Published: April 21, 2020
According to experts, older adults with or without pre-existing chronic conditions are at higher risk of COVID-19 infection and are also more likely to have severe cases requiring intubation, ventilator support, and intensive care.1,2 In fact, the CDC reports that about 8 of 10 COVID-19 deaths in the U.S. have been adults over the age of 65 years, with the majority over 85 years of age.1 The risk of contracting and dying from COVID-19 is an even greater problem in the almost 16,000 U.S. nursing homes, where there are concentrated numbers of older adults with chronic disease and frailty. Nursing homes in general have been challenged with infection prevention and control management in the past; outbreaks of Norovirus, Clostridium difficile, and other infectious diseases have been widely reported over the years despite greater regulatory attention.2-5 As of April 18, 2020, the New York Times has reported more than 7,000 residents in U.S. nursing homes having died.6 Nursing homes are particularly challenged because of the age and health status of their residents, a physical environment that includes multi-resident rooms, close physical proximity, and shared bathrooms, and relatively low levels of registered nurse staffing.7 In addition, most nursing homes have relatively little information technology,8 few infection control supplies, and typically only one part-time infection preventionist who may not be a registered nurse.5,9 Assisted living communities and residential care facilities for the elderly are also at high risk because they have older adult populations that typically have multiple chronic diseases and these facilities have fewer clinical resources than nursing homes. Most of these facilities provide assistance with meals, activities, and some with medications; however, they typically do not employ licensed nurses to provide direct care.10
The Patient Safety Problems
Infection Control and Prevention:
COVID-19 has spread quickly through hundreds of nursing homes across the U.S., partially due to the challenges of providing adequate infection control and prevention measures in these congregate living facilities. The Washington Post has reported that 40% of the 650 nursing homes that have reported having residents with COVID-19 have been cited at one point in time for infection-control infractions.11,12 There are a variety of contributors to this problem, some of which are not modifiable such as older age, more chronic diseases, and close living quarters. Additional factors include lower and sometimes inadequate staffing,13-15 frequent hospitalizations, co-morbid conditions, and higher levels of functional impairment requiring close physical contact between staff and patients.16 Infection control and prevention problems are the most commonly found deficiencies in nursing homes, even in the highest CMS rated nursing homes.17 Multiple vulnerabilities in nursing homes have been reported widely during the COVID-19 pandemic including:6,12-18
- Inadequate staffing
- Lack of adequate personal protective equipment (PPE)
- Lack of knowledge and adherence to appropriate use of PPE
- Inconsistent hand hygiene
- Improper isolation techniques
- Inconsistent sanitization of equipment
- Poor tracking of infections
- Staff working in multiple facilities
- High staff turnover
- Staff working while ill
In particular, inadequate staffing and lack of a stable workforce has been identified as a weak point in nursing homes.18,19 In recent years, CMS has required that nursing homes employ a trained infection preventionist at least part time; however, that requirement is relatively new and little is known about how they are impacting infection rates.
Transitions of Care:
Previous Medicare and Medicaid regulations required that residents who left a nursing home for family visits and medical appointments or were transferred out of a nursing home to the hospital must be allowed to return to that nursing home. Nursing home leaders have expressed concern that residents who were exposed to COVID-19 in the emergency department or the hospital or from visiting family members should not be readmitted to the nursing home because of the potential risk of exposure to existing residents.20
In some states, nursing homes have been mandated to accept new COVID-19 patients.13Transferring COVID-19 positive patients who no longer need acute care but require nursing home care from the hospital to a COVID-19 naive nursing home is a significant patient safety concern as existing residents at that home would be at risk. Recent federal guidance advised nursing homes to designate separate staff or units for COVID-19 positive patients;21 however, this guidance has not been well received by many nursing home leaders due to concerns about their ability to prevent viral transmission.22
Telehealth and Telemedicine:
Historically, Medicare payment for telehealth visits in nursing homes was restricted to rural areas. Regulations have been loosened to allow Medicare telehealth visits in nursing homes so that practitioners can conduct routine, urgent and non-urgent video visits, which will help minimize spread of the virus and improve patient safety.23 This relaxed regulation can significantly improve access to care during this time of social distancing and the need to limit visitors, and reduce the number of clinicians (including physicians, nurse practitioners, physician assistants, dentists, and some therapists) who need to be physically present in the nursing home. Telehealth also allows a more immediate response to urgent patient safety issues as practitioners can initiate a video visit at any time using a cell phone, notebook, or computer, allowing them to address medication errors, adverse events, falls, pressure injuries, or health care associated infections. The Centers for Medicare & Medicaid Services (CMS) has published a telemedicine/telehealth toolkit for providers, available in the Tools and Resources section below.
