Caregiving at a nursing home is a hard job. Coronavirus could make it even harder

On Tuesday, a 77-year-old man who was living at an assisted living facility in Broward County died of COVID-19, the disease caused by the novel coronavirus that is particularly dangerous for older adults. A day later, it was announced that 19 nursing homes or assisted living facilities across the state also had suspected or confirmed COVID-19 cases.

Given Florida demographics, those were consequential events. Florida is the second-grayest state in the country, with more than a fifth of its population aged 65 and older. Roughly 170,000 Floridians live in elder care residential facilities.

“This is an important issue for every state, every community, but there’s almost nowhere in America where it’s more important than Florida,” said Dave Bruns, communication manager at AARP Florida.

Among the people on the front lines caring for the state’s most vulnerable population are the nurses and certified nursing assistants who staff Florida’s nursing homes, hospices, and long-term care facilities. As a group, their responsibilities include providing nursing care as well as help with eating, bathing, dressing, physical transfer and more.

Now, they’ll also be responsible for helping keep a pandemic at bay. Many will earn around $11 an hour for their efforts, the average pay for certified nursing assistants in the state.

“We are talking about literally backbreaking work,” said Dequasia Canales, a vice-president at 1199SEIU United Healthcare Workers East, the largest healthcare union in Florida. “And it’s going to get more challenging.”

STAFFING ISSUES

As COVID-19 spreads, keeping a full staff will be one of the most pressing issues healthcare facilities will face, experts say.

That’s because caregivers who come in contact with infected patients are ordered to self-quarantine and taken off the job, restricting the labor pool even as demand for care grows. (Sheltering staff is important: healthcare workers themselves are almost always hit hard in times of pandemic).

But despite legally-mandated minimum staffing requirements, nursing homes and elder care operations nationwide had already been facing personnel crunches and high turnover before the arrival of the new coronavirus, raising questions over the industry’s ability to weather the crisis.

“We can’t keep up,” said Kristen Knapp, a spokeswoman for the Florida Health Care Association which represents nursing homes. “We have more seniors than we have caregivers, and that’s a challenge.”

Margalie Williams, a CNA who works two jobs at two different Miami-area nursing homes to make ends meet, agrees. She says caregivers sometimes have to look after up to 18 patients in a shift.

“The staffing problem is the no. 1 problem we have,” she said. “At the end of the day, it’s the patients who end up suffering.”

Losing staff to sickness or quarantine, according to Canales, “would be devastating.”

“We can’t say, ‘Oh, I’m sorry, I can’t feed you today even though your hands are too shaky and weak and you can’t feed yourself because, you know, we have two people out sick,” she added. “The work will still have to be done. The industry will have to find a way to fill in the gaps.”

Another union representative, Jude Derisme, says that concerns over inadequate supplies of protective wear are on the minds of workers and could accentuate a potential staffing shortage. (There are reports that facilities don’t have fully-stocked supplies of N95 respirator masks, which protect from airborne diseases).

“If there is even word of an infection inside a facility, people would be afraid to show up knowing that they could get infected because they feel like they don’t have the proper gear to protect themselves,” he said. “You could have a situation where people will stop coming to work because they will be afraid to come to work. They’re afraid they are not going to have the supplies and therefore might get exposed.”

Pilar Carvajal is the CEO of Innovation Senior Management, a Miami Beach-based company that operates six assisted living and elder care facilities across the state.

Because of her company’s size and “purchasing power,” Carvajal says getting needed supplies isn’t a big problem — though staff at one property recently made its own sanitizer by mixing alcohol and aloe while waiting for a shipment to be delivered.

“We are going to be getting the [N95 masks] and those masks I have told my staff are to be under lock and key when they arrive, because they are so valuable at this point,” she said. “This is the kind of stuff I would have never thought in my life I would have to deal with.”

The challenge of maintaining adequate staffing levels is on her mind.

“We already had a staffing crisis. It was a difficult situation. We had to bring in staffing agencies and even some of those staffing agencies had trouble staffing us,” she said.

“Now, if our staff gets sick we have to send them home, and that is going to add additional pressure to the staff that is in place. It’s going to be a very difficult situation, one that I think we’ve never encountered before, ever.”

Because of precautions taken to contain COVID-19, a potentially reduced staff would have a bigger than normal workload.

That includes checking the temperatures of all persons going into the facilities, to make sure anyone with a fever doesn’t step inside the premises, and compensating for the lack of family visitors, who have recently been banned from all Florida nursing homes.

“We hear from AARP members who have loved ones in skilled nursing facilities, and very often those people that we are hearing from are in the habit of visiting nursing homes every day to help their loved ones eat, for example,” said Bruns. “And very often it’s quite difficult for staff to have the same rapport with the nursing home residents that their loved ones do.”

“Without a doubt, not having visitors is going to be more work” for staffers, added Derisme. An additional complication: some folks like Williams work at more than one facility, which puts them in contact with different groups of residents. Should they be exposed with the virus and have to stay home, their absence from work would be widely felt.

“We’re working with our staff and identifying lists of where else they work. We have staff that don’t just work for us,” said Carvajal. “They work at other properties, so we are getting lists and if there is an issue, which we’ve already identified in Broward, we have to figure out if we have staff that work there. If so, we would not allow them to come to work here. It’s just really gotten quite complicated very, very quickly.”

The pressure of work on the front lines of the COVID-19 pandemic can take a toll.

“It’s very tough psychologically. Workers are afraid of the virus, there’s tension there,” said Derisme. “We’ve heard of employees getting into altercations … fighting over masks, over supplies. And the underlying cause is fear.”

CHILDCARE NEEDS COMPLICATE STAFFING

Along with all other front line health care workers, nursing home employees are facing a childcare quandary as schools close around the country, as they have already done in Miami-Dade and Broward counties.

Given the lack of childcare benefits at many healthcare facilities, parents who work in the sector could find themselves compelled to stay home.

“Necessary school closings are prudent precautions for public health, but they are added elements of pressure for South Florida healthcare workers,” Dale Elwart, Florida Regional Director for 1199SEIU, wrote in a statement. “If our healthcare workers have children home from school it could reduce this key workforce at the greatest time