Worries About Asymptomatic Staffers Prompt New Nursing Home Rules

Drawing on COVID-19 data from Washington State, officials require surgical masks for staffers at long-term care facilities
Credit: Tai's Captures on Unsplash
Staffers at nursing homes, residential hospitals and assisted-living facilities are now required to wear basic masks at all times.

Armed with data from hard-hit Washington State, and with cases on the rise at nursing homes and other long-term care facilities here, New Jersey officials have called for increasing precautions to help protect the state’s most vulnerable citizens from COVID-19.

Leaders at the state Department of Health issued new guidelines in recent days that require staffers at nursing homes, residential hospitals and assisted-living facilities to wear basic masks at all times. Residents with respiratory symptoms must also don the same protection when interacting with caregivers. If a resident can’t tolerate a mask, they can cover their nose and mouth with a tissue.

In Washington State — an initial hotspot in the nation’s coronavirus outbreak — COVID-19 was spread by asymptomatic staffers who worked at multiple nursing homes, officials said. There is some research that suggests surgical or cloth masks can, when used correctly, help prevent an infected person from spreading the virus to those nearby.

The DOH order also forbids long-term care operators from denying admission to anyone with COVID-19 for that reason alone, whether they are discharged from a hospital or admitted from home. But facilities must strictly separate those with respiratory symptoms — regardless of their diagnosis — from residents who aren’t experiencing breathing problems.

“We continue to be most concerned about our long-term care facilities who care for the most vulnerable populations,” Health Commissioner Judith Persichilli said Tuesday during the state’s daily media briefing on the crisis.

The state suspended visitation weeks ago and has taken other measures to protect these residents. But even so, 81 of the state’s 375 long-term care facilities now have at least one COVID-19 case.

Grim toll, especially for elderly

Overall, nearly 18,700 New Jerseyans have now tested positive for COVID-19, including 267 who have died. Testing has been limited to individuals who have a fever, cough or other respiratory symptoms, so the full extent of the virus is unknown. But one in five of those who have died called a long-term care facility home and nearly half of fatalities were among those over age 80.

While the majority of those infected are unlikely to experience serious illness, the coronavirus is particularly hard on elderly individuals or those with underlying medical conditions — the very population that often depends on long-term care.

One facility, St. Joseph’s Senior Home in Woodbridge, was evacuated last week after the virus infected two-dozen residents and five staffers, overwhelming their ability to provide care.

In the U.S., COVID-19 was first connected to a nursing home in Kirkland, WA, which was eventually linked to 129 cases among residents and staffers, some of whom unknowingly spread it to other elder-care facilities. Nearly three-dozen residents have since died at the home.

A report released Friday by the federal Centers for Disease Control and Prevention examines this spread and notes that, among the first group of 23 individuals found to have COVID-19 in Washington State, 13 — or 57% — did not show symptoms when they were tested. A week later, 10 of the 13 had a fever, shortness of breath, or other signs of the disease, the CDC found.

Persichilli said Tuesday she contacted Washington State officials as case numbers grew at nursing homes here.

“They shared that their state had shown it was individuals coming in — workers, health care workers — who had contracted the disease and were asymptomatic and spread it into their long-term care facilities,” she said. “So that is why we are recommending universal masking of the health care workforce that comes into the facility.”

The guidance also applies to long-term-care residents who have respiratory symptoms of any kind — regardless of whether they have been tested or diagnosed with COVID-19 — when they are interacting directly with staff. At most hospitals, patients with these symptoms are also required to wear masks while in treatment during the current outbreak.

Rethinking efficacy of masks

Health officials have not called for widespread public use of masks in the United States, but new research based on the experience in China — where the novel coronavirus first emerged in late 2019 — suggests that masks can help reduce the spread of infected droplets when properly worn by those with COVID-19. But the protocol is only effective in certain limited situations, like close quarters, and when masks are properly affixed to the face.

Union officials in New Jersey have raised concerns about a lack of supplies and training to adequately protect workers at long-term care facilities here and the state is already facing a shortage of certain masks and gowns to protect health care staff. But Persichilli said basic “surgical masks” or even cloth or paper covering is appropriate for most long-term care situations, and these items remain in stock.

The new requirements add additional complications for long-term care facilities as they must now carefully segregate potentially infectious patients from those who are not, creating separate wings or floors as needed. In some cases this could mean moving assisted-living residents from their home apartment to another part of the building, or placing multiple COVID-19 cases in one unit.

While all residents require some level of care or assistance, the guidance also calls for long-term care staff to limit their movement between the area reserved for symptomatic individuals and the floors or wings where others are living. And they must carefully monitor residents returning from the hospital for signs of the virus.

Persichilli conceded these steps would be difficult for some facilities, based on their layout or operations. She planned to hold a conference call Tuesday afternoon with all facility leaders to go over the requirements and discuss possible solutions to these hurdles.

“Together these two steps — universal masking and appropriately separating residents returning to the facility (with respiratory symptoms) — will help facilities reduce the risk of exposure to the virus,” she said.

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