Could a simple lack of personal protective equipment, including proper masks, gowns and gloves, have increased the COVID-19 death toll at nursing homes across Colorado?
Nursing home workers, patients and families interviewed by KUNC think so.
They allege personal protective equipment (PPE) use began too late or its use was too lax at some facilities. State data requested by KUNC apparently supports their contentions. Deficiencies involving PPE top the list of problems inspectors identified at facilities during the first two months of the pandemic.
"We have not had all of the tools that we wish we had to fight this pandemic in terms of PPE, testing supplies and things of that nature," said Randy Kuykendall, with the Colorado Department of Public Health and Environment.
About one third of the 1,135 deaths due to COVID-19 in Colorado were nursing home patients, according to the most recent facility outbreak data analyzed by KUNC. Though outbreaks at jails and meat packing plants have grabbed headlines, outbreaks at nursing homes have been far more deadly.
Kuykendall is the director of the division that oversees some 3,300 health facilities across the state, including nursing homes.
Of the 405 deficiencies CDPHE inspectors issued through early May, 59 were for facilities that failed to follow PPE guidelines or did not ensure adequate supplies. Another 47 citations were issued for facilities that failed to follow proper hygienic measures, like hand washing.
Dozens more citations were issued for facilities that failed to follow social/physical distancing measures as well as failing to ensure residents had face coverings when staff visited their rooms or when the residents ventured outside of their rooms.
Kuykendall said while limited supplies have been a factor in outbreaks at nursing homes, he cautioned that state officials don't have all the answers for why there have been so many deaths among nursing home patients.
"I can't tell you that we've been able to determine yet whether or not there's a correlation between the number of cases and the levels of PPE," Kuykendall said. "I think that will be something that we will only be able to figure out probably down the road a little bit."
The department said it would not release the names of the facilities cited because the findings are preliminary and facilities are being given "due process" to challenge them.
A nursing patient remembers when the pandemic struck
Rewind to mid-February, before the pandemic hit Colorado and when there were only a few cases of coronavirus in the United States.
That's when 51-year-old Tara Frechea of Greeley was hospitalized for pneumonia. She's been more susceptible to serious illnesses since she was in a motorcycle accident as a teenager and lost her spleen, which helps the body's immune response.
Later, she was sent to a nursing home, Centennial Healthcare Center in Greeley to recover. That was on March 4, the same week that a nursing home in Washington state made national headlines as the epicenter of the country's emerging pandemic. Also that week, Colorado announced its first confirmed cases.
Frechea was watching the news from her nursing home bed, where she had been improving. Because of the news, she said she paid close attention to the habits of the workers and aides caring for her.
"They didn't wear masks," Frechea said. "No masks."
She claimed workers at the home weren't wearing gowns or gloves either.
At that time, as the virus first struck the state, there was no requirement that nursing home workers use PPE. That would soon change.
The following week, Gov. Jared Polis declared a state of emergency. There were just 17 known cases in the state. In a press conference on March 11, Polis was flanked by key health and emergency operations officials. He highlighted that those most at risk for severe cases or death from COVID-19 are people older than 60 and/or those with compromised health conditions, like people in nursing homes.
"I've asked the CDPHE executive director to engage in emergency rulemaking to limit visitation to senior facilities, to conduct screening of visitors and staff and take additional necessary steps to protect those in our care," Polis said.
Health officials ramp up
On March 12th, the CDPHE issuedPublic Health Order 20-20. It barred most visitors to long-term care facilities and also required PPE, like masks, gowns, gloves, as well as screenings for workers.
But it did not stop the coming wave of coronavirus outbreaks at nursing homes, including at Centennial Healthcare Center, where Frechea's family said they struggled to get answers.
"They didn't tell us anything," Frechea's daughter, Raquel Stevenson, said.
Freschea watched as other residents suddenly fell ill. She wasn't sure if they had coronavirus or not. Then her own health took a turn for the worse.
