Kind, intelligent and handsome, James Rovi was a beloved father and grandfather.
A World War II combat veteran who survived the battle of Guadalcanal and malaria, he built a successful landscaping business, raised three children and was widowed twice. Nicknamed “the Puzzle Master" for his fondness for assembling jig saw puzzles, he lived a remarkably independent life until his 100th year. His daughter is a close friend of mine.
Growing frailty led him to move to the New Jersey Veterans Home at Paramus, where on Feb. 1, wearing his World War II army jacket, he celebrated his 100th birthday.
Just three months later, on May 4, he died of COVID-19.
The particulars of Mr. Rovi’s life are unique. The story of his death is not. According to The New York Times, more than 54,000 deaths due to COVID-19 had occurred at U.S. long-term care facilities as of June 27. Eighty-two people died of COVID-19 at the New Jersey Veterans Home at Paramus, placing it at the top of The New York Times’ list of 12,000 nursing home facilities that have experienced at least one COVID-19 death.
Lancaster County long-term care homes also have experienced the devastation of widespread death among their residents. As of Thursday, the Pennsylvania Department of Health website reported 265 deaths at 48 nursing and personal care homes in Lancaster County.
The spread of COVID-19 through long-term care facilities has raised many questions.
It is not hard to understand why many elderly people, frail and with multiple health problems, died as a result of COVID-19. Conditions such as heart disease, pulmonary disease and diabetes enhance the likelihood that COVID-19 will result in life-threatening complications. Skilled nursing facilities house a disproportionate number of people whose age and poor health greatly increase their risk of death if they contract COVID-19.
Though these factors explain why nursing home residents have higher COVID-19 death rates than the general population, they do not explain why some nursing homes have had significantly higher infection and death rates than others. This question has been the subject of much speculation.
Importance of location
Some have argued that the directives of some governors requiring skilled nursing facilities to readmit residents after hospitalization for COVID-19 is to blame for high nursing home infection and death rates.
Little evidence supports that claim, with high mortality occurring in nursing homes where readmissions did not occur, as well as in facilities where it did. Nursing homes with adequate space and sufficient staff to quarantine still-contagious COVID-19 residents fared better than crowded and understaffed facilities.
Ideally, there should be specialized facilities available for recovering COVID-19 patients, who cannot return to their home facility without endangering other residents.
Health policy researchers at Harvard University, University of Chicago and Brown University have identified a number of factors that are associated with high rates of COVID-19 infection and death. A facility’s location is the prime factor.
“No care facility, no matter how excellent, can keep (COVID-19) away if it’s widespread in the areas where staff members live and work,” according to a Washington Post column co-authored by Harvard Medical School professor David Grabowski.
Indeed, that column noted, “location and facility size matter much more than prior quality in predicting whether a nursing home will have a serious (COVID-19) outbreak. The most important factors influencing whether and how large an outbreak occurs in a nursing home are the population density of the county in which the facility is located, the prevalence of the virus reported in the county and the racial distribution of the nursing home, which are all correlated.”
Once in a facility — because many residents share rooms and bathrooms, and because staff members provide hands-on care to residents — the novel coronavirus easily spreads.
Importance of RNs
These findings suggest that prevention of further spread of COVID-19 in long-term care facilities requires sufficient personal protective equipment and implementation of a plan for regular, universal testing of nursing home residents and staff.
Nursing home administrators report that protective equipment is much more available than at the pandemic’s start, though it remains costly. And in response to Pennsylvania Department of Health directives, local facilities have embarked on a program of universal testing of residents and staff.
It is imperative that long-term care facilities receive ongoing assistance to maintain sufficient protective equipment and to ensure that testing continues on a regular basis as long as the coronavirus is present in the community.
Dr. Yue Li, a professor at the University of Rochester Medical School, identified another factor associated with lower COVID-19 death rates in a just-published study of Connecticut nursing homes: registered nurse staffing.
Long-term care facilities that provided more hours of care per resident from a registered nurse had lower COVID-19 infection and death rates.
Registered nurses play crucial roles in assessing patients, monitoring their care, supervising other nursing staff, and identifying and responding to emergencies. Ensuring that there is sufficient staffing of registered nurses, and addressing the turnover associated with all nursing staff in skilled care facilities, are critical.
What’s needed now
Like most nursing home patients with COVID-19, Mr. Rovi died without the loving presence of a family member.
Could widely available protective equipment and rigorous, regular testing help alleviate the extraordinary loneliness affecting residents of virtually all the country’s long-term care facilities by enabling visitation? It’s an important question, because the spread of COVID-19 in nursing homes has resulted in unprecedented periods of isolation for their residents. And the presence of loved ones would not only improve the mental health of residents, but would help to ensure they are receiving appropriate care.
It is a mistake to view the coronavirus outbreak in long-term care facilities as something we can consider apart from the outbreak in the rest of the community. Protecting the residents of long-term care communities requires reducing infection rates in the community as a whole and investing in effective measures to prevent the spread of the virus into these facilities.
It means addressing already-existing deficiencies in our nursing home standards to protect the lives of vulnerable nursing home residents.
Finally, it requires that we ensure that no group in society is at greater risk of illness or death because of poverty or other barriers to medical care.
The COVID-19 nursing home crisis is a community crisis.
Mary Glazier, Ph.D., is a retired professor and director of the Center for Public Scholarship and Social Change at Millersville University.