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Even as California begins to loosen some restrictions on its shelter-in-place orders, there’s one group of people whose lives won’t be returning to normal in the months ahead or perhaps ever: those who live in nursing homes and assisted living facilities.
Shut in their care homes with no visitors allowed, they are alone. No hugs from family. No watchdogs making sure they receive proper care. No trips to dining halls to share meals with friends. No group activities. Doctors aren’t even able to see them in person, in many cases. The only time a family member can get in is if their loved one is about to die.
“I’ve got many calls from my own patients who say they cannot take it anymore,” said Dr. Mehrdad Ayati, a geriatrician who teaches at Stanford’s medical school.
The isolation of locked-down assisted-living and skilled-nursing homes is taking a toll, experts here and across the country say, as health officials and caregivers scramble to contain an outbreak that accounts for almost half of California’s coronavirus deaths.
Patients “are more agitated, there is significant depression and symptoms like weight loss,” Ayati said. These patients may not have COVID-19. No one where they live may have it. But the virus is affecting them nonetheless. “I don’t think we can continue for more weeks and months this way.”
But it appears likely they will.
“At this time, we don’t have an anticipated date to open up long-term care facilities to visitors,” Cassius Lockett, San Mateo County’s director of Public Health, Policy and Planning, wrote in an email. “We can expect this will persist until a vaccine is eventually made available or until we are confident we understand more about who has been previously infected, recovered and are immune.”
At least 9,463 patients and staff at California’s 1,224 skilled nursing homes have tested positive for COVID-19 as of May 13, and at least 1,171 have died. Of the state’s more than 7,460 assisted-living facilities, which include small board-and-care homes, at least 1,803 residents and workers have tested positive, and 257 of them have died.
Dr. Deborah Birx, the White House coronavirus task force response coordinator, issued a recommendation to state governors Monday to test all nursing home residents and staff within the next two weeks. Some states already have ordered testing in nursing home communities.
But California’s Health and Human Services secretary, Dr. Mark Ghaly, said Tuesday that the state is still a couple of weeks away from announcing any plans for statewide, mandatory testing of patients and staff, noting that the barriers include availability of the tests as well as people to administer them.
Bay Area counties have teams to work with nursing homes, but testing there is typically in response to an outbreak among patients or staff. In the region, only San Francisco has embarked on complete testing for its 21 nursing homes. Contra Costa Health Services Director Anna Roth told the Board of Supervisors Tuesday the county is finalizing a plan for widespread testing, but only once a month.
So the seniors must wait. Isolation takes a toll, but weighing it against the risk of catching the virus is complicated, experts say.
“There is definite morbidity (risk) with social isolation. So by socially isolating, are we causing some degree of harm?” asked Dr. Mike Wasserman, president of the California Association of Long Term Care Medicine. “The flip side is that there is a virus here that if people contract it, they have a higher chance of dying.”
Wasserman suggests that care providers get creative to enhance socialization such as making use of video conferencing and other technology.
Some care homes are too overwhelmed by the crisis to set up regular video chats or calls. And for patients with cognitive impairments, it can be agitating and confusing to see or hear family members on a screen but not in front of them, said Ayati.
It also doesn’t substitute for the in-person care and oversight that family members can provide.
Before the pandemic, Dr. Teresa Palmer would regularly visit her mother, Berenice Palmer, outside the Jewish Home and Rehab Center in San Francisco. Palmer is often the one to coax her mom, a dementia patient, into the shower, or to clean her mom’s glass eye. Palmer and her brother used to spend afternoons sitting with their mother outside in the sun, talking to her in between her naps.
“We can’t do that now,” Palmer lamented, noting the twice-weekly Zoom calls with her mom are nice but not the same as visits. And without that stimulation, she said, “we think she’s actually lost processing ability and memory retention.”
Some facilities have found ways to have more in-person interaction. At Byron Park, a senior living community in Walnut Creek, the building is closed to visitors, but families can make appointments to visit with their relatives from a balcony outside a vacant apartment. On Mother’s Day, families talked to their loved ones from a safe distance — with staff disinfecting the apartment and balcony between each visit.
Families of residents at other facilities must devise their own ways to communicate, by standing outside windows or sliding glass doors, able to see but not touch.
Jeannie Richards of Hayward and her sister visit through the window with their brother, who is a patient at Gateway Care and Rehabilitation Center, recovering from a leg amputation. On Wednesday, her brother called and said he hadn’t been taken out of his bed at all that day.
“He wants to escape,” she said. “He’s so mad.”
Still others have struggled to communicate with families. One woman whose mother has been a patient at the Redwood Convalescent Hospital in Castro Valley says she often has to call multiple times to connect with staff for an update or to speak with her mother. She spoke on condition of anonymity, as she fears retaliation against her mom for complaining about the situation there.
Advocates say the lockdown of nursing homes has all but eliminated oversight provided by families and others who keep an eye out for elder abuse or neglect.
Patients who might routinely speak out about poor conditions “are concerned about retribution,” said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties, which monitors long term care facilities. “No one is in the building to keep them safe.”
And the sad reality, experts say, is there is no way that nursing homes and assisted-living facilities could open to visitors responsibly without a regular testing regimen and more adequate supplies of protective equipment for staff and residents.
“We have to be very careful and thoughtful about how we do this to prevent more suffering in these environments, and the major barrier to that is really testing and PPE,” said Dr. Marina Martin, section chief of the geriatric medicine department at Stanford. “Those are the key limitations that prevent us from reopening these facilities, which are housing the most vulnerable communities.”
