Inspectors find hand-washing neglected in NC nursing homes with COVID-19 outbreaks

On April 9 at PruittHealth-Carolina Point, a nursing home on the Orange-Durham border, an aide walked from room to room, passing out lunch trays.

In between, a state inspector observed, the aide did not wash their hands.

On any given day, that could earn a nursing home a citation for poor infection-control practices.

But on this day, the stakes were particularly high. The coronavirus was already known to be rampaging through the facility. At least 60 residents had tested positive for the virus, seven were hospitalized and two had died.

State inspectors were on site to check that the nursing home was using sound infection-control practices. Routine inspections had been canceled due to the pandemic, but the U.S. Centers for Medicare and Medicaid Services, nursing homes’ main regulator, ordered state inspectors to perform limited inspections focused on measures thought to be crucial in keeping the virus from spreading.

Chronic health conditions and close living quarters put nursing-home residents at particularly high risk of contracting the virus and having serious complications from it, experts say. More than half of deaths in North Carolina attributed to COVID-19 have been among nursing-home residents. In several facilities, 3 out of every 10 residents who caught the virus have died.

Even before COVID-19, infection control was a challenge in skilled-nursing facilities. The U.S. Centers for Medicare and Medicaid Services, which oversees nursing homes that accept federal insurance payments, has called infections “the leading cause of morbidity and mortality” in nursing homes, with 388,000 deaths attributed to infections each year.

Roughly three-quarters of nursing homes in the country have been cited for an infection-control deficiency in past three inspection cycles, some of them repeatedly, a News & Observer analysis shows.

“Unfortunately, the system hasn’t treated infection control as something that’s all that important, and now we’re seeing now how incredibly important it is,” said Toby Edelman, a senior policy attorney with the Center for Medicare Advocacy, a nonprofit that works to ensure quality health care for older people and people with disabilities.

In April, state inspectors found infection-control violations at three Triangle nursing homes with a major coronavirus outbreak.

Problems at Carolina Point, Signature in Chapel Hill and Springbrook

Some of those inspection reports point to staff being stretched exceptionally thin.

The aide at Carolina Point who was distributing lunch trays did not work in nursing or in the kitchen, but rather in transportation. The worker jumped in to help because a nurse aide was responsible for tending to 21 patients, according to the inspection report, which state officials redacted to remove the gender of the workers.

The transportation aide had taken an online course on COVID-19, but when asked about hand hygiene, the aide responded: “I am not sure when I should wash hands. I am just helping out.”

A corporate nurse was filling in for the director of nursing, according to the report, and the activity director was working as a nurse’s aide.

Before the pandemic, regulators rated Carolina Point below average for staffing and much below average overall, though the facility had not been cited for an infection-control violation in the past three inspection cycles.

As of Friday, 112 residents and staff at Carolina Point had caught the virus and 20 residents had died, state data show.

A report from an April 17 inspection at Signature HealthCARE in Chapel Hill also includes a description of an aide going from room to room, delivering food without washing their hands.

The aide claimed they didn’t sanitize their hands because the dispenser outside one of the rooms was broken and their personal bottle was missing. The inspector found the dispenser outside the room to be functioning and full.

The most recent figures show 84 residents and staff at the facility have tested positive for the virus and 20 residents have died.

Before the pandemic, the facility was rated much below average. It had one infection-control violation in the past three inspection cycles, for bed bugs in 2017.

Springbrook Healthcare and Rehabilitation Center, a nursing home in Clayton where 83 people have tested positive and 20 have died, was cited for letting residents leave the facility during the pandemic when it wasn’t medically necessary.

One resident went across the street to a fast-food restaurant with a friend, an April 7 inspection report said. At least two other residents got fast food while outside the facility for a doctor’s appointment.

None of the people the inspector interviewed could recall the residents’ drivers being screened for signs and symptoms of COVID-19.

Springbrook was rated much below average, but it did not have a recent infection-control citation.

Questions about preparing for a pandemic

One Triangle-area nursing home was cited for failing to meet federal emergency preparedness standards in March, around the time that coronavirus infections were first being detected in the state.

Nursing homes are required to have plans that would help guide their response to a pandemic, but it’s a requirement that many experts think has not been vigorously enforced.

The Oaks at Whitaker Glen-Mayview in Raleigh was cited for failing to have a plan for working with government officials during an emergency and neglecting to carry out the required practice for disaster response, a March 12 inspection report shows.

The most recent data released by the state shows no coronavirus infections at the facility.

Nursing-home industry leaders say their response to the coronavirus has been unfairly maligned, pointing out they serve a frail population yet received no priority for help securing personal protective equipment (PPE) and test supplies early on in the pandemic.

“From the very beginning, nursing homes have done everything in our power to protect the patients, residents, and staff members in our facilities,” Adam Sholar, president and CEO of the North Carolina Health Care Facilities, a trade group, wrote recently in an op-ed published in The News & Observer. “It is irresponsible and unfair to suggest otherwise.”

Sholar and others have blamed low Medicaid reimbursement rates for facilities’ persistent difficulty recruiting and retaining frontline employees. Boosting pay would “reduce turnover, promote stronger relationships with residents, and provide stability that will strengthen the implementation of policies and procedures around infection control and other critical issues,” Sholar wrote.

The industry has gotten some relief. North Carolina boosted Medicaid reimbursements during the pandemic to pay for elevated costs. The legislature gave nursing homes liability protection during the pandemic. And both federal and state governments recently sent nursing homes shipments of PPE.

Regulatory rollbacks introduced by the Trump administration at the industry’s suggestion remain under consideration.

This story was originally published June 15, 2020 at 11:56 AM.