Federal Guidance to Nursing Homes:
CMS published guidance on March 13th advising nursing homes to screen all staff and residents for fever and respiratory symptoms and restrict nonessential healthcare personnel and visitors, including family, except for compassionate care such as end of life situations.24 The April update has additional guidance on infection control and CMS announced enhanced inspections to focus on infection control.25 CMS also strengthened prior recommendations that staff wear appropriate PPE with patients if PPE is available and that facilities either use separate staff for COVID-19 positive patients or designate separate facilities for these patients.26
Several additional resources have been made available to nursing home leaders.
The Centers for Disease Control and Prevention (CDC) published a guideline entitled Preparing for COVID-19: Long-term Care Facilities, Nursing Homes.27 The CDC also included a self-assessment guide (CMS Self-Assessment Guide: Nursing Home Preparedness Checklist).28 This checklist is designed to ensure that nursing homes and other long-term-care settings can assess their ability to care for patients who may have or be at risk for COVID-19 and how to prevent other residents from exposure. From this checklist, long-term care facilities should devise a comprehensive COVID-19 preparedness plan. Another recently published resource from CMS is a toolkit that provides new guidance on telemedicine/telehealth visits in nursing homes.29
COVID-19 Guidance for Assisted Living and Residential Care and Retirement Communities
The CDC published interim guidance for owners, operators, and administrators of Assisted Living Communities, Residential Care Facilities for the Elderly, and other retirement communities including:
- Cancel all non-essential group activities and events
- Clean and disinfect all common or shared facilities such as dining rooms, libraries, and living rooms
- Clean all high touch areas such as doorknobs, handrails, shared exercise equipment
- Inform visitors, volunteers, staff, and residents about COVID-19, screen staff when possible
- Encourage personal protection measures such as social distancing
- Create buddy systems so that residents stay connected socially
- Limiting non-essential visitors
Further CDC guidance for retirement communities and independent living advising them to post the signs and symptoms of COVID-19 and directions on what to do during an outbreak is also available on the CDC website.30
Professional Organization Resources
The Society for Post-Acute and Long-Term Care Medicine has published guidance for nursing homes, providers, and medical directors that is freely available on its website that provides extensive guidance for COVID-19 related issues.31 The website has a series of practical resources available including a COVID-19 frequently asked questions for nursing home staff, guidance on transfer of hospital patients to post-acute and long-term care settings, a COVID-19 Update that prioritizes care, keeping residents safe from transmission.32 Included are practical lessons learned from a nursing home that had a COVID-19 Outbreak: Lessons Learned from the COVID-19 Outbreak at Canterbury Rehab with timely information about reducing harm to NH residents.33
The American Geriatric Society published an article in the Annals of Long-Term Care emphasizing the ABCDs (awareness, behaviors, containment, and decisions) of the pandemic for older adults to improve patient safety, particularly cognitive bias in diagnosing older adults, behaviors to clinically manage patients, and efforts to contain the virus to prevent harm to other older adults, particularly in nursing homes and other long-term care environments.34
Deb Bakerjian PhD, APRN, FAAN on behalf of the AHRQ PSNet team
Clinical Professor, University of California Davis School of Nursing
Co-Editor-in-Chief, AHRQ PSNet
- Center for Disease Control and Prevention. Older Adults. Coronavirus Disease 2019 (COVID-19). Accessed April 4, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html
- Gaur S, Dumyati G, Nace DA, et al. Unprecedented Solutions for Extraordinary Times: Helping Long-Term Care Settings Deal with the COVID-19 Pandemic. Infection Control & Hospital Epidemiology. 2020 Mar 30:1-8.
