As the coronavirus stalks Arkansas' nursing homes, state records show some facilities still struggle to comply with infection-control practices like cleaning thermometers and wearing masks.
Seven weeks after the long-term-care sites entered a mandated lockdown to protect elderly or infirm occupants, new cases of covid-19, the illness caused by the coronavirus, appear daily and often at places with no previous infections.
The number of infected nursing-home residents statewide nearly doubled in the two-week span that ended Friday, climbing to 225 from the 122 cases reported on April 17, according to state data.
Infections among residents have been reported in roughly one of every eight nursing homes in the state. The five such homes with the largest clusters each have at least 27 residents who have tested positive for the virus.
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As of Friday, 22 residents in six facilities had died.
Smoldering outbreaks around the state reveal the difficulty in protecting thousands of people who live in nursing homes. That's especially true as businesses and restaurants outside those facilities prepare to reopen this month.
Industry and health officials have described some new infections as almost inevitable, but inspections of nursing homes from late March and April show some sites faltering in basic prevention measures.
At Briarwood Nursing and Rehabilitation Center in Little Rock, a maintenance worker told an inspector that he had not been tested for covid-19. A housekeeper and a laundry worker both said they had received little information from supervisors about the disease.
"I watch the news, and you hear people talking about it," one worker told an inspector on March 31 for a report compiled by the state's Office of Long-Term Care. "No one ever updates us."
At least two other nursing homes had infection-control failures in late March and early April, according to state surveys.
Nationally, long-term-care sites that include nursing homes have reported some of the pandemic's bleakest statistics, with at least 10,000 deaths, according to the health policy nonprofit Kaiser Family Foundation. The numbers are fueled in part by the virus's higher death toll among older people and people who have chronic health conditions.
Social distancing to slow the transmission isn't always possible in such facilities, where residents often need help eating, washing themselves, using the toilet or moving from bed to a wheelchair.
Dr. Naveen Patil, the Arkansas Department of Health's medical director for infectious disease, defended the state's nursing homes strategy, which includes testing every resident and staff member in sites that have at least one positive case.
"We have done the best given the circumstances. And I don't think any state in the country is as aggressive as we are" on testing, he said.
Of the six states that border Arkansas, only Louisiana reports the number of nursing home residents infected on a daily basis. Texas reports deaths specific to nursing home residents, but not infections.
As of Wednesday, nursing home cases made up 7% of Arkansas' total cases, compared with 10% in Louisiana. Nursing home deaths represented 31% of the total deaths in Arkansas, 33% in Louisiana and 35% in Texas.
"All those precautions have gone in place and have helped -- but it's not perfect," said Arkansas Health Care Association executive director Rachel Bunch, referring to visitor restrictions, temperature checks and other measures.
"It's invisible," she said of the virus. "People can have it and not know it, which is what is so scary."
Patil and Bunch, whose association is the state's largest nursing-home trade group, also said the porous nature of lockdowns, where doctors and staff members continue to come and go, may contribute to the virus spread.
While it was expected that residents would be at risk, "the impact could have been, and still can be, much less," said Richard Mollot, executive director of the New York-based Long Term Care Community Coalition.
Mollot and other advocates for nursing-home residents say the pandemic sheds light on a pattern of weak enforcement of staffing and safety regulations, such as infection-control practices, even when those standards are strong on paper.
"You're caring for very vulnerable individuals. You're not shipping cartons of eggs or milk or toilet paper."
Recordings of 911 calls from Arkansas nursing homes with the most severe outbreaks, obtained through the state's public-records law, offer a glimpse into the unprecedented strain on nursing-home residents and their caretakers.
On April 3, the day an 89-year-old man died at Walnut Ridge Nursing and Rehabilitation Center, that site's assistant director of nursing called Lawrence County's 911 dispatch service to ask where she could obtain a body bag for a resident with "an infectious disease."
Ten days later, she called back to request a transfer to the hospital for a resident with covid-19 who had low oxygen levels. "I don't know who's going to be willing to accept him or not," she said.
Combined, 70 residents and staff members have been infected at the Walnut Ridge facility, and three of its residents have died.
