WASHINGTON — The hardest part of running a nursing home during the coronavirus pandemic, according to Bruce Lederman, is dealing with the “unknowns unknowns.”
Lederman, president and executive director of Charles E. Smith Life Communities in Rockville, Maryland, was borrowing a famous phrase of former US secretary of defense Donald Rumsfeld’s during the Iraq War.
“It’s the things we don’t know that we don’t know — until we know them,” Lederman told The Times of Israel, recounting his organization’s initial response to the COVID-19 outbreak.
The chief example, he said, was finding out from the Centers for Disease Control and Prevention (CDC) last winter that there were asymptomatic carriers of the virus who could easily infect others.
That knowledge led Lederman and his team to halt all visitors and non-essential personnel from entering the facility — also known as the Hebrew Home of Greater Washington — with the exception of family members in end-of-life situations, who then have to wear personal protective gear.
“There was a lot of that, and there’s no fault there,” he said. “Everyone was learning at the same time. But that was very frightening.”
Nursing homes have been acutely susceptible to the virus, with hundreds of elderly persons living in close proximity to one another. Those living arrangements have led to increased viral transmission.
In the Boston area, for instance, more than 100 residents have died from coronavirus outbreaks at rehabilitation and nursing facilities owned by Hebrew Senior Life.
New York has been hit especially hard, with more than 5,800 nursing and adult care facility deaths — more than in any other state. The crisis there was compounded by the fact that the state sent recovering COVID-19 cases into nursing homes, filled with already vulnerable populations, leading to high rates of contagion.
Roughly one in five of the reported coronavirus deaths in the United States have been of people living in or connected to nursing homes, according to the Wall Street Journal.
The Hebrew Home of Greater Washington, which was established in 1916, has been no exception. The largest skilled nursing center in Maryland, with more than 500 beds, the facility has so far lost 13 patients to the virus and has had 77 positive cases.
It has also had 33 residents test positive and then recover. All of those people were older than 65, in what health experts have deemed an at-risk category.
Still, Lederman recognizes how quickly the situation can evolve and escalate. While there have been previous pandemics — the Spanish Flu, HIV/AIDS — none have been quite like this one. In other words, there is no history that can serve as an exact guidance for nursing homes.
We are dealing with something that no one has seen or dealt with before in any meaningful way
“When you’ve seen one pandemic, you’ve seen one pandemic,” he said. “Because this novel coronavirus is so new, we are dealing with something that no one has seen or dealt with before in any meaningful way.”
Now, the DC-area Hebrew Home has moved into what Lederman described as the next phase of its fight against the virus — from altering its policies and purchasing equipment, to learning to live with new norms that can keep its residents and staff safe.
“We are in what I call the ‘defensive portion’ of the work,” he said
Going on defense
Lederman said the Hebrew Home of Greater Washington began reviewing its pandemic and emergency response procedures as early as last January, when news emerged of the coronavirus outbreak in Wuhan, China.
Once there were reports of infections in the United States, the facility began to make modifications. It changed its visiting policy in phases, at first by allowing no more than two visitors per resident at a time, then within a matter of days, it shifted to its current restrictions.
The no-visitor policy, except in extreme circumstances, extends to the entire campus, which includes two skilled nursing units, an assisted living facility and apartment buildings.
The Times of Israel spoke with the wife of a former resident who died from the virus in April. Requesting anonymity, she said she visited her husband every day until March 11, when the facility stopped allowing visitors. Before then, she had to have her temperature taken in the hall.
“I think what happened was unfortunate, but I don’t think it was for the Hebrew Home’s lack of trying or being scrupulous in terms of working to fight this,” she said. ” I think they really did their best.”
Her husband, who lived in the long-term care unit, began to show symptoms and was taken to the hospital, where he was diagnosed with COVID-19. He died a week later. The last time she was able to see him was in March, before Smith Communities changed its visitation policy.
Overall, Lederman said, families have been understanding of the new constraints to stop the spread of the virus.
Still, other complications do arise, such as when a resident wanted to leave the campus to attend the funeral of a family member. After that person attended the service, they agreed to self-quarantine for 14 days once they got back, in accordance with CDC guidelines, Lederman said.
Even without those circumstances, however, the residents have had to get used to more isolation and less person-to-person contact.
Smith Communities has ended communal activities and communal dining. Instead, all the residents now eat in their rooms. The Hebrew Home has also set up two COVID recovery units — separating the patients who have been infected from everyone else.
The Maryland Department of Health did not respond to repeated requests for comment on how the Hebrew Home is adjusting amid the pandemic.
One thing Lederman realized early on, he said, was that there needed to be a easy forms of communication with the families about how the facility was adjusting.
Today we are able to get tests, but we don’t know about tomorrow
“The families want information, for obvious reason,” he said. “They want to be part of this journey. They want to understand the challenges that we’re facing.”
Smith Communities therefore created regular virtual meetings for the families with the facility’s vice president of medical affairs and has put all the coronavirus data on the website, which it updates daily.
The widow felt that the Hebrew Home was transparent about what was unfolding. “They were pretty open about ‘we regret to inform you that there’s been a case,'” she said. “I thought they were pretty upfront about it.”
One of the families’ biggest concerns has been whether the Smith Center has enough testing and personal protective equipment (PPE).
Lederman said they have not had a problem acquiring those materials thus far, although gowns have been the hardest to come by.
Across the country, front-line medical workers have struggled to get all of the protective gear they need. A recent survey found that the majority of US nursing home staff feel they are not getting enough support from their employers or the federal government.
“If we are still able to acquire at the same rate that we have been and if our utilization stays at the current rate, then I feel confident,” he said. “That said, circumstances can change. Today we are able to get tests, but we don’t know about tomorrow. The situation has been evolving.”
Unfortunately, Lederman doesn’t think the current state of affairs will be over any time soon — not until there is a material development in the battle against coronavirus.
“We will be in the second phase until there is a vaccine or effective therapies,” he said. “In terms of restricting visitors, I don’t see that guidance changing. Of course, we will follow the CDC or the Maryland Department of Health, but I don’t see either of those bodies changing the current restrictions on skilled nursing.”
That’s largely because asymptomatic carriers can transmit the virus without knowing they have it. And until there is a way to address that invisible threat, Lederman emphasized, this new regime will be the new norm.
“For all skilled nursing centers, it is about trying to reduce the exposure from outside the community as much as possible to stop the spread,” he said. “Of course, no place is a bubble.”