Infectious disease specialist Ronald G. Nahass was called into an ailing New Jersey nursing home in late November, not long after federal regulators reversed course and allowed broad visitor access.
What he saw then has Nahass and many other healthcare providers clamoring for more ways to protect patients from the friends and loved ones who are increasingly reintroducing COVID into their buildings — even as federal officials Thursday strongly emphasized that the doors will be staying open.
“We have seen the negative effects of banning visitation, which can lead to worse outcomes for people in nursing homes,” Centers for Medicare & Medicaid Services Administrator Chiquita Brooks-LaSure said during a call with industry stakeholders Thursday.
“I strongly encourage nursing home facilities to use extra caution, such as creating dedicated areas for visitation to occur, if possible, preferably outdoors for those of you so fortunate to live in the warmer parts of the country, or in designated spaces with good ventilation,” she said.
But multiple providers have said this week they are irritated that attempts to institute such infection control measures are sometimes being undermined by the visitors themselves.
Nahass traced the roots of an eight-person outbreak at the New Jersey nursing home to one ill resident’s family members, two of whom had visited just before Thanksgiving, despite being unvaccinated. They were seen at times without masks on, a fact that was noted by infection control-conscientious staff.
Afterward, the resident who was visited and five others on the same wing developed COVID-19, along with two staff members. Four cases were serious, and a resident receiving hospice care died, Nahass said this week.
“Those innocent people who got COVID-19 were not given the opportunity to exercise their right to personal safety by not being exposed to this deadly virus,” he wrote in an op-ed calling for the Centers for Medicare & Medicaid Services to revise its visitor policies. “Those senior citizens and healthcare workers had no choice in this situation. … Nursing homes must be allowed to test visitors and/or require a vaccine for SARS CoV2 prior to a visit.”
‘Rare exceptions’
Providers have their hands tied when it comes to restricting visits, despite stories like Nahass’. Responding to providers’ concerns just before the winter holidays, CMS on Dec. 23 clarified its stance, saying nursing homes could slow or stop visits in “very limited and rare exceptions.”
Families and consumer organizations have kept pressure on CMS to keep buildings wide open after visitation was limited for much of the pandemic’s first year and half.
“Residents must continue to have access to family members and other support persons, and facilities must ensure that proper infection prevention protocols are being followed by staff and visitors,” National Consumer Voice wrote in a letter to regulators Dec. 23. “We strongly urge CMS to continue to stand strong with residents and preserve their critical right to visitation.
Brooks-LaSure reinforced that view with her comments Thursday, adding that mask wearing, hand hygiene and physical distancing further the cause of resident safety. She also urged providers to work with state and local health departments during outbreaks for management of ongoing cases and structured visitation.
She said her agency would send best practices to states “to make sure everyone has information needed to keep residents safe.”
But providers are pleading for more leniency as they struggle to control omicron-fueled outbreaks, with some facilities once again reporting cases numbers by the dozens. While omicron cases anecdotally have been reported to be more moderate in nature than those caused by COVID-19’s delta variant, the World Health Organization on Thursday cautioned against stereotyping omicron cases as mild. The agency noted the jury is still out on the effects among older people, who were largely excluded from early studies.
‘Illogical’ policy
Understanding that risk, providers must accommodate visitors and protect residents as the rollout of vaccine boosters plods along slowly in some places. Nursing homes are still not allowed to require visitors to be vaccinated or submit to COVID tests before being allowed in a building. It’s a condition that Ruth Katz, senior vice president of public policy and advocacy for LeadingAge, said “feels almost illogical” given the current surge.
“It’s really hard to keep everyone safe and do thoughtful infection control and open up to visitors with really kind of no guardrails, no limitations,” added Leslie Eber, M.D., medical director of Colorado’s Orchard Park Health Care Center, during a recent COVID update call with LeadingAge members. “We all want to make sure that our residents have as fulfilling a life right now as they possibly can have … but I think that this line to walk is really challenging, especially in this moment with omicron.”
During outbreaks at her community, Eber has worked with visitors to make them aware of the conditions and encourage safer alternatives such as staff-assisted virtual visits or phone calls.
“We’re not trying to prevent access of any kind, but if possible, if you can work with us and we can keep everyone safe at least for 48 hours until we know where we are, that’s going to benefit everyone, especially the residents,” she said. “We’re feeling our way … We can give our honest expertise and guidance to family members.”
On the same call as Brooks-LaSure Thursday, Evan Shulman, director of the CMS Division of Nursing Homes, promoted the idea of working with families and other visitors. But he also underscored the importance of vaccinations, without any indication that visitors would ever be required to have them.
“Vaccination is clearly our strongest defense against severe disease and hopefully infection,” he said. “So we need people to get vaccinated, we need everyone to practice frequent hand hygiene, we need everyone to wear their masks, and we need physical distancing. … Now visitors and family, we need your help with this as well, this is not only on the facilities. We need you to again mask up and make sure that you’re following these principles of infection control so that we can keep visitation going.”
