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Many Nursing Homes Are Failing the Coronavirus Stress Test

Long before the novel coronavirus made its surprise appearance, the nation’s nursing homes were struggling to obey basic infection prevention protocols designed to halt the spread of viruses and bacteria they battle daily.

Since the beginning of 2017, government health inspectors have cited more nursing homes for failing to ensure that all workers follow those prevention and control rules than for any other type of violation, according to a Kaiser Health News analysis of federal records.

In all, 9,372 nursing homes, or 61%, were cited for one or more infection-control deficiencies, the analysis showed. It also found violations were more common at homes with fewer nurses and aides than at facilities with higher staffing levels.

Even among nursing homes crowned with the maximum government rating of five stars for overall quality, 4 in 10 have been cited for an infection-control lapse. Those include the Life Care Center of Kirkland, Washington, a Seattle suburb, where  five people who had lived at the facility have died.

Inspection reports from around the country show many errors are rudimentary, such as workers not washing their hands as they moved to the next patient, or failing to don masks, gloves and gowns when in the rooms of contagious patients in isolation.

“It’s all these little things that are part of infection-control practices that when they are added up can create an environment for an infection outbreak,” said Patricia Hunter, the Washington State Long-Term Care Ombuds, who addresses complaints from residents and families and pushes for improvements in facilities.

In recent years, the federal government has been ramping up the standards for nursing homes, but inspectors remain frustrated by the prevalence of sloppy or nonexistent handwashing. “We have got to do better on handwashing,” Evan Shulman, the director for the nursing home division of the Centers for Medicare & Medicaid Services, told an association of nursing home directors in 2018.

While citations are rampant across the industry, health inspectors have classified all but 1% of violations as minor and not warranting fines, the KHN analysis found. A single low-level citation usually has limited impact on the overall star rating, the only metric most consumers examine.

The coronavirus has demonstrated its potential lethality among the old and frail in Kirkland, but the infections that nursing homes already battle with mixed success — influenza and antibiotic-resistant bacteria like methicillin-resistant Staphylococcus aureus (MRSA) — can be equally fatal. As many as 3.8 million infections occur in nursing homes each year, killing nearly 388,000 residents.

Dr. David Gifford, the chief medical officer for the American Health Care Association, the primary nursing home trade group, told reporters Monday that these facilities were ready to deal with coronavirus infections through the prevention plans they have in place. “We prepare for seasonal influenza every year — it’s very similar to that,” he said.

“We are reinforcing the information for basic procedures for how to prevent the spread,” he added, such as keeping infected residents away from others and having sick employees stay home.

Yet the same industry deficits that have hampered past infection-control efforts are in play with the coronavirus. Nursing homes experience frequent staff turnover, and new or temporary workers are less likely to be familiar with a facility’s protocols. Also, inspectors have found that these homes have had difficulty making sure that potentially infected workers stay home, a problem compounded by the low pay and limited time-off benefits many receive.

During a norovirus outbreak in 2017 at another Washington state nursing home, for instance, at least six infected employees returned to work earlier than they were supposed to. Inspectors discovered the virus ultimately spread to 32 employees and 43 residents — more than 40% of those living in the home, according to an inspection report.

Even if nursing homes are successful in getting infected workers to take days off, they may run into trouble finding replacements. Dr. David Nace, director of long-term care and flu programs at the University of Pittsburgh Department of Medicine, said staffing issues are compounded by a national shortage of healthcare workers. “Facilities may be faced with the issue of closure if they don’t have the staffing,” he said.

KHN’s analysis found that 53% of homes with the most nurses and aides — which CMS awards five stars for staffing on its Nursing Home Compare website — had been cited for infection-control violations in the past three years, while 65% of homes with the fewest staff — garnering only one star — were cited for the same type of failing. The staffing stars make up one component of the overall rating.

“So many times, when there aren’t enough staff, the aides and nurses are literally trying to do 50 things at once, running from person to person,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit based in Washington, D.C. “That’s when things fall through the cracks, like handwashing, which is the most useful thing to do to prevent infections.”

More sparsely staffed nursing homes were also cited more often: one-star facilities averaged 1.5 deficiencies while five-star facilities averaged 1.3 deficiencies. But out of more than 13,000 citations for infection-control lapses, regulators classified only 109 as serious harms or threats to patients. That finding echoed the results of a similar investigation KHN conducted in 2017. “It shows how ineffectual the enforcement situation is,” said Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy.

One such violation was cited last April at the Kirkland nursing home after inspectors there observed a registered nurse treating a patient whose feet were touching the floor, even though one heel had a pressure sore that the resident’s daughter said she feared was infected. “It was unhygienic,” the daughter told inspectors.

