Why Nursing Homes Are Vulnerable to Another Devastating COVID Winter

Omicron, with its ability to swiftly evade the antibodies produced after vaccination or infection, made boosters even more critical for nursing home residents. New CDC data shows that the COVID-19 case rate among residents with a booster is more than 10 times lower than those rates among unvaccinated residents and residents who’ve received only their primary series of shots.

But almost 40 percent of fully vaccinated nursing home residents hadn’t received a booster as of Jan. 9, according to CDC data. That’s in addition to the roughly 13 percent of residents who are unvaccinated or only partially vaccinated and are, therefore, ineligible for a booster. 

More than 70 percent of fully vaccinated nursing home staff, meanwhile, haven’t gotten a booster, CDC data shows. That’s along with the approximately 18 percent of staff who are unvaccinated or only partially vaccinated.

“We’ve got to change that,” said Health and Human Services Secretary Xavier Becerra in a virtual forum with the long-term care industry in late December. Describing omicron as “lightning fast” and “a game changer,” he urged nursing home residents and staff to get boosters as soon as they’re eligible.

Nursing homes report that hesitancy among family members or residents, delays in receiving consent from resident representatives, long waits for pharmacy partners to provide on-site vaccinations, and staffing shortages are all contributing to the lag in boosters. Some facilities are also citing recent COVID-19 outbreaks; once residents or staff are infected with the virus, it’s recommended that they wait until symptoms have resolved before receiving a booster.

Many staff are also confused about the official guidance or fatigued by constantly changing guidance, says Glen Lewis, executive director of the Edgewater senior living community in West Des Moines, Iowa. “That’s causing some to delay or just give up trying to keep up,” he says.

Industry groups such as the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), which lobbies on behalf of more than 14,000 nursing homes and long-term care facilities nationwide, and LeadingAge, which advocates on behalf of 5,000-plus nonprofit senior-care providers, are urging facilities to get residents and staff boosted as soon as possible.

Staff vaccination requirement delayed

Nursing home staff vaccinations have lagged resident vaccinations since the shots first became available. A recent study coauthored by Harvard’s Grabowski found that low rates of COVID-19 vaccination among nursing home staff are linked with high rates of coronavirus illness and death among residents, even when residents have been vaccinated. 

The national study revealed that more than 4,770 COVID-19 infections in residents and 700 COVID-related resident deaths might have been prevented in just a two-month period last summer had more nursing home staff been vaccinated. 

In mid-August, Biden announced that all U.S. nursing homes that receive federal Medicare and Medicaid funding — the vast majority of facilities — must require workers to be fully vaccinated against COVID-19. The federal Centers for Medicare and Medicaid Services (CMS), which regulates nursing homes, later announced a Jan. 4 deadline.

But the federal requirement has faced legal challenges, causing enforcement delays. While the mandate has since been allowed by the courts in all states except Texas, nursing homes have been granted more time to fully vaccinate all staff; 25 states have until March 28; the other 24 have until April 14.

“Unfortunately, when courts block these mandates, it means that vaccinations are delayed,” says Lawrence Gostin, a professor of global health law at Georgetown University Law School, “and that could mean people lose their lives unnecessarily.”

AARP “strongly supports” the federal vaccine requirement for nursing home workers, the organization wrote in a recent letter to the CMS, adding that it’s “an important step to protect the health and safety of those working in, and those seeking treatment or care at, Medicare and Medicaid facilities, especially nursing homes.”

But other nursing home stakeholders have pushed back. “We are deeply concerned that the current mandate issued by the CMS will cause nursing homes to lose staff at a time when we are already grappling with a historic labor crisis,” said Mark Parkinson, president and CEO of American Health Care Association and National Center for Assisted Living, in a statement.

Severe staffing shortages getting worse

Staffing shortages have long plagued U.S. nursing homes, but the pandemic exacerbated them by infecting workers with and exposing them to COVID-19, rendering them unable to work while they quarantine or recover, as well as causing burnout among the labor force. Many nursing home employees — who held one of the deadliest jobs of 2020 — have left the field for other positions with better pay, benefits and working conditions.  

