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'The worst perfect storm.' How the second COVID surge is ravaging NC nursing homes.

Charlotte Observer - 1/9/2021

Jan. 8—For nearly all of the pandemic, not a single resident at Olde Knox Commons tested positive for COVID-19, even as the virus ravaged other nursing homes and long-term care facilities across Mecklenburg County, officials say.

It was as if the skilled nursing and rehabilitation facility in Huntersville, existed in a "magical bubble," says former clinical liaison Sarah Ficara.

The facility — home to about 110 people when it's full — closed to visitors and suspended activities like communal dining rooms even before the state of North Carolina required long-term care centers to do so. Residents started playing hallway bingo, sitting near their doors to maintain six feet of social distancing. All employees began regular COVID-19 testing regimens as supplies became available.

But the latest surge of COVID-19 infections locally, rapidly worsening about two months ago, eventually overcame Olde Knox's safeguards.

"We knew it was going to pop. We just didn't know when," said Ficara, who this week started working on a COVID-19 unit at Atrium Health.

The first COVID-19 diagnosis for a resident in the nursing home came in early December, she said. The outbreak spiraled rapidly before Christmas. Within three weeks, 15 staff members and 37 residents were sick, according to Mecklenburg County Public Health. The latest data from state health officials, from the first week of January, show 22 staff members and 61 residents have been infected at Olde Knox. Two residents have died of coronavirus-related complications.

Ficara found out she was positive on Dec. 21. A day later, in a phone interview with the Observer, she explained she'd likely contracted the virus while helping move coronavirus patients to a separate wing of the nursing home.

Ficara said she sat in her car "crying my eyes out, feeling like, 'Oh my gosh, we went 40 weeks and now all these people are sick.'"

Olde Knox is one of hundreds of congregate living facilities in the state currently managing an outbreak. Nursing homes, where both seniors and other adults in frail health live, have experienced the deadliest consequences of a raging pandemic across the United States.

Despite gains in mitigating the transmission of the virus, health experts tell the Observer outbreaks inside nursing homes remain a large threat for the people who live and work there.

Patty Brown's 77-year-old mother tested positive on Dec. 23 and was moved to the isolation unit at Olde Knox. The tight-knit pair had feared the looming diagnosis, after a roommate became ill two days earlier, Brown said.

"She's doing physically well. She's mentally strong," Brown said on the day of the diagnosis.

"My goal is just to protect her, so there's a sense of just guilt that I wasn't able to do that... The feeling of disconnect is what's most scary to me, not being able to just patch in and make sure (she's) OK."

It's a familiar, albeit heartbreaking, trauma at this juncture of the pandemic.

Nearly half of Mecklenburg's 606 coronavirus-related deaths are tied to these types of outbreaks, even though adults ages 60 and older account for only 13.6% of the county's more than 67,000 cases.

Thousands of people who live in nursing homes will soon be vaccinated across the Charlotte region. Ficara's voice alternates between a deep, rough cough and trembling as she talks about the coming hope: "I think the majority of family members and residents are excited."

'Total chaos'

The crush of skyrocketing infections in Charlotte has inescapably wormed its way into nursing homes, assisted living communities and memory care facilities. In some cases, November and December marked the second time that facilities were dealing with outbreaks.

There are 51 active outbreaks in Mecklenburg, local health officials said Friday.

The total number of cases reported inside local nursing homes with COVID-19 outbreaks ranges from 3 to 128.

The number of outbreaks in facilities in the first week of January is almost double the number of outbreaks reported in mid-November, a Charlotte Observer review of public health data finds.

In mid-October — when coronavirus conditions briefly stabilized in Mecklenburg — the number of outbreaks dipped below 20, before rising by over 40% a month later.

"It really has just been total chaos at many points," said Dena Shenk, the former director of UNC Charlotte's gerontology program, who has extensively interviewed front-line workers and administrators at long-term care communities throughout the pandemic.

"The administrators and managers who we talk to feel calmer (now), feel like they have control over it. Understand, however, that it's luck if they have not had an outbreak. It's not just that they were so perfect and so skilled."

Oftentimes, all it takes is a single confirmed case to catapult a facility into a health crisis, senior care experts told the Observer in recent interviews.

Nurses, for example, could be exposed to the virus outside of work and then unknowingly spread it to susceptible residents under their care, said Hillary Kaylor, a regional ombudsman at the Centralina Area Agency on Aging.

She said these settings serve an extremely vulnerable population, where residents' old age, underlying chronic illnesses and close living quarters compound the risk of getting sick. (Similar circumstances have caused COVID-19 infections, some spurred by asymptomatic transmission, to explode at the Mecklenburg County jail and a Charlotte homeless shelter.)

"They're such a frail communal environment. It's almost the worst perfect storm to be in," said Kaylor, who advocates for nursing home residents and their families in Mecklenburg. "The health department has realized infection control is a huge issue at facilities."

Systemic problems

The pandemic has also exposed systemic issues in long-term care facilities, especially for certified nursing assistants who earn low wages, Kaylor and other experts say.

CNAs are responsible for feeding and bathing residents daily, among other tasks. As Brown puts it, CNAs are like her mother's hands and eyes, delivering continuous care and becoming an extended part of the family.

The work is grueling and can leave little time to linger or don new personal protective equipment between dozens of rooms, said Bryan Rife, director of education quality at the National Certification Council for Activity Professionals, which credentials the people who lead arts and crafts, exercise, bingo and other social programs at long-term care facilities.

