Image of male nurse pushing senior woman in a wheelchair in nursing facility

Tales of extremely short-staffed long-term care facilities, and calls for federal funding and support for the direct care workforce led the way during a Wednesday Senate hearing aimed at uncovering what went wrong at nursing homes during the early days of the COVID-19 pandemic. 

“To be trusted by families to care for their loved ones is a great honor, but over the past year my days have been filled with fear and sadness,” Adelina Ramos, a Rhode Island-based certified nursing assistant, testified on Wednesday to the Senate Finance Committee. 

Ramos, a COVID-survivor herself, reported that her facility wasn’t prepared when the pandemic first arrived in the United States early months of 2020. She described feelings of being “horrified” as dozens of residents and staff died in the first few weeks of the crisis. 

The lack of personal protective equipment, infection control training and staffing was a common complaint among staff, she said. CNAs also had to step into the roles of morticians and “had to put bodies into body bags” due to a lack of PPE, she added. 

She said the challenges existed long before COVID but they were “exposed” during the pandemic and called for better wages to help attract more workers to the industry. 

“Things are looking up but the physical and emotional trauma that this pandemic caused can’t be cured with a shot in the arm,” Ramos said. “This pandemic has shown us what happens when we’re not prepared to meet the demands for care.” 

‘Harder’ problems than staffing

Image of Tamara Konetzka, Ph.D., of the University of Chicago
Tamara Konetzka, Ph.D., of the University of Chicago

Research has shown that while having more staff did not reduce the probability of a COVID-19 outbreaks in nursing homes, facilities with the most staff hours experienced fewer deaths and cases once an outbreak occurred, University of Chicago health economic professor R. Tamara Konetzka, Ph.D., reported during the hearing. 

“The effects of staffing are still dwarfed by the effect of community spread but increasing staffing represents a clear intervention that could improve care and save lives during this pandemic and beyond,” she said. 

Konetzka reported that more than 99% of nursing homes have had at least one COVID patient and more than 80% have had at least one COVID-related death. Researchers have also found that the top predictors of nursing home coronavirus cases and deaths are facility size and community spread. Attributes not linked with COVID-19 outcomes included standard quality metrics, like infection control citations.

“These results suggest that high quality and good infection control are not enough in this pandemic,” she told senators. “This is clearly not a ‘bad apples’ problem and no subset of nursing homes has found a magic bullet to keep the virus out.” 

“The single most important thing we could’ve done as a nation to reduce the tragedy in nursing homes over the past year was to use public health measures to control the spread of the virus in the general population,” she later added. 

Her suggested policy recommendations included allocating more funding toward nursing home strike teams to help with staffing shortages to prevent outbreaks, mandating federal agencies to release complete data on vaccinations in facilities and increasing direct care staffing in nursing homes. 

“Addressing this challenge requires resources, which is where the agreement about staffing ends and the harder problems begin. Many argue, and I largely agree, that America’s long-term care system is grossly underfunded. At the same time, the growing role of related party transactions and private equity ownership makes it difficult to see where taxpayer money is being spent and what profit margins truly are. Greater transparency about the flow of money is urgently needed,” Konetzka said. 

“We will never achieve adequate nursing home quality unless we find a way to support the workforce. In addition to low pay and few benefits, the job of direct care nursing staff is difficult, often dangerous, and emotionally and physically taxing — add the risk of a potentially fatal infectious disease and it’s amazing they show up,” she added. 

Delayed help faulted

The devastation in long-term care caused by the pandemic can be attributed, in part, to delayed public health advice for providers even as knowledge about the virus continually evolved, according to David Gifford, M.D., chief medical officer of the American Health Care Association. 

David Gifford, M.D., chief medical officer at AHCA and NCAL.

“Initial guidance was focused on a symptom-based approach that we now know is ineffective since half the people spreading the virus don’t have symptoms. But guidance on mask wearing for all staff did not come until June — four months into the pandemic,” he said. 

The failure to make nursing homes a priority on a federal level for PPE and testing compounded the problems, as well. Gifford testified that testing kits weren’t provided to nursing homes until six months into the pandemic. 

“With these delays even the best nursing homes with the most rigorous infection control practices could not stop this highly contagious virus. The long-term care community was left behind, forgotten and even blamed,” he said. This further demoralized the staff who are risking their lives and trying their best with inadequate support.” 

Gifford noted it’s critical the long-term care industry reflects on challenges that this pandemic exposed, like its past struggles to attract and retain a strong workforce. 

“We recognize that providers can and must do better to meet the needs of the elderly,” Gifford said. “What we’ve learned from this tragedy is that it will take considerable investment to make meaningful changes. We stand ready to work with policymakers and others to take bold action.” 

The full hearing broadcast can be seen here.