US: Concerns Of Neglect In Nursing Homes

Potential neglect and prolonged isolation may have caused serious harm to many people in nursing homes in the United States during the Covid-19 pandemic, Human Rights Watch said Thursday.

Human Rights Watch interviews with more than 60 people, as well as reports from independent monitors, revealed concerns including extreme weight loss, dehydration, untreated bedsores, inadequate hygiene, mental and physical decline, and inappropriate use of psychotropic medications among nursing home residents. Staffing shortages, a longstanding issue that was a significant problem during the pandemic, and the absence of family visitors, many of whom nursing homes rely on to help staff with essential tasks, may have contributed to possible neglect and decline. Federal and state authorities should investigate the situation and ensure accountability for abuse.

“Even before the pandemic, the US government failed to ensure that nursing homes were adequately staffed and regulated,” said Laura Mills, researcher on older people’s rights at Human Rights Watch. “The huge number of deaths in nursing homes from Covid-19 and emerging reports of neglect during the pandemic show that these failures have come at an enormous cost.”

More than 1.4 million residents and long-term care employees have been infected with the coronavirus and more than 178,000 have died, making up 34 to 40 percent of all United States deaths from Covid-19.

Even these numbers appear to underestimate the overall toll of the pandemic on nursing home residents. One analysis by the Associated Press estimated that there were about 40,000 excess deaths—beyond the normal number in a given year—in nursing homes nationwide that were not from Covid-19 between March and November. The precise causes merit investigation.

Nursing home staff and administrators told Human Rights Watch that understaffing influenced their ability to provide sufficient and consistent support to residents, and that the absence of family visitors who previously assisted with care exacerbated this problem. Family members and independent monitors, who were restricted in their ability to visit facilities during the pandemic, raised concerns about inadequate care and limited transparency.

One woman, who had visited her mother, who was in her 70s and had dementia, in a nursing home daily to support her with eating and bathing before the pandemic, said that when she was no longer allowed to visit, her mother appeared more lethargic and less talkative during video calls.

After staff could not wake her mother during a call in the fall, the woman insisted that they take her to the emergency room. There, she said, a doctor told her that her mother had lost a significant amount of weight since the start of the pandemic and had a large infected bedsore. She died soon after. According to her death certificate, seen by Human Rights Watch, the cause of death was sepsis from a staph infection, and she was dehydrated and had a bedsore at the time of her death.

“Before Covid-19, when I said something it got fixed,” said the woman, who said she was not informed of changes to her mother’s condition before her hospitalization. “But [during the pandemic], I had to believe what they [staff] were telling me. It was my only option because I [couldn’t] get in.”

Independent monitors, known as ombudspersons, and investigators have also reported receiving complaints about potential neglect during the pandemic. The New York Attorney General’s Office received “reports of neglect and abuse of nursing home residents seemingly unrelated to Covid-19.” A September independent investigation of Connecticut nursing homes found that depression, unplanned weight loss, and severe bed sores among nursing home residents worsened during the pandemic.

The pandemic exposed many existing gaps in nursing home regulation, particularly around staffing. Academic research has found that nursing homes are chronically understaffed. Staff, administrators, and independent experts told Human Rights Watch that during the pandemic, shortages became particularly acute, undermining some nursing homes’ ability to provide quality care.

One certified nurse aide who has worked in nursing homes for decades told Human Rights Watch that during the pandemic, “We’re working [with] anywhere from 12 to 15 residents in the morning now, [when] we are supposed to have 7 or 8. You give [residents] five minutes each to eat so that you can feed everybody, but if… they’re not taking it in, you have to move on. If you want to do oral hygiene you have to shortcut it in some way in order to get to everybody.”

These challenges were exacerbated by the absence of family visitors, who prior to the pandemic often helped with essential tasks such as eating and hygiene, emotional support, and communication with staff. In March 2020, the Centers for Medicare &Medicaid Services (CMS), the federal regulator for nursing homes, restricted all visitation in response to the coronavirus, with the exception of end-of-life situations. CMS expanded visitation somewhat in September, though family members told Human Rights Watch that visits remained limited. In March 2021, amidst high vaccination rates among nursing home residents, CMS reauthorized most visitation.

Other policies contributed to reduced transparency into nursing homes’ operations. In March 2020, CMS barred long-term care ombudspersons from visiting facilities, with limited exceptions, and suspended all routine inspections by state surveyors except for infection control. Standard ombudsperson visits and state inspections were resumed in September, although some ombudspersons reported barriers to entry due to limited personal protective equipment or testing, and inspections have been inconsistent across states.

Despite serious concerns about the treatment of nursing home residents during the pandemic, 32 states have passed laws or executive orders shielding nursing homes from civil liability during the pandemic, making lawsuits more difficult. Several states have included criminal liability protections as well.

Even before the pandemic, many nursing home residents faced obstacles to accountability through the courts. In July 2019, the administration of President Donald Trump authorized nursing homes to use pre-dispute arbitration clauses in their contracts with residents, forcing them to waive their right to sue. CMS had previously stated such clauses were “fundamentally unfair” for residents and had a “deleterious impact on the quality of care.”

Under international human rights law, everyone, including nursing home residents, has the right to the highest attainable standard of health and to an effective remedy for violations of their rights. Older people also have the right under US and international law to be protected from abuse, mistreatment, and neglect.

“The arrival of vaccines to long-term care facilities undoubtedly brings great relief to a population that has suffered disproportionately from Covid-19, but there needs to be accountability for neglect and abuse,” Mills said. “The pandemic should serve as a wake-up call to everyone that we need systemic reform to prevent this from ever happening again.”