RALEIGH -- This year's fatal outbreak of hepatitis B in a North Carolina assisted-living home unfolded like a singular nightmare, but state and national experts predict such events will grow more common in years to come.
State public health officials say poorly trained staff - who weren't required to have high school diplomas - and unsafe diabetes care led to six fatal cases of the disease at Glen Care Mount Olive, a Wayne County assisted-living center, between June and late November. By the time the presence of hepatitis B brought state investigators to the facility in October, the transmission of infection via reuse of glucometers and other devices had likely been going on for more than four months, their report said.
"What we saw were people who were not trained in fighting infection," said Julie Henry, spokeswoman for the state Division of Public Health. "It's not even sloppiness; it's really ignorance."
Glenn Kornegay, the facility's administrator, has denied the state's conclusions and says the infections could have originated elsewhere.
"We strongly disagree to the findings related to this deficiency," he wrote to the state Division of Health Service Regulation.
A Dec. 14 reinspection by state inspectors found no additional violations, but the facility still faces fines of $20,000 or more for a type A, or highest level, violation found during a first round of investigation in October, said officials of the state Division of Health Service Regulation. Efforts to reach Kornegay last week were unsuccessful.
The deaths at Glen Care fueled concerns about the training and supervision required of assisted-living staffers, the subject of a long-running debate in North Carolina.
Under state and federal law, only highly trained professionals such as registered and licensed practical nurses can administer insulin at nursing homes, designed for residents with higher levels of medical needs.
But the state-overseen assisted-living centers, once known as rest homes, have much looser guidelines. At these facilities, "med techs," who are unlicensed and may get only one-on-one training from a nurse on diabetes care, are allowed to take blood glucose samples and inject insulin for people with diabetes.
"We see this over and over again, where a staff member is providing care to multiple residents," said Nicola Thompson, an epidemiologist at the federal Centers for Disease Control in Atlanta. "We know that the majority of staff in assisted living are paraprofessionals that don't have a degree in health care.
"With more people with diabetes and more people in long-term care, the situation is unlikely to get any better."
State and national public health experts say they have tried for years to change this seeming contradiction in standards.
"There is a disconnect there," said Polly Johnson, former executive director of the state Board of Nursing and now CEO of the nonprofit Foundation for Nursing Excellence.
"Part of that disconnect is related to the way assisted living was set up - not as a health-focused system."
Assisted-living centers are an industry that grew out of county rest homes. They are cheaper than nursing homes, in part, because health care is supposedly incidental to helping residents with activities such as bathing and eating.
"The reality is that there are more people in assisted living with major health care needs," Johnson said.
Thompson said 29 million people, most older than 65, will have diabetes by 2050. In North Carolina today, about 1 in 5 people older than 65 has diabetes.
The average age of the victims in the Glen Care outbreak of hepatitis B was about 70. Their caregivers had not taken a state-approved infection control course, and there was no staff member named to coordinate infection control, investigators from the state Division of Public Health said.
Violations often found
Outbreaks of hepatitis B have been identified as a public health problem for at least 20 years, Thompson said. With the first examples seen in hospitals, a notable shift followed in which the outbreaks occurred in nursing homes, and beginning in 2004, more often in assisted-living centers.
In North Carolina, state investigators often find violations of safe practice involving diabetes care; between November 2006 and this year, the state Division of Health Service Regulation fined 42 adult care homes a total of more than $238,000 for infractions involving insulin.
"Diabetes is an epidemic in this country," said Bob Konrad a member of the policy committee at the advocacy group Friends of Residents in Long Term Care. "This is probably going to happen again and again and again as we have all these challenges in assisted living."
Beginning in the 1990s, the state's Board of Nursing proposed a uniform set of standards for medical technicians in skilled nursing homes, assisted living and other settings.
"We had hoped that this would be a requirement across all settings where medications were given," said Polly Johnson, the former Board of Nursing executive director. "In the political process, it was only passed in connection with nursing homes."
Lou Wilson, executive director of an assisted-living trade group, said she sees no problem with unlicensed staff administering insulin. A longtime lobbyist for the industry, she said the state, county and federal funds that adult care homes receive don't include enough money to pay for higher levels of training.
"It's something that has gone on for a long, long time," Wilson said.
"North Carolina just does not seem willing to put the money out for people to be better trained. That's been my experience."
Both Wilson and Dr. John Buse, a UNC-Chapel Hill physician and former president of the American Diabetes Association, point out that many people with diabetes test their own blood sugar and administer insulin daily.
However, Buse also noted that insulin is a powerful drug that has to be administered with care.
"It is the drug that is most commonly associated with serious medical errors in medical facilities," Buse said. "Hopefully the people that own these facilities, that run these facilities, understand that insulin is a drug where the margin for error is very small."
A difference in care
In May 2009, the N.C. Board of Nursing issued a position paper that gathered information about the requirements for medication aides in skilled-nursing and assisted-living homes. The board has no authority over the unlicensed techs in assisted living, but it wanted to make clear the distinctions between the levels and care and scope of practice in the two settings.
"In this case, we're not really setting out what the folks can and can't do," said Eileen Kugler, manager of practice at the Board of Nursing. "We're providing information that comes out of other laws and rules."
The group representing nursing, long-term care, state officials and advocates for residents of these facilities decided against recommending the uniform standards for people handling medication that the board and the state had initially proposed.
State Rep. Jennifer Weiss, a Cary Democrat who has frequently advocated for older people, noted that the state Institute of Medicine is examining the problems of assisted-living homes that house people with mental illness alongside frail elderly residents.
The presence of the mentally ill residents, some of whom have been released from former state mental hospitals, is one factor in the mix that makes dispensing insulin to people with diabetes a difficult and sometimes deadly event.
Chronic short-staffing, in settings where one aide can be responsible for 30 residents during night shifts, can also make it hard to dispense meds properly.
"Clearly if people are administering medicine or dealing with bodily fluids, they need to know how to do it carefully and safely to make sure people don't get sick," Weiss said, adding that the state's Commission on Aging should look at the issue for possible recommendations to the legislature.
As part of the national health-care reform legislation, the U.S. Department of Health and Human Services is presenting more than $300 million in grants to training and career-development programs - from skilled nursing to front-line aides. The North Carolina health and human services department is getting more than $578,000 to train, provide career paths for and create certification for personal care aides, both in-home and in facilities.
If society wants qualified people dispensing medication and performing other personal care, institutions will have to offer quality jobs, said Deane Beebe, the Washington-based director of public education for PHInational, a national nonprofit organization that advocates for direct-care workers.
"This includes not only training but decent wages, benefits, and career advancement opportunities," Beebe said. "Without adequate compensation, experienced aides will move onto retail sales jobs which pay more. Are we as a nation prepared to care for elders and people with disabilities?"