Inspectors also watched another nursing home employee work in the room of a patient with pneumonia without wearing a mask, gown and gloves as required by a sign outside the room. They noted in their report that the facility had experienced two outbreaks of influenza that year, affecting at least 17 residents and seven staff members all told. Inspectors labeled the violations they observed as low level because they caused “minimal harm or potential for actual harm.” The nursing home pledged to reeducate staff on procedures and investigators found no problems when they revisited two months later.

Life Care Center, in an upscale, wooded neighborhood less than a mile from Lake Washington’s popular Juanita Beach Park, said in a statement released Monday that it is screening workers before they start work and after and has suspended visits and new admissions.

“We are also following infection control recommendations, including proper hand-washing techniques and wearing masks, gowns and gloves when caring for any symptomatic patients,” the statement said. The facility declined to discuss its previous citation.

Seema Verma, the CMS administrator, said during a press briefing at the White House Tuesday night that her agency is sending inspectors to the nursing home, as well as a hospital and dialysis center that treated coronavirus patients, to see if federal health and safety regulations were followed.

Hunter, the Washington state ombud, said that during her recent visits to 14 nursing homes in three Northwestern states, she observed that aides were generally good about using hand sanitizer but rarely washed residents’ hands. Not every resident room had a sink, she said. “I haven’t seen one resident have their hands washed during lunchtime or dinnertime,” she said.

While some nursing homes are making concerted efforts, “there are nursing homes that are really dirty and there are concerns that they’re not getting the job done,” Hunter added.” The trouble is when you don’t have enough workers, or you don’t have a stable workforce that’s trained to follow your protocol, that’s a weakness in the system.”

In 2016, CMS updated and expanded its infection-control rules, requiring among other things that each facility appoint one person to be in charge of infection control. CMS required the employee in that position, known as an infection preventionist, to complete specialized training and work at the facility either part time or full time. The Trump administration has proposed eliminating the on-site requirement.

Instead, CMS proposed the preventionist be someone who has spent “sufficient time” at the facility to oversee its infection-control efforts. It has asked the public for advice on how to define sufficient.

“We believe this is an appropriate standard,” the agency wrote in its proposed rule, issued last July. “However, we are also concerned that there could be a substantial variance in how LTC [long-term care] facilities interpret this requirement.”

KHN senior correspondent JoNel Aleccia contributed to this report.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

One-On-One With Trump’s Medicare And Medicaid Chief: Seema Verma

Seema Verma, administrator for the Centers for Medicare & Medicaid Services, sat down for a rare one-on-one interview with Kaiser Health News senior correspondent Sarah Varney.

They discussed her views on President Donald Trump’s plan for sustaining public health insurance programs, how the administration would respond if Obamacare is struck down by the courts in the future and her thoughts on how the latest “Medicare for All” proposals would affect innovation and access to care.

A portion of their conversation aired on PBS NewsHour on Dec. 23. A transcript follows, edited for length and clarity.

Skin Lightening Cream Put a Woman in a Coma

She had been buying face cream through a friend of a friend for 12 years. This time, it was Pond’s “Rejuveness,” a version of the company’s anti-wrinkle cream that is made and sold in Mexico. But someone in the Mexican state of Jalisco laced the cream with a toxic skin-lightening compound, and it had a devastating effect on the 47-year-old Sacramento resident. She showed up at the emergency room this summer slurring her speech, unable to walk or feel her hands and face, public health officials said. She now lies semi-comatose in a hospital. Authorities aren’t releasing her name, but they say she is the first known victim of methylmercury poisoning from a cosmetic in the U.S.

Methylmercury is a heavy metal used in things like thermometers, batteries and mirrors, and long-term exposure can cause kidney damage, loss of peripheral vision and lack of coordination. The chemical — along with a less potent, but still toxic, form of mercury known as calomel — is also a key ingredient in skin-lightening products. A bustling market for these products is driven by immigrants who buy them from their home countries. The face cream that sickened the Sacramento woman was tampered with after manufacture, but some other skin-lightening products made overseas intentionally contain mercury as an active ingredient, said Bhavna Shamasunder, an associate professor at Occidental College in Los Angeles who studies skin-lightening cosmetics. While mercury removes skin pigmentation, Shamasunder said, the side effects are toxic.

Pond’s, owned by the international consumer products giant Unilever, said it doesn’t use mercury in its products. It encourages consumers to buy their products only from authorized retailers to avoid tampering. The company said it is working with authorities to investigate the Sacramento woman’s case.