'IMMEDIATE JEOPARDY'
Of eight nursing-home inspection reports reviewed by the Arkansas Democrat-Gazette, three show cases of poor infection-control practices, even in facilities where covid-19 was known to be present.
In the Briarwood report, dated April 2, a licensed practical nurse wearing gloves, a mask, a gown and foot covers handed out protective equipment to inspectors, who asked if any staff members on the floor had tested positive.
"Me," the nurse replied.
Laundry employees told the inspector that they worked without wearing N95 respirator masks, and used less-protective masks instead, though they had been told to treat all laundry as contaminated.
The Little Rock facility drew an "immediate jeopardy" citation for violations that the inspection report says "caused or could have caused serious harm, injury or death to 44 residents who were not currently positive for covid-19."
The citation was later removed after Briarwood submitted its plan to address the violation. The plan says all housekeeping and laundry staff members would be trained in how to wear protective equipment and "fit tested" for the high-quality N95 masks by April 6.
Briarwood's administrator did not respond to a message left at the facility seeking comment. Bunch, who has acted as the facility's spokesman at times, did not respond to a similar request for comment.
Briarwood on March 20 was among the first group of nursing homes to report covid-19 cases. As of Friday, 43 residents and 17 staff members were reported to have the illness.
In a March 26 inspection at Longmeadow Nursing Center in Camden, an inspector documented a certified nursing assistant interacting with residents without first washing or sanitizing her hands, and using a single alcohol wipe to clean a thermometer through uses by multiple residents.
No infections have been reported at the Camden facility, whose owner did not respond to a message seeking comment.
Martha Deaver, president of Arkansas Advocates for Nursing Home Residents, said all nursing home staff members, including laundry workers, should have access to protective equipment, intensive infection-control training and at least weekly covid-19 tests.
Deaver also suggested calling on medics in the Arkansas National Guard, as was done in Alabama, to help alleviate the burden on nursing home health care providers.
"At least give these residents and employees a fighting chance," Deaver said. "They're already the sickest and the most frail healthwise and mentally in the state."
Records show the spread of coronavirus through nursing homes has affected even residents who weren't touched by the illness.
Residents were moved from The Waters of Woodland Hills in Little Rock to convert the facility into a site for covid-19 positive individuals. At least 10 of them described an abrupt and chaotic transition.
One employee, distressed by the situation, told an inspector that the residents were "pulled out of their beds and put in their wheelchairs and put out in the hallways lined up like cattle."
Residents and their families said they weren't given a choice about where they'd go, and families scrambled to collect possessions, including a hearing aid and glasses left behind.
"I had a best friend in there, but they split us up," one resident with anxiety and schizophrenia told the inspector, according to a report. "They sent him to [Facility #4] and I'm here [Facility #2]."
"You get in a routine and you get secure with it, and it gets pulled out from under you," another resident remarked to an inspector.
The Waters at Woodland Hills did not return a message requesting comment about the report.
Deaver said residents have the right to choose the nursing homes in which they live.
NO KISS GOODBYE
As of Friday, the virus had entered 36 of Arkansas' 226 licensed nursing homes. Infected were 225 residents across 28 facilities and 139 workers statewide, according to state data.
The five nursing homes in Arkansas with the largest outbreaks are: The Lakes at Maumelle Health and Rehabilitation, The Waters of White Hall, Willowbend Healthcare and Rehabilitation in Marion, the Briarwood facility in Little Rock and the Walnut Ridge facility. Infections at the five facilities totaled 184.
Administrators at all five declined or didn't respond to interview requests.
"We are working very closely with the Arkansas Department of Health and adjusting our operations in lock-step with federal and state regulation and guidance on how to combat the pandemic within our facility," Austin Treadway, administrator at The Lakes, said in an emailed statement.
Family members of five residents at those homes who spoke at length with the newspaper all said they don't blame the nursing homes for the outbreaks, which one called "the luck of the draw."
They included Sheri Brown, whose father, Harry Drabelle, was asymptomatic for nearly two weeks after he tested positive for covid-19 at The Lakes of Maumelle.