"I had a temperature of 104 for two days," Frechea said.
Then she was rushed by ambulance to the hospital.
"They told me, 'We're going to put a ventilator in and you've tested positive for COVID,'" she said. "I was freaked out at that point."
That was late March. Finally, in early April, Centennial confirmed several deaths related to an outbreak of COVID-19. In a statement at the time, the nursing home said it was doing "everything" in its power to protect residents and workers.
Weld County's public health department reacted to the outbreak at that nursing home and others.
"We brought testing in, which was a challenge in the beginning and, I think, why we saw some of these facilities unfortunately have that kind of an outbreak," said Dr. Mark Wallace at the time. He's the recently retired director of the department.
"You end up, as you're trying to control the spread, doing what we call 'cohorting,'" he said. "So trying to keep a ward that becomes a respiratory ward and a ward that is not for respiratory illness as you try to break that cycle. So all of those things went in. We review all of their infection prevention plans to really get in there and say, 'OK. Here's another little measure that can be done over here and really be very disciplined about people not coming into work, not putting people into the facility who could put other residents at risk.'"
To date, 66 residents and staffers at Centennial Healthcare Center have tested positive for the virus and another 22 possibly had it, according to state outbreak data. Twenty-two people died at the nursing home and two more deaths were listed as "probable" cases.
In response to this story, Centennial Healthcare Center issued another statement. It said in mid-March it "immediately began restricting visitors" and following "PPE guidance" as the state directed.
PPE in short supply
Getting proper PPE hasn't been easy for nursing homes, according to officials in several state and local agencies. They sounded the alarm early and often, including Katie O'Donnell, the public information officer for Larimer County's public health department.
"A lot of these guys are starting to run out of PPE," she said in early April.
She predicted that PPE shortages would be an ongoing problem.
"That's becoming a bigger and bigger issue in our community because as infection control ramps up and the state says they need to be using more PPE than they originally did, there's not PPE for us to replace it with so that's becoming an ongoing issue with our nursing homes," she said.
On the ground, this meant care workers could be open to infections if the nursing home they worked at didn't have adequate supplies or procedures.
Nurse Carolene Quezada alleged that's what happened to her at Cherry Creek Nursing Center in Aurora as a large outbreak brewed.
"Pretty much, it was a huge mess," Quezada said with her attorney present.
She was contracted through an agency to work at the nursing center and quit after one shift on April 6. Quezada and her attorney claim she had agreed to work with patients who did not have COVID-19 but she ended up working with infected patients anyway. Moreover, Quezada claimed she was not told they had the virus.
"I had to do assessments, you know, assessments head to toe," she said. "You know, I'm listening to their heart. I'm listening to their lungs. I'm touching their body, looking for pressure ulcers, having to give them their meds."
She said a manager told her later during her shift that the patients had coronavirus.
"Everything inside of me just wanted to fall apart," Quezada said. "I could not believe this was happening."
Making things worse, Quezada says she wasn't given the proper PPE. She wore a surgical mask, but not an N-95 mask that's effective at preventing infections. Because patients were depending on her, she finished her shift.
"As a nurse and a person who I am, I'm going to do the right thing," she said.
Afterwards, she cried in her car. Then she refused to return. Because she had been exposed to the virus, she went into self-quarantine and eventually became ill with COVID-19.
Cherry Creek Nursing Center has had 27 confirmed COVID-19 deaths among its patients. To date, that's the most in the state for a nursing home. Another six are considered probable virus deaths. Sixty-eight residents and 44 workers were confirmed to have the virus and dozens more were listed as probable cases.
The nursing home declined our request for an interview but issued a lengthy response to Quezada's allegations, stating that she knew she would be "working in a COVID-19 environment" and that since the outbreak began the nursing home has strived to "protect residents and staff," including providing PPE.
Nursing home triages PPE requirement
It's rare to find nursing home workers who are willing to talk about outbreaks and deaths.
