The high death rates in Assisted Living Residences (ALRs) and Nursing Homes (NHs), especially in New York, have been attributed by some to positive COVID test results among staff who then infect residents.1 To whatever degree that may be true, the advanced age and underlying conditions of so many people in ALRs and NHs make such facilities high risk for negative COVID outcomes.2 Even with such high risks, however, some families have little choice but to place or keep their loved ones in ALRs and NHs.
As a former Alzheimer disease spouse caregiver who visited my late wife for nearly 3 years in dementia units of an ALR and NH, I believe that there are actions that can be taken now to possibly reduce COVID deaths in such facilities. I would recommend that these 4 factors be looked at more closely:
Availability of Medical Staff
In NY, there is a minimal requirement for the presence of physicians in NHs. According to the New York State Department of Health, Nursing Homes in New York State, “The frequency of (attending physician) visits shall be no less often than once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter.” 3 This is simply not acceptable! My wife’s ALR had 2 “visiting” doctors who each came onsite for about 3-4 hours every week, but often did not see my wife during their visits unless I specifically requested that she be seen. My wife’s NH had one doctor “on call” for its 300 residents and was so busy that numerous requests to meet with him were unsuccessful.
To provide better medical care to residents, especially during this pandemic, ALRs and NHs must have well trained doctors available onsite, and more often. As soon as possible COVID symptoms are detected, decisions should be made on either immediate treatment in that facility, or hospitalization. Delays due to time are unacceptable, but only if a doctor is onsite will time delays be avoided.
Quality, Training, and Supervision of Non-Medical Staff
Whereas there are many highly dedicated and caring people working in these facilities, too many staff members are simply not given proper training, and too many are simply not dedicated or caring. Aides are often paid at, or barely above, minimum wage. According to the Paraprofessional Healthcare Institute, its latest available data from 2016 indicated that “nurse aides, who provide most of the direct care in nursing facilities, earn near-poverty wages.” 4 To attract more highly qualified people, salaries must be increased immediately—especially given the risks that aides are taking each day during this pandemic by being in such close contact with residents.
Supervisors must provide, or arrange for others to provide, adequate orientation and training for every aide. Supervisors, often underpaid—between $29,000 -$38,000—also need more training.5 Based upon my observations on an almost daily basis, too many supervisors remain closeted in their offices instead of being out on the floor directly observing and supervising aides interacting with residents.
Well-trained aides and supervisors who recognize the earliest signs of possible COVID can alert doctors onsite and may help prevent some deaths.
Testing and Personal Protective Equipment (PPE)
There must be better testing capabilities, PPE, and frequent COVID testing with results available within hours so personnel testing positive can be sent home immediately before infecting others. That is a recognized “given,” but ALRs and NHs need better plans in place to immediately replace absent staff. Residents already often lack proper attention due to shorthanded staffing on many days.6 With higher salaries, more people might be willing to become “substitute emergency aides.” However, before being placed on any substitute list, aides must also receive proper orientation and training. Shorthanded staffing increases the chances of staff not recognizing the earliest signs of COVID in residents.
State Supervision Responsibilities
When my wife was admitted to her NH, I was told the regular visiting hours. However, I should have been told that state and federal law allow a spouse to visit anytime. When I learned about this legal right, I contacted the NYS Department of Health and was told that all NHs in NY are in full compliance with this law. But that was not true. I went to the DOH website listing of about 630 NHs throughout the state, and I called every 10th NH on that list to ask about their visitation policies. Of the 63 NHs I contacted, only 24 indicated that spouses can visit anytime. Sadly, 39 of the 63 NHs indicated that spouses can only come during regular posted visiting hours, which was not in compliance with state and federal law.7
Admittedly, I did this survey in 2016, 4 years before Covid played havoc with all NH visitation policies. However, my point remains valid … whatever new state laws or mandates arise to make ALRs and NHs safer for residents, unless the state DOH exercises better supervision with frequent (and, I would suggest, unannounced) onsite inspections, meaningful change may not happen.
One Last Point
For as long as this pandemic is with us, facilities must find ways to designate safe areas where visitors can briefly meet with residents. One way to make this happen is to construct a temporary “safe corridor,” either within the facility or in a “tent-like” open or enclosed attachment to the facility. A safe corridor would enable visitors to enter, meet with residents, and leave without being in contact with others.
I cannot even imagine the pain of ALR and NH residents, and their families, who have been unable to visit with each other during these past many months. The pain of residents dying such lonely deaths is not something that should be allowed to continue. ALR and NH visitor restriction policies must be changed immediately.
Dr Vann has written frequently for caregiver magazines, other medical journals, and major newspapers. After his late wife, Clare, was diagnosed with early onset Alzheimer disease, Dr Vann made it a point to increase public awareness of Alzheimer and to help fellow caregivers.
1. New York State Department of Health. Data Indicates COVID-19 Was Introduced into Nursing Homes by Infected Staff. July 6, 2020. https://www.health.ny.gov/press/releases/2020/2020-07-06_covid19_nursing_home_report.htm.
2. The New York Times. More than 40% of U.S. Coronavirus Deaths Are Linked to Nursing Homes. Updated on August 13, 2020. https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html.
3. New York State Department of Health, Nursing Homes in New York State. Role of the Attending Physician in the Nursing Home. 2011;(pages 4-5). https://www.health.ny.gov/facilities/nursing/all_services.htm.
4. Elder Law Answers. How Low Nursing Home Wages Are Contributing to the Spread of Covid-19. April 12, 2020. https://www.elderlawanswers.com/how-low-nursing-home-wages-are-contributing-to-the-spread-of-covid-19-17702.
5. Salary. How Much Does a Residential Supervisor Make in the United States? May 28, 2020. https://www.salary.com/research/salary/benchmark/residential-living-supervisor-salary.
6. Reuters. Special Report: Pandemic Exposes Systemic Staffing Problems at U.S. Nursing Homes. June 10, 2020. https://www.reuters.com/article/us-health-coronavirus-nursinghomes-speci/special-report-pandemic-exposes-systemic-staffing-problems-at-u-s-nursing-homes-idUSKBN23H1L9.
7. Annals of Long-Term Care. Is Your NH Visitation Policy in Compliance with Federal Law? [blog]. May 9, 2017. https://www.managedhealthcareconnect.com/blog/your-nh-visitation-policy-compliance-federal-law.
Published in Annals of Long-Term Care, October 1, 2020. Access online only at: