All but one of Michigan’s 21 regional hubs for nursing home patients recovering from COVID-19 have been cited for an infection-control deficiency in the last four years, according to data from the Centers for Medicare and Medicaid Services.
Four of those facilities were cited for infection-control violations that occurred in the weeks just before the state designated them as hubs.
When selecting the hubs, the state health department looked for skilled nursing facilities that had space and could physically isolate recovering COVID-19 patients in separate units. Controlling infection was their reason for existence. So why did the state pick homes that had so recently violated infection-control guidelines?
Given available bed space, there may have been no better options. And in early April, in facilities that were dealing with a poorly understood disease for which state and federal guidance was constantly changing, the slip-ups may have been inevitable.
“If you push yourself back to March, there was very little discussion of what was personal protective equipment, and there was an appalling lack of testing,” said Kathryn Hyer, who researches quality of care in long-term care facilities at the University of South Florida.
Regardless, Hyer says facilities don’t deserve “a pass” if they failed to follow their own policies, which many of them did.
The offending hubs
Inspectors cited four of the 21 regional hubs — SKLD West Bloomfield, Shorepointe Nursing Center, Medilodge of Frankenmuth, and Medilodge of Livingston — for infection-control violations that occurred just before they were selected as hubs at the end of April.
Improperly trained, or not trained at all, staff at these facilities cared for residents sick with COVID-19 just as they would ones with a nasty cold, according to inspection reports. Some staff skipped important infection-control measures because they didn’t understand the virus’s unique danger.
One resident at SKLD West Bloomfield had been exposed to COVID, had a fever, and posed a potential risk to others if not monitored closely. His physician ordered his temperature taken every four hours, but staff didn’t do so. This was despite the facility’s policy that all care plans to be “in accordance [with] the licensed physician’s orders.”
Hyer says a facility’s failure to follow its own protocol is “not good, nor is it acceptable.”
At the same time, she acknowledges that “to really implement a protocol well, you have to have time to do the training.” Time to train staff is something many Michigan nursing homes did not have as COVID cases began to rise.
Medilodge of Frankenmuth did hold frequent trainings to update staff on CDC guidance, but attendance was low through the spring. One nurse’s aide attested to not receiving any COVID-specific training beyond a brief handwashing drill. Another said her orientation had been cut short so she could start working.
“Now, she was just given handouts, there was no formal training,” reads the report.
At other facilities, staff seemed generally unprepared to handle a threat of COVID’s novelty and magnitude.
In mid-March — a week after Michigan’s first detected case, and days after nursing homes had closed to visitors — a man having trouble breathing was admitted to Shorepointe Nursing Center in St. Clair Shores. He was placed with a roommate. This was more than a month before Shorepointe became a hub and set up its discrete isolation unit.
Both men were in generally poor health, with respiratory and other symptoms, and within a few days, both had a fever. They were tested for COVID, but kept together, even though the facility had a policy stating that any resident who gets swabbed must be isolated afterward.
A few days later, the first roommate died. Days later (and still without test results) the second roommate, “very anxious and sad since he lost his roommate,” according to the report, was finally isolated.
The following day he rode in an ambulance to the hospital, where he died. The first roommate’s test came back positive; the report doesn’t give a result for the second.
We spoke with a nurse at Shorepointe (to protect her job, we’re not using her name), who said the incident sounded familiar, especially so early in the pandemic.
“They were just slow to the uptake,” she said of Shorepointe’s administration in general. “They assumed it was either a horrible cold or the flu.”
Similarly, at Medilodge of Livingston, one resident who tested positive for COVID was isolated at the facility — but not until eight days had passed. The inspector found “no document with complete Infection Control tracking information.”
Michigan Radio asked to talk to administrators at all four of these facilities, but none responded.
Why were homes with deficiencies chosen as hubs?
For the most part, Michigan’s Department of Health and Human Services had no better options.
Brian Barrie, the interim director of the Bureau of Medicaid Policy and Health Systems Innovation at MDHHS, explained to Michigan Radio in May that the first requirement for a hub was having enough beds to accommodate an entire isolation unit.
But empty space often correlates with a poor CMS rating, one measure that consumers use when deciding where to place family members.
Regional hubs’ average CMS rating is 2.8 out of 5, with a 5 being exceptional. The average number of health citations per facility in 2019 was 16 (the state average is 13.5).
Barrie’s team also spoke with state inspectors about a home’s history of violations. If it had a history of problems controlling infections, inspectors would swing by in person to see if conditions had improved.
“I think the danger would be leaving residents in facilities that do not have the proper equipment for the staff, that don't have the proper training, that don't have the ability to isolate or quarantine residents properly,” Barrie said.
If a nursing home had been cited for abuse, it was supposed to be disqualified from becoming a regional hub in Michigan. But two of the 21 regional hubs, SKLD Beltline (in Grand Rapids) and Cambridge South Healthcare Center (Beverly Hills), were cited for abuse in the last year.
Another hub, Medilodge of Grand Blanc, was designated a special focus facility by CMS, meaning its deficiencies were so chronic and potentially harmful it needed extra oversight.
MDHHS spokesperson Bob Wheaton said Medilodge of Grand Blanc was “reviewed with extra scrutiny” and designated a hub “given the improvement the facility had shown.” Of those with infection-control deficiencies, he said it is “very rare” for homes “to not receive low level citations during a survey,” and that in the hubs’ cases, the issues were “corrected,” with oversight from LARA.
Of the homes cited for abuse, he said “any major deficiencies, particularly those around abuse and infection controls, were reviewed very closely.”
Did those deficiencies make a difference once the homes became hubs?
The new inspection reports say nothing of how these homes performed as regional hubs — that is, whether they succeeded in keeping infection out of the non-COVID units once they’d set up their isolation units.
Even with other available information, that question is hard to answer, since the state’s publicly available data for hubs is unreliable.
What we do know is how many patients have been transferred in an out of regional hubs. According to the Wheaton, those facilities have reported 1,272 admissions (if readmitted, a patient would count for two admissions), and 1,151 recoveries, or patients transferred out.
“Facilities that operate a regional hub complete multiple regular reports to the [health] department,” he wrote.
Nursing homes in general can expect more scrutiny in the months ahead.
Michigan Attorney General Dana Nessel announced yesterday that her office would take legal action against long-term care facilities (that includes nursing homes, adult foster care facilities, and homes for the aged) that do not comply with executive orders imposed in the spring.
Otherwise, families and lawmakers should get a clearer picture of how regional hubs in particular have performed in the next few weeks.
The Center for Health and Research Transformation, a research group out of The University of Michigan, plans to release its report on the nursing home hubs at the end of August. The study’s goals are to evaluate the hub policy, draft recommendations for future pandemic preparedness, and minimize infections among these populations overall.
There’s also a nursing home task force, convened by Governor Gretchen Whitmer and charged with “producing a recommendation to the governor for an action plan on how to prepare nursing homes for any future wave of COVID-19 cases.”
That report is also due at the end of August.