In the past nine years, there have been more than 60 poisonings in California linked to “foreign brand, unlabeled, and/or homemade skin creams” that contained calomel, Sacramento County officials said. While it is illegal to sell cosmetics in the U.S. with more than 1 part per million (ppm) of mercury — except eye products, which can have up to 65 — the Food and Drug Administration can’t keep up with the imports, whether they’re shipped, tucked into suitcases or purchased online. Nor does it have the regulatory power to enforce recalls or require preapproval of cosmetic products and ingredients before they’re sold, Shamasunder said.

“The FDA has extremely poor oversight over our beauty products,” she said. “The burden of proof is on the consumer to get sick first.”

The FDA declined to comment on the record for this story.

Skin-lightening products are popular throughout the world, and the market is projected to grow to $31.2 billion by 2024, according to Global Industry Analysts, a publisher of market research. Products made outside the U.S. aren’t subject to the same standards as American-made ones and may contain poisonous chemicals, like mercury, or have higher proportions of potentially dangerous ingredients, such as steroids.

Skin-lightening products are advertised for their ability to even out blemishes and skin tone, but some consumers feel pressure to use them on their whole face or body in cultures that tend to confer more money and social status on people with lighter skin. Nearly 40% of women surveyed in Taiwan, Hong Kong, Malaysia, the Philippines and Korea said they used skin lighteners, while 77% of women in Nigeria and 25% in Mali said they did so, according to the World Health Organization. In the U.S., potentially hazardous skin-lightening products can be purchased in some ethnic beauty stores, in ethnic supermarkets and at swap meets. They can even be found online at sites like Amazon and eBay.

It’s difficult to estimate how many people have been affected by mercury poisoning from cosmetics because screening for the heavy metal is not routine, said Tracey Woodruff, a professor of reproductive sciences at the University of California-San Francisco. The problem appears to be concentrated among certain ethnic groups. A recent Minnesota study measuring mercury in the urine of 396 pregnant women from 2015 to 2017 revealed that nine had elevated levels, mostly linked to skin-lightening product use among Hmong and Latina women. Ongoing testing is revealing even more cases, said Jessica Nelson, program director for the state’s biomonitoring project.

Often, poisoning victims get their spiked products from people they trust, Woodruff said.

Woodruff co-authored a report about a pregnant woman in San Francisco who had unusually high levels of mercury in her blood. The source was a jar of Pond’s face cream that had been adulterated in the Mexican state of Michoacán. “A family member gave it to her, so it was a trusted source of information,” Woodruff said. A 2013 study that sampled 367 skin-lightening products purchased in Chicago, Los Angeles, New York and Phoenix turned up at least a dozen products with exceptionally high levels of mercury, ranging from 1,729 ppm to 38,535 ppm.

In the Sacramento woman’s case, the contaminated face cream contained a methylmercury concentration of over 12,000 ppm. The level of methylmercury in her blood was 2,630 micrograms per liter, according to Sacramento County Public Health. Normal values are less than 5. It’s unclear whether the FDA could have done anything to prevent her poisoning, said Melanie Benesh, legislative attorney for the Environmental Working Group, a nonprofit advocacy organization.

While the FDA has been able to intercept some high-mercury imports and turn them away, the agency lacks the authority to require companies to register their products and ingredients with the agency. That would make it easier to screen shipments that have a higher risk of being poisonous, Benesh said.

In a 2017 letter to Congress, the agency said it had six full-time inspectors to monitor 3 million cosmetics shipments annually. “Right now, the FDA is really flying blind,” she said. So it’s up to public health officials to catch poisoning cases as they happen and then trace their way back to the source.

In California, state public health officials are developing a campaign to educate shopkeepers and consumers. They also train volunteer community health workers like Sandra Garcia, 63, to meet with families to discuss the symptoms of mercury poisoning. Garcia, who lives in Tulare County and picks and packs grapes for a living, estimates that she has purchased creams from 40 stores to send to public health officials for testing since March. And she has visited 60 homes to hand out brochures and help residents identify poisonous products. “There are people that get angry and say that the cream is good and that nothing bad has happened to them,” she said. “But the majority of people are frightened and give me their creams.”

Leads on retailers that sell mercury-laced products may be handed over to law enforcement for potential follow-up, said California Department of Health spokesman Corey Egel. Public health officials recommend consumers avoid buying cosmetics at swap meets and flea markets, and check that products are properly sealed and labeled.

At a discount store near MacArthur Park in Los Angeles, shop worker Lili Garcia dismissed the notion that consumers should avoid skin creams manufactured abroad. She sells unopened jars of Pond’s Rejuveness cream from Mexico for $5 and $10, depending on the size, while Target lists American versions for $8 and $15, respectively. Garcia, who uses the same cream herself, said she had heard about the Sacramento woman on the news and felt sorry for her. But she said it’s up to consumers to check that products are sealed; beyond that, there isn’t much else they can do. “Well, the buyer buys the product, and they don’t know what’s inside,” she said.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.