Some of the worst coronavirus outbreaks have occurred at long-term care facilities that now account for more than one-third of all COVID-19 deaths in America. Some states have taken aggressive actions to slow the spread of the virus among residents and workers in nursing homes. Texas formed a strike force to assess problems at its 1,222 nursing homes.
On a bright South Texas morning in the parking lot of a suburban nursing home, paramedics from the San Antonio Fire Department were setting up swabbing stations and donning periwinkle-blue protective gowns. They were part of the massive state intervention to stop infection from spreading in nursing homes. Municipal and Texas State Guard medics have fanned out to test more than 250,000 residents, as well as staff, for the coronavirus.
"OK, guys, so we got 260 swabs we're gonna do here today. It's 200 staff and 60 residents. We got y'all divided up in your teams already," shouted paramedic Lt. Travis Hopp. "Be safe, take care of each other, and stay clean."
Their work is critical. In Texas, 47% of the state's nearly 1,900 COVID-19 deaths have been tied to skilled nursing and assisted living facilities — an even greater proportion than national COVID-19 fatality figures.
"Right now we're focused on licensed nursing facilities. We've seen extremely high mortality rates and that's a very vulnerable population," said Eric Epley, executive director of Southwest Texas Regional Advisory Council, who is coordinating the statewide paramedic teams.
As the public health crisis that began in winter enters the summer months, why is the virus still running rampant through nursing homes?
The fundamentals of infection control are well known by now: frequent hand-washing, wearing masks, social distancing, donning protective gear and disposing of it properly, and isolating sick people.
"Let me tell you, some of this stuff is really basic and I don't understand why they're not getting it," said Kevin Dinnin, president of BCFS. The nonprofit emergency provider of health and human services is part of the Texas Quick Reaction Force for nursing homes. BCFS medical teams have completely taken over operations at six Texas nursing homes where a third to a half of the population contracted COVID-19 and staffers were too afraid to come back to work.
Dinnin has a picture on his phone of a nurse's aide — without a mask — standing in the hallway of an East Texas facility, and directly behind her is an elderly resident who is COVID-19 positive.
What's alarming, he said, is that staffers are contracting the sickness, they don't know they have it, and they're likely infecting residents.
"And they're moving room to room to room with close patient contact," Dinnin continued. "Certainly, if they're not wearing any mask at all to protect others from them there's a good chance they're shedding the virus and they're exposing those high-risk patients to the virus."
His chief of operations, Todd Gates, has been working inside nursing home hot zones in Texas for weeks.
"They [nursing home administrators] are acting generally out of ignorance because they just don't know what they're doing is wrong," Gates said.
Dinnin said guidance on infection control from state and federal health care authorities "is too complex and it needs to be simpler and easier to understand."
The nursing home industry has generally blamed its coronavirus crisis on the early scarcity of masks and other protective equipment and the lack of testing. Moreover, they say, older adults are especially vulnerable, and no one saw this virulent disease coming.
But infection control has been a perennial problem well before 2020.
Nursing homes throughout America have fallen short for years, according to a report released last month by the federal Government Accountability Office.
"We found that a number of nursing homes had deficiencies in their infection prevention and control efforts and that these deficiencies unfortunately were widespread across most nursing homes," said John Dickin, director of GAO's health care team, on an agency podcast.
The GAO report found that 82% of America's nursing homes got at least one deficiency in infection control between 2013 and 2017. And about half of the homes "had persistent problems and were cited across multiple years."
Texas — with more than 1,200 nursing homes — is always a trouble spot.
"This is a long-standing problem, particularly in Texas, with basic infection control practices," said Patty Ducayet, the long-term care ombudsman for Texas.
Federal and state inspections show that Texas nursing homes have among the most citations for infection deficiencies in the country and that infection prevention is the No. 1 problem in the state.
Ducayet said nursing homes conduct emergency planning, and infectious disease epidemics are supposed to be part of that.
"Without a doubt," she said, "nursing homes could have been better prepared for this."
In their defense, a nursing home trade association said its members have taken stringent measures to stop the spread, such as canceling family visits and eliminating communal activities such as dining and bingo.
"I think there's always room to look at infection control protocols and how do we improve the process," said Kevin Warren, president of the Texas Health Care Association. "And how do we learn from this moving forward so that if and when something like this happens again, we don't have concerns like this."
The Texas Health and Human Services Commission, which regulates skilled nursing facilities, said it has conducted hundreds of on-site inspections over the past two months because of the coronavirus crisis. Now the agency is ratcheting up the response.
Last week, HHSC announced that — in light of continuing serious problems with the coronavirus in nursing homes — it has created Special Infection Control Assessment teams. They will visit troubled facilities throughout the state to review their practices and provide immediate guidance in an attempt to prevent further outbreaks of COVID-19.