Drabelle, a 78-year-old Army veteran, had moved into the facility with his wife almost a decade ago. Brown said the family was pleased with the quality of care.
He was one of the first two residents to test positive for the virus and was transferred to a hospital on a Monday afternoon when he had trouble breathing after a meal, she said.
"It was pretty bad when they sent him," Brown said. "When the doctor called me from Baptist, they said it was not good."
Drabelle had been treated with a ventilator in the past and disliked it, so Brown told doctors to instead provide comfort care. He received oxygen through a mask and was treated with antibiotics, and he died the next morning, April 14.
"I wanted to make sure he was peaceful," Brown said.
Anne Broadwater and Mark Jansen, whose mother, Frances Jansen, was a resident at the Briarwood home, also praised their mother's care at that facility where she had lived for about two years.
Broadwater visited her mother almost every day until the facility closed to visitors in mid-March. Frances Jansen, 94, initially tested negative for covid-19, but developed a fever and was retested.
Near midnight one evening, Broadwater said she got a phone call from an aide who said her mother might be near death. Broadwater put on goggles, an N95 mask and a protective gown so she could sit at her mother's bedside.
"I really wanted to kiss her goodbye, but I knew I couldn't do it, so I didn't," Broadwater said.
Frances Jansen died shortly after 9 p.m. on April 1.
Because of visitor bans, Broadwater said she still has not been able to collect her mother's makeup or the clothes from her closet, which she said is a source of "subconscious angst."
"I know her room is still there," she explained. "I know it's still there, without her in it."
'REALLY SCARED'
Mollot, the long-term-care advocate, says he hopes the pandemic will encourage regulators to "rethink" their approach to managing nursing homes.
Residents are "people that you're being paid a minimum of a couple hundred dollars a day to provide care for," he said. "So how are we doing that?"
The federal Centers for Medicare and Medicaid Services announced last week that it would form a commission to review the coronavirus's impact on nursing homes, and rules announced April 19 will mandate that nursing homes notify residents' family members and the federal government when there is a positive case.
Currently, that notification process varies among providers in Arkansas, a Department of Human Services spokeswoman said.
Bunch said hard-to-solve issues that have come to her attention recently include residents' frequent, necessary transportation out of nursing homes to receive dialysis and other treatments. Some staff members also may work at multiple sites, she said.
"There's more that we don't know than what we do know" about why outbreaks at some facilities are more active than others in the state, she said.
She added that new universal mask protocols and rules on isolating residents who have returned from the hospital should help staunch virus transmission.
Patil said the Health Department is stressing isolation of residents who have tested positive or who were exposed to the virus, and has stepped up its education on hand-washing and infection control.
While masks should help, he acknowledged that limiting the spread of infection from people without symptoms is a challenge.
"That would require testing everybody with rapid tests, every day, which is not feasible," he said.
Meanwhile, family members of people who live in nursing homes can do little.
Essie Lawrence praised the quality of care her grandmother, Betty Riggs, has received at Willowbend while living through the outbreak at the Marion center.
In a photo taken by Lawrence on a recent visit, Riggs, who is in her 80s, smiles at her family through a window of the nursing home as horizontal blinds partially obscure her face.
"I'm not going to lie, I was scared to death -- really scared," when she heard about the virus' spread in the facility, Lawrence said.
The nursing home has made weekly calls to the family to share information, including about Riggs' negative test results, new positive cases in other residents, plans for testing and the home's two covid-19 deaths.
Her grandma, who typically enjoys bingo and visits from beauticians, hasn't liked being confined to her room, Lawrence added. But Lawrence thinks the facility had done a good job of isolating those who are infected.
"I'm not concerned about it. They'll do what they have to do to try to contain it."
Information for this article was contributed by Ginny Monk of the Arkansas Democrat-Gazette.
SundayMonday on 05/03/2020
CORRECTION: A map and list in an earlier version of this story incorrectly identified one Arkansas nursing home. The graphic and interactive map should have named Encore Healthcare and Rehabilitation of West Little Rock as having one resident who has tested positive for the virus, and not a similarly named property in Malvern that has had no cases.