- Herzig CT, Stone PW, Castle N, Pogorzelska-Maziarz M, Larson EL, Dick AW. Infection prevention and control programs in US nursing homes: results of a national survey. Journal of the American Medical Directors Association. 2016 Jan 1;17(1):85-8.
- Krishna A, Chopra T. Control of Clostridium (Clostridioides) difficile Infection in Long-Term Care Facilities/Nursing Homes. In Chopra T (ed), Clostridium Difficile Infection in Long-Term Care Facilities. Springer, Cham; 2020 (pp. 53-64)
- Montoya A, Cassone M, Mody L. Infections in nursing homes: epidemiology and prevention programs. Clinics in geriatric medicine. 2016 Aug 1;32(3):585-607.
- Condon, B & Herschaft, R. (April 13, 2020) Time [ONLINE] Accessed April 2020 https://time.com/5819859/us-nursing-home-deaths/
- Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care–associated infection. American journal of infection control. 2012 Aug 1;40(6):486-90.
- Degenholtz HB, Resnick A, Lin M, Handler S. Development of an applied framework for understanding health information technology in nursing homes. Journal of the American Medical Directors Association. 2016 May 1;17(5):434-40.
- Stone PW, Agarwal M, Pogorzelska-Maziarz M. Infection preventionist staffing in nursing homes. American Journal of Infection Control. 2020 Jan 3.
- National Institute on Aging. Residential Facilities, Assisted Living, and Nursing Homes. Accessed April 10, 2020. https://www.nia.nih.gov/health/residential-facilities-assisted-living-and-nursing-homes
Cenziper, D., Jacobs, J. & Mulcahy, S. Hundreds of nursing homes with cases of coronavirus have violated federal infection-control rules in recent years. The Washington Post. (April 17, 2020) [ONLINE] Accessed April 18, 2020 https://www.washingtonpost.com/business/2020/04/17/nursing-home-coronavirus-deaths/?arc404=true
- Ingold, J. Many Colorado nursing homes were already struggling to control infections. Then came coronavirus. The Colorado Sun. (April 8, 2020) [ONLINE] Accessed April 18, 2020 https://coloradosun.com/2020/04/08/colorado-nursing-home-infection-coronavirus/
- Harrington C, et al. Nurse staffing and deficiencies in the largest for‐profit nursing home chains and chains owned by private equity companies. Health services research. 2012 Feb;47(1pt1):106-28.
- Williams C, Zheng Q, & White A. Payroll-Based Staffing Measures for Nursing Homes. Innovation in Aging. 2019 Nov;3(Suppl 1):S62.
- Harrington C, et al. Article commentary: The need for higher minimum staffing standards in US nursing homes. Health services insights. 2016 Jan;9:HSI-S38994
- Pineles L, et al. Frequency of nursing home resident contact with staff, other residents, and the environment outside resident rooms. Infection Control & Hospital Epidemiology. 2019 Jul;40(7):815-6.
