Amy Fernandez considers her grandmother, 92-year-old Dolores Wilson, lucky.
A “tough lady” from a tight-knit Italian family, Wilson has a window room at Manassas Health & Rehab Center, where her relatives still visit multiple times a week, Fernandez said. The nursing home is closed to visitors, but Wilson’s children, grandchildren and great-grandchildren often set up camping chairs outside the window and have meals with her. Fernandez, like other family members, drops off treats to entice her grandmother to eat — things like pastrami sandwiches and lobster ravioli — which are delivered to Wilson after the facility disinfects the packaging.
“We even put a bird feeder outside her window so she can see the birds,” Fernandez said. “She’s just grateful to have family that comes to visit her.”
Not every resident is as fortunate. Fernandez said Manassas Health has been closed to nonessential visitors since mid-March, when the U.S. Centers for Medicare & Medicaid Services pushed new safety measures in response to the COVID-19 pandemic. Other Virginia nursing homes closed even earlier as cases popped up in surrounding communities.
For the last three months, long-term care residents have been confined to their rooms as nursing homes and assisted living facilities remain in lockdown. Guidelines from the Virginia Department of Health instructed facilities to close down communal areas and cancel group activities. Residents are largely prohibited from leaving unless they have an outside medical appointment.
As the restrictions continue, some facilities have gotten creative, hosting Mother’s Day parades or orchestrating games of bingo from the hallway. But Virginia’s long-term care ombudsman, Joani Latimer, who acts as an advocate for residents and their families, said the isolation has also become a “huge issue” that’s brought to her office.
“We’ve certainly heard of situations where a family member will call and say, ‘She’s just sitting there in the room with the door closed,’” Latimer said. “It paints a picture of a really distressful, lonely situation for an elder.”
The continued lockdowns have become a point of frustration for many residents and their advocates. Over the past few weeks, Gov. Ralph Northam has released guidelines on reopening businesses and schools as the state moves into the second phase of his “Forward Virginia” plan. But the Virginia Department of Health — the agency charged with drafting state-specific guidelines for reopening nursing homes — has yet to chart a similar path.
That’s despite the fact that CMS released sweeping recommendations for reopening nursing homes more than a month ago, on May 18. VDH is responsible for adapting the federal guidance and handing it down to state nursing facilities, and originally aimed to release guidelines by the first week of June, according to Sarah Lineberger, director of the agency’s health care-associated infections program. It’s a deadline that’s been repeatedly pushed back as VDH works to interpret guidance that would dramatically expand the testing requirements for nursing homes.
“[VDH] anticipates the Virginia-specific guidance will be published this week,” spokeswoman Maria Reppas wrote in a Tuesday email. “It is a complex document, and we need to ensure stakeholder input and sufficient technical review.”
Some members of the state’s long-term care task force, though, say collaboration with the agency seemed to fade after the release of the federal guidelines. Group leaders cancelled two consecutive meetings after CMS released the guidance, a decision Reppas contributed to an “increasing number” of subgroup meetings within the more than 150-member taskforce.
Discussions about the guidelines resumed last week, but the cancelled meetings — and continued delays — were a concern to some frontline providers, said Dr. Christian Bergman, the medical director of Bonview Rehabilitation & Healthcare in Richmond and assistant professor of geriatric medicine at Virginia Commonwealth University, who also advocates with AMDA – The Society for Post-Acute and Long-Term Care Medicine.
“It just felt like the sense of urgency that we need to get a plan out there right now — at least from our conversations with them, that was not as clear as we would have wanted,” he added in a phone interview on Monday. Several other states have since announced their own guidelines for reopening nursing homes, including West Virginia, Tennessee and Oklahoma.
For nursing homes, part of the anxiety over the delayed guidelines traces back to costs. CMS recommendations call for a dramatic expansion of COVID-19 testing in nursing homes, including weekly swabs for staff members. Some states, including Washington, have pledged to pay for employee testing, which facilities can’t bill to Medicaid or Medicare. But Virginia providers are still in the dark over who’s responsible for shouldering the costs, which are estimated to be in the millions for testing every nursing home in the state, said Dr. Jim Wright, the medical director at Canterbury Rehab in Henrico.
Wright, who guided the facility through one of the deadliest COVID-19 outbreaks in the country, said there’s concern that VDH officials won’t give nursing home providers the chance to weigh in on state-specific guidelines. He’s personally concerned that the agency will retain weekly staff testing requirements, even though results from commercial laboratories can often take days to return.
“For instance, we did testing on Friday and we’re still waiting for results,” Wright said in a phone interview on Monday afternoon. Canterbury sources its tests from Genetworx, a private lab in Glen Allen, but some providers relying on nationwide companies such as Quest and LabCorp report even longer turnaround times.
“We believe baseline testing of all facilities is important, but additional testing isn’t helpful if it takes days to deliver results,” Wright added, saying that asymptomatic staff members could easily spread the disease to residents while they’re waiting. He, and other local providers, have urged VDH to direct what Wright described as “limited health care dollars” toward alternative preventive measures, such as personal protective equipment,
But he and Bergman both said they’re more concerned that continued delays by VDH could hurt patient health outcomes. Continued isolation has both physical and mental effects on nursing home residents, from decreasing mobility to pressure ulcers in bed-bound patients.
“Then there’s the mental ramifications — that lack of connection to others,” Wright added. “Watching television all day as your only source of connection to the outside world. You can imagine that will increase your risk for depression or anxiety. Psychologically, our patients are suffering, and we have a sense of urgency in reopening our facilities.”
Latimer, too, said she’s anxious to see the guidelines, recalling one particular resident — a “brilliant, lovely, wonderful” woman with mild dementia — who keeps up on current news but still sometimes forgets why she’s being forced to stay in her room alone.
“You can just feel the pain of that,” she added. “It’s like, how long is this going to last? Having her continually, because of short-term memory loss, revisit that panic and that despair?”
The separation can be equally hard on relatives. Fernandez said her grandmother was one of three residents at Manassas Health to test positive for COVID-19 after the nursing home implemented facility-wide testing in May. Wilson was asymptomatic, and she’s scheduled to move out of quarantine if she tests negative later this week. But the diagnosis was a difficult experience for the entire family, Fernandez added.
“My mom was devastated,” she said. “My aunt was terrified. Even the idea that she was sick and she was alone — that we couldn’t hold her hand or brush her hair, anything we’d normally do to provide her comfort — that was the really hard part.”