms were shut down, patient demand was low, and most clinics were closed or only working via telemedicine. The state could coordinate a reallocation of furloughed direct care personnel to places like nursing facilities where they're desperately needed.

I was fortunate enough to be at a facility that was able to offer a higher pay scale to individuals to come in and work during that time, but not every facility can do that. The state or the federal government could offer grants to increase pay scale, just during crises like this, to encourage staff to not leave and to be able to bring on new staff.

The last piece that I believe could really make a difference is setting up a system to draw in volunteers who don't have medical training but are willing to come and do basic activities like feeding and helping toilet residents. With minimal training, volunteers would be able to safely assist with some of those tasks of daily living, which would then take the burden off of the medical personnel to allow them to focus on the more intricate side of the medical care.

Amez-Droz: Speaking of nonmedical volunteers, there exist Good Samaritan laws, which offer legal protection for bystanders who give assistance to those who are or seem to be injured or ill. These laws don't apply to people who care for others as a part of their job. How did Good Samaritan laws apply to you while you were working at the facility?

Furth: Once a medical professional works in a paid position, those laws don't apply to them. However, they do apply to volunteers, which is how I started out. Before I ended up at this facility, I volunteered for several days at another one, and the situation there was exceptionally unsafe. On the first day, I was alone with 34 skilled nursing rehab and long-term patients. It was terrifying.

As a volunteer, I received no orientation or training for that facility, and I had no access to the usual systems of calling on a supervisor or calling in extra help. It was then the same thing when I started at the facility where I'm currently working. During the first week, I was a volunteer. They had not hired me yet. I was unpaid, just helping. In those situations, Good Samaritan laws would apply.

Right now, a Good Samaritan law is primarily supposed to come into effect in emergency situations where someone jumps in to help out and save a life. I think that we, as a nation, should look into expanding those laws to include situations like a global pandemic, so that people like me aren't afraid to lose our license by helping out.

If you put me in a situation with 34 patients, the odds that I can make it through that day without committing an error that jeopardizes someone's life are slim. Most medical people are not going to be willing to take that risk if it means losing their license and therefore their ability to work, but if Good Samaritan laws can be expanded to cover people like me and the several other volunteers that I met and worked with during those first few weeks, people would be willing to step up and help during emergency situations.

Amez-Droz: Finally, could you tell me about the role of testing in nursing facilities, especially as we move forward with the ongoing threat of a surge?

Furth: I think the big misunderstanding with COVID-19 from early on is comparing it to the flu. It's not the flu. You can't wait until individuals show symptoms before testing them. We know that you can be contagious when you're asymptomatic. We know that nursing home residents are among our most vulnerable because of their age and their comorbidities. We have to put a real emphasis on testing not just residents, but all staff in the facility—direct care staff as well as indirect staff.

That testing has to be redone habitually, every two weeks or maybe more frequently. It should be staggered so that there isn’t a large number of staff potentially going out at the same time. If we look at a potential resurge in the next few months, we need reliable, regular testing that can get results in a quick enough fashion that you don't have staff being tested, going back to work, and potentially carrying the disease around, not knowing that they're positive until the results come back three, four, or five days later.

This isn't news. People know that we need to increase our testing, but when we look at the numbers for the United States, a significant portion of the people who are getting infected are working at nursing homes or are residents of nursing homes, and an even more significant number of those who are dying are those who live at nursing homes. We need to focus our testing on those areas.

Amez-Droz: Thank you very much for taking the time to speak with me in the middle of this pandemic, and thank you for putting your health and safety on the line to care for some of the most vulnerable members of our society.