An AARP analysis of federal nursing home data shows that 30 percent of U.S. nursing homes have reported monthly shortages over two four-week periods from mid-September to mid-November, when staff COVID-19 infections were relatively low. That's about 7 percentage points higher than shortages reported to the CMS this summer and just above the worst shortages reached last winter.

The current virus resurgence is likely to make them even worse by pulling infected staff out of facilities, raising concerns that care for residents will suffer, particularly during outbreaks, when it’s needed most.

Even at facilities with high rates of boosters, such as the Jewish Home Family in New Jersey, where 100 percent of residents and 90 percent of staff are boosted, omicron is taking a toll. “The hardest thing is staffing as folks go out with a positive test result,” says Carol Silver Elliott, president and CEO.

Studies from the pandemic have found that low staffing levels translate into higher COVID-19 cases and deaths in nursing homes, particularly once the virus has entered a facility.

“Research tells us that nursing assistants shouldn’t have more than seven patients during a shift to take care of, but I’ve heard of some having 30 patients during the pandemic — that’s insane,” says Charlene Harrington of the University of California, San Francisco, who cowrote a study on the issue in California. “Staff are just running from patient to patient — trying to feed them, take them to the toilet — and basic things like handwashing go out the window.”

The CDC recently updated guidance for health care workers, which shortens their isolation time after a COVID-19 infection in order to get them back to work faster. Some states are training soldiers from the National Guard as certified nursing assistants to support understaffed nursing homes.

Visits return, bringing their own risk

Family caregivers, who have only recently been granted reentry into nursing homes after 20 long months of COVID-induced lockdowns, will also play a stepped-up role in facilities this winter, says the National Consumer Voice for Quality Long-Term Care’s Smetanka.

A recent study of pre-pandemic data found that nursing home residents already receive an average of roughly 37 hours of informal care (including help with household activities, mobility needs and self-care) per month, roughly equivalent to an extra full-time shift of care per month. “Family members are an invisible workforce in nursing homes,” the authors wrote.

They also are essential in combating social isolation and loneliness, both of which took a tremendous toll on residents during the extended lockdowns, says Smetanka: “For so many, the isolation and neglect that they experience was just as deadly as COVID.”

In mid-November the CMS released sweeping updates to its visitation guidelines,elling facilities to open their doors and allow visits for “all residents at all times,” barring those who have a positive COVID-19 test or are showing symptoms of COVID-19. The recent resurgence caused the CMS to backpedal slightly, allowing facilities to regulate visits more, but the exceptions are “very limited and rare.”

Many are applauding the relaxed rules, citing the tremendous toll of lockdowns. But reopening to visitors allows another way for the virus to potentially get into facilities, triggering possible outbreaks.

Visitors are not required by the CMS to be vaccinated or to test negative before a visit, which is believed to have led to two unvaccinated, unmasked and infected guests sparking a COVID-19 outbreak in a New Jersey nursing home just before Thanksgiving. One hospice resident who contracted the virus died, and three others were hospitalized.

“The visitors should have been vaccinated or tested prior to the visit,” wrote Ronald G. Nahass, president of ID Care, a New Jersey medical practice. “This situation is simply wrong.”

AARP, the California Association of Long Term Care Medicine and other groups representing long-term care residents are asking the federal government to prioritize nursing homes for COVID-19 tests amid the current shortages. The Biden administration is making 500 million rapid COVID-19 tests available for the public to order. In a statement, the administration said the country’s “hardest-hit and highest-risk communities” would be prioritized. There was no specific mention of nursing homes, however.

Editor’s note: This article, published Jan. 14, 2022, was updated Jan. 20 with new details on the CMS vaccination requirement for health care workers and the Biden administration’s at-home COVID-19 testing campaign.