"We have been told that if it becomes apparent that we're talking to any media, we'll lose our jobs," one nursing home worker in Arapahoe County told KUNC on the condition of anonymity.
Like Quezada, the worker said some precautions were in place, as required by the state's public health order. Yet the PPE requirement was changed.
"Nobody was wearing protective equipment under any circumstances."
"Our director of nursing was hesitant to start universal masking because she did not want to go through all of the masks before the virus came into the building," the worker said.
That meant that "nobody was wearing protective equipment under any circumstances" the worker said.
It was only after the first COVID-19 case was confirmed at the nursing home that was PPE required. In the weeks following, at least two patients died at that home. And more than two dozen workers and residents caught the virus or likely had it.
In late April, the narrative from state health officials regarding PPE had not changed.
"PPE is strained throughout the state in all kinds of facilities, including nursing homes — long term care facilities, skilled nursing facilities," Mike Willis, the director of Colorado's Office of Emergency Management said in an online press conference.
His brief answer to a KUNC question about whether there was enough PPE came after hundreds of COVID-19 deaths had already swept through nursing homes and other long-term care facilities — and seven weeks after the governor declared a state of emergency.
"We're doing everything we can, including significant cooperation with the federal government to push PPE to those facilities, but it is very strained right now," Willis said.
Since that time, the state has received millions of pieces of PPE - but not all of it made its way to these facilities because others, including hospitals and first responders, need it too.
Asymptomatic spread
Complicating outbreaks at nursing homes is that workers may have unwittingly infected some of the very patients in their care. Randy Kuykendall, with CDPHE's health facilities division, said that tests indicate that some workers have the virus but did not know it because they did not have symptoms.
"There may be as many as 12 to 18% of individuals working in these facilities that are asymptomatic carriers," Kuykendall said.
That means that health screenings that ask workers about symptoms and temperature checks aren't enough to protect the people inside nursing homes. The state is studying the issue. So is the federal Centers for Disease Control and Prevention, which completed a case study at the Life Care Center of Kirkland, the Seattle-area nursing home that made national news in early March.
Asymptomatic spread was a factor there — and not everyone was wearing PPE until after the virus hit, according to the CDC, which declined an interview but answered questions by email.
"The facility in King County was initially using recommended PPE for symptomatic residents only, and then started using recommended PPE for the entire unit that was heavily affected," the CDC said in an email.
Asked what the top takeaways from its study were, the CDC said: "Transmission of the virus that causes COVID-19 can happen before a person starts to show symptoms. This is why it is so important for everyone to wear facemasks (in health care facilities) or cloth face coverings (for the general public) and to practice social or physical distancing in all settings to prevent further spread."
At least 80% of nursing homes that have had outbreaks had at least one patient die because of COVID-19. About a fifth have lost 10 or more patients to the virus or in virus-probable cases, according to KUNC's analysis of state outbreak data.
Gov. Polis was asked about the availability of PPE at nursing homes during a press conference on Tuesday, June 2. He pivoted, talking about increased testing for coronavirus instead.
"The best way to prevent loss is to keep (the virus) out of those facilities," Polis said.
Testing in all long-term care facilities, including nursing homes, is widespread, he added, and that should make a difference in slowing the spread of COVID-19.
"That was not a testing capability that we had in Colorado or that anyone had in our country two months ago," he said. "We were barely — and I say we, I mean we as America — were barely, if at all, even able to test people who were symptomatic two months ago. Now we're at the point where we can test everyone who is symptomatic with additional targeted testing for people who are asymptomatic."
Former nursing home patient Tara Frechea in Greeley is glad that she wasn't one of the statistics. She drifted in and out of consciousness for about three weeks before she could be taken off a ventilator. She's now recovering at her sister's house in the city. It hasn't been easy for her.
"I'm literally scared of going up and down stairs because I lose my oxygen so fast," she said.
She added, however, that her health is finally starting to improve for the first time in months.