- Rau J. Coronavirus Stress Test: Many 5-Star Nursing Homes Have Infection-Control Lapses. Kaiser Health News. (March 4, 2020) [ONLINE] Accessed April 2020 https://khn.org/news/coronavirus-preparedness-infection-control-lapses-at-top-rated-nursing-homes/
- Kavanaugh, K.. As COVID-19 Knocks on Nursing Homes’ Doors, Full-Time Infection Preventionists Needed More Than Ever. Infection Control Today. (March 27, 2020) [ONLINE] Accessed April 2020 https://www.infectioncontroltoday.com/covid-19/covid-19-knocks-nursing-homes-doors-full-time-infection-preventionists-needed-more-ever
- CDC: Life Care staff worked in multiple facilities and while symptomatic for COVID-19. Seattle Weekly. March 19, 2020. [ONLINE] Accessed April 2020 https://www.seattleweekly.com/news/cdc-life-care-staff-worked-in-multiple-facilities-and-while-symptomatic-for-covid-19/
- Mettler, M & Oldham, J. Coronavirus limbo: Seniors need to leave hospitals but some nursing homes won’t let them return. The Washington Post. March 30, 2020. [ONLINE] Accessed April 2020 https://www.washingtonpost.com/health/2020/03/28/nursing-homes-coronavirus/
- Centers for Medicare and Medicaid Services. Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments. Accessed April 2020 https://www.cms.gov/newsroom/press-releases/trump-administration-issues-key-recommendations-nursing-homes-state-and-local-governments
- Brown, D. Providers: Death total would rise if nursing homes forced to admit COVID-19 patients. McKnight’s Long-Term Care News. March 30, 2020. [Online] Accessed April 2020 https://www.mcknights.com/news/providers-outcry-efforts-to-place-covid-19-patients-into-nursing-homes-to-alleviate-hospital-overcrowding/
- Hollander JE, Carr BG. Virtually perfect? Telemedicine for covid-19. New England Journal of Medicine. 2020 Mar 11.
- Centers for Medicare & Medicaid Services. COVID-19 Long-Term Care Facility Guidance. [ONLINE] Accessed April 2020 https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf
- Centers for Medicare & Medicaid Services. CMS Announces Findings at Kirkland Nursing Home and New Targeted Plan for Healthcare Facility Inspections in light of COVID-19 (March 23, 2020) [ONLINE] Accessed April 2020 https://www.cms.gov/newsroom/press-releases/cms-announces-findings-kirkland-nursing-home-and-new-targeted-plan-healthcare-facility-inspections
- Centers for Medicare & Medicaid Services. Trump Administration Issues Key Recommendations to Nursing Homes, State and Local Governments [ONLINE] Accessed April 2020 https://www.cms.gov/newsroom/press-releases/trump-administration-issues-key-recommendations-nursing-homes-state-and-local-governments
- Centers for Disease Control and Prevention. Preparing for COVID-19: Long-term Care Facilities, Nursing Homes. [ONLINE] Accessed April 2020 https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/prevent-spread-in-long-term-care-facilities.html
- Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings. [ONLINE] Accessed April 2020 https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf
- Centers for Disease Control and Prevention. Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit. [ONLINE] Accessed April 2020 https://www.cms.gov/files/document/covid-19-nursing-home-telehealth-toolkit.pdf
- Centers for Disease Control and Prevention. Preventing the Spread of COVID-19 in Retirement Communities and Independent Living Facilities (Interim Guidance). [ONLINE] Accessed April 2020 https://www.cdc.gov/coronavirus/2019-ncov/community/retirement/guidance-retirement-response.html
- Centers for Disease Control and Prevention. Guidance for Retirement Communities and Independent Living. [ONLINE] Accessed April 2020 https://www.cdc.gov/coronavirus/2019-ncov/community/retirement/index.html
- AMDA- The Society for Post-Acute and Long-Term Care Medicine. AMDA Update on COVID-19. [ONLINE] Accessed April 2020 https://paltc.org/COVID-19
- AMDA- The Society for Post-Acute and Long-Term Care Medicine. Lessons Learned from the COVID-19 Outbreak at Canterbury Rehab, 3/29/2020. [ONLINE] Accessed April 2020 https://paltc.org/sites/default/files/Lessons%20Learned.pdf
- D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in Geriatrics and Long-term Care: The ABCDs of COVID-19. March 25, 2020 [ONLINE]. Accessed April 2020 https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16445
Patient Safety Primers: