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Nursing home let staff with COVID care for patients

STORY BY MICHELLE GENZ (Week of February 18, 2021)

In the lull between Vero’s summer and winter COVID-19 surges, and as families began to be able to visit residents in long-term care, a November inspection of Consulate Health Care revealed a frightening fact.

Rather than tightening controls on COVID-19, one of Vero’s most problem-ridden long-term care facilities was letting down its guard.

Nine months into the pandemic, when COVID-19 precautions should have been second nature, frontline caregivers – including a registered nurse in a supervisory role – were coming to work with symptoms of COVID-19, and in some cases, even after testing positive.

The report, conducted by the state’s Agency for Health Care Administration (AHCA) in response to a complaint, showed screenings weren’t consistently being done as required. Mask-wearing was found to be lax or abandoned by some. In one instance, the inspector noted a mask dangling off one ear of an RN as she chatted with patients two feet away from her.

When Consulate’s director of nursing was asked by the AHCA inspector who was making sure people were being properly screened, the director of nursing said “the front desk was doing it. I don’t know who’s doing it now,” according to the report.

That casual attitude belies the importance of screening as a means of keeping patients and staff safe.

The Centers for Medicare and Medicaid Services requires nursing homes to test staff and patients according to the county’s positivity rate, with frequency ranging from monthly when positivity is low, to twice a week if positivity is high.

Screening fills in between regular tests, and the Centers for Medicare and Medicaid Services requires the procedure in long-term care on entry for visitors and vendors; daily for residents; and at each shift for staff.

The screening protocol requires temperature taking but also forces staff to take note of symptoms ranging from cough and shortness of breath to more innocuous-seeming complaints including headache, runny nose or sore throat, all of which could indicate coronavirus infection.

“Staff with symptoms or signs of COVID-19 must be tested and are expected to be restricted from the facility pending the results of COVID-19 testing,” according to the CMS website.

Yet at Consulate, the state inspector found four frontline caregivers – two of them RNs – who were not screened for COVID-19 symptoms on the last day worked before testing positive. All four were showing symptoms at work, including one RN who was the designated weekend supervisor, according to the timeline of the cases as reported to the health department.

Other frontline caregivers at Consulate stayed on the job even after the facility was notified they had tested positive for COVID-19, according to the report.

The report also noted a failure of Consulate to properly report positive cases to the health department, sometimes waiting two, three and even four days to report infections. The state health department mandates that positive test results be reported by facilities within 24 hours of receipt.

One nurse who was tested at a hospital and found to be positive for COVID-19 was never reported by Consulate, the inspector found, even though Consulate was aware of the case. The director of nursing “offered no explanation why the employee was not [reported].”

Another staffer, a CNA, tested positive in August in routine testing at the facility, but her case was never reported, the investigator found.

The AHCA report does not include names, identifying staff only by a letter of the alphabet. But it does describe their positions.

Among the employees who were found to have worked even after testing positive was a personal care assistant, an entry-level position created during the pandemic to ease the shortage of workers in long-term care. 

That staffer was tested for COVID-19 on Oct. 22; two days later, on Oct. 24, Consulate was notified of the positive result. But records show the caregiver’s last day worked was Oct. 25 – even though, on top of the positive COVID-19 test, Consulate’s own screening from that day showed the caregiver with a COVID-19 symptom – a headache.

Another employee, a certified nursing assistant, or CNA, went to work on the nursing home’s 7 a.m. to 3 p.m. shift on Oct. 30 with a headache bad enough that she mentioned it to the charge nurse, her supervisor. But there was no evidence that anyone made sure she went through the required symptom screening. The charge nurse did not send her home, nor did she order a COVID-19 test, the report said.

“There is no evidence of further evaluation by the infection preventionist and director of nursing, or no evidence of a rapid test being done prior to working her shift,” the report noted.

The next day – Halloween – when the CNA got a COVID-19 test that came back positive, she still had the headache, along with other symptoms.

The facility line listing – the document nursing homes are required to turn in to the local health department within 24 hours of a positive test – showed the employee had “myalgia/muscle aches, unusual fatigue, headache, fever, cough, difficulty breathing, shortness of breath and sore throat for more than 48 hours.”

Based on when she tested positive, that timeline would put a highly symptomatic CNA squarely in the halls of Consulate, moving among staff and patients prior to her positive test.

But the timeline is muddied, since Consulate did not report the case to the health department until Nov. 2, three days after the positive test, and two days beyond the required 24-hour reporting window.

An LPN who last worked Nov. 16 – with no evidence of screening – had a positive rapid test the next day on Nov. 17. The line listing for that positive case showed muscle aches, headache, fever and runny nose for 56 hours beforehand.

Another CNA whose last day was Nov. 16 also lacked any evidence of a screening. Like the LPN, she tested positive the next day, Nov. 17. The line listing showed she had a runny nose for 72 hours before her test.

And then there is the registered nurse who took her job very seriously. She was the weekend supervisor on Oct. 24-25 and the report cites her “work ethic” as the reason she stayed on the job with COVID-19 symptoms.

The inspector went into great detail in her interview with the nurse, confirming she had worked Oct. 24-25 even though she was experiencing headache, nausea and throat irritation. “She said it did not occur to her she would have COVID-19,” wrote the inspector – even though there were numerous known positive cases in the facility that week.

“She denied telling anyone, stating that she was the weekend supervisor, and her work ethic made her work,” the report said, noting the nurse had to use a rescue inhaler on Sunday.

The next day, her day off, she stayed in bed. Tuesday, she was scheduled to work “but felt hot.” She took her temperature and found it was 102 degrees. It was only then that she let Consulate know she was sick, she told the inspector.

Finally, after four days with symptoms – two of them while on the job at Consulate – she had a COVID-19 test at CareSpot. It was positive.

During the inspection, the state inspector noted multiple cases of staff and residents not wearing masks as required. Four staffers were observed without facemasks, including a registered nurse whose mask was dangling from her ear as she stood in a hallway preparing medications.

Twice she had conversations with residents who were just 2 feet away. Those residents wore masks, but the inspector noted seven other residents without masks in close proximity to each other.

A second nurse, an LPN, was also unmasked as she worked at a different medications cart.

The same inspection noted multiple medication errors, including switching the entire morning pill regimen of two patients who were roommates.

It is not known whether state or federal authorities will impose any penalty on Consulate for its deficiencies in the November inspection. Those typically come weeks or months after the report is posted, which typically is 30 to 45 days after the inspection.

That was the case with the facility formerly known as Grace Rehabilitation Center, now known as Orchid Cove. Records show the nursing home and rehab center incurred a federal fine of $105,147 after a cognitively impaired wheelchair-bound patient went unnoticed as he rolled himself through the length of the facility and out an unlocked exit door where he remained unnoticed for up to two hours in the August sun.

It is by far the largest federally imposed fine at any of the county’s five nursing homes. The next largest fine was imposed on Palm Garden, fined more than $80,000 two years ago for filthy conditions and degrading practices. In March 2020, it was fined again, $14,000 for performing CPR on a patient who had a do-not-resuscitate order.

Consulate was fined $16,000 for a similar do-not-resuscitate issue in January in which advanced directives could not be found and CPR was given despite a DNR.

Calls to Consulate’s executive director were not returned. Neither were emails sent to Consulate’s corporate communication staff.