Rife, who's based in Charlotte, started his healthcare career as a CNA in the '90s, earning just $9 an hour while assigned to 35 residents.

He's quick to point out some CNAs could earn more money working as a supermarket cashier, or at other essential jobs that carry significantly less coronavirus exposure risk. It's partly why facilities experience such high staff turnover rates.

"You have to be a very special person — you have to be in it for the smiles and knowing you're making a difference in somebody's life," Rife said. "They've been the chosen ones to do this, because it's not an easy thing ... They can still change their profession. But every day, they roll out of bed, and they get up knowing what they're having to go into."

To make ends meets, many CNAs work more than one job, often inside multiple long-term care facilities.

Shenk, of UNCC, said some places urged staff to work at their primary employer to avoid cross-contamination of coronavirus outbreaks. Travel was also discouraged.

"That was one point of probable contagion," Shenk said. "You don't know what people are doing or what their loved ones are doing as they're also working as essential workers."

And to a certain extent, some officials and advocates — tasked with oversight responsibilities — didn't know exactly what was going on inside the buildings, either.

Kaylor used to only spend one day a week at her office, with the bulk of her time spread across visits to different communities. When access was blocked in March, she assumed she'd gain reentry by June at the latest, not October.

"Everything we've done has been very much tele-health and Zoom," she said. "It's been a real struggle."

But not all residents are sealed off from the outside world.

Some need to leave facilities for dialysis, with other new residents moving in after hospital stays. Despite COVID-19 testing and other safeguards, positive cases still happen, such as when people produce a negative rapid test but then test positive a day or so after.

Mental and emotional decline

The unrelenting virus has forced thousands of elderly residents across North Carolina to stay alone in their small rooms — sequestered from loved ones, and even friends across the hallway, since last spring.

The pangs of depression are staggering, with residents' social interactions mostly reduced to sterile plexiglass panels and brief FaceTime calls.

In the time of coronavirus, gone are the large communal dinners, the nurturing touch of loved ones who may live only miles away, and the ease of simply stepping outdoors. For months, not even beauticians, dentists or podiatrists were granted access inside the building, as state leaders remained wary of heightened exposure risks.

"When the pandemic hit, it really flipped nursing homes on their heads," Rife said. "It's not like us living at home, where we're able to come and go freely. For the residents, they were confined to their rooms, double the size of a walk-in closet or a normal size bathroom."

In sprawling case studies, Shenk and Andrea Freidus — a UNCC assistant professor of anthropology — have chronicled the pandemic's trajectory in Mecklenburg, querying the housekeepers, dining staff, medical technicians, nurse practitioners and other personnel who keep long-term care communities functional each day.

The researchers, hoping to swiftly improve public health guidance, are simultaneously publishing articles with gut-wrenching accounts from as close as they could get to the frontlines and residents.

"We talk about people who are dying of COVID and people who are dying because of COVID," Shenk said. "The mental and emotional decline is real, and it's severe. It's particularly traumatic for people with cognitive impairments (and) dementia."

Those residents may not remember why they should be wearing a face mask, and they can struggle to hear what a nurse, standing six feet away with her mouth covered, is saying. Shenk said confused residents might conclude they angered their families — and that's why they've been abandoned since March.

The psychological impact manifests physically, as residents stop getting fed meals by loved ones, lack interest in eating alone, and end up losing weight.

"This is ongoing isolation," Shenk said. "We may be saving lives, but we're causing the end of other lives."

Brown used to visit Olde Knox Commons three to four times a week. She hasn't stepped inside since March 12 when Ficara urged her to swing by after work, believing a lockdown was imminent but only temporary.

When window visits were allowed in September, Brown and her mother put their cell phones on speaker mode to talk as freely as possible, given the circumstances. Brown would bring candy bars and magazines.

If there were no families scheduled after her slot, Brown could linger for two or three hours. Brown wishes she could just hug her mother freely and put her in a protective bubble until the pandemic subsides.

"She's continuously treated with dignity and respect," Brown said of the staff. "I wish that people could see the work that happens in these facilities and what it can do to enhance somebody's life."

Hope and love

Jodi Cooper, a nurse at Olde Knox Commons, never used to pray in public.

Yet it has become a ritual for her and the other nurses as they start their 12-hour shift on the coronavirus unit, a 7 a.m. to 7 p.m. frenzy that leaves Cooper's ankles burning by Friday.

"We just ask that He gives us the strength, the knowledge, the energy to take care of the residents," Cooper said. "We thank Him that we are all able to be here together. We pray for the residents that are positive. We pray for the staff members that may be positive."

Cooper isn't scared of contracting COVID-19. She said she has all the PPE she needs to stay safe.

Her responsibilities are draining. But she and other workers say they're motivated by the deep love they feel for residents.

They know those residents could have enjoyed a high-quality of life for years to come, if the pandemic had not erupted in 2020.

"We're losing a whole generation," Shenk said. "What scares me is the people who don't care: who say they're so old, they're already in nursing homes, they're going to die anyway. That's the part that offends me."

There's now a sense of hope in long-term care facilities as doses of COVID-19 vaccines arrive and residents receive their first shots.

Soon, senior care experts say, vaccines could replace overwhelming anguish and despair among staff, who have watched their residents gasping feverishly for breath.

Cooper said she's probably been coddling her residents more than usual. She says they are the essence of Olde Knox, an endearing blend of more than 100 grandmas and grandpas.

"We're going to do whatever we can to keep our residents alive and try to communicate with the families as much as we can," Cooper said. "Maybe one day when this is all over, you can come see how sweet and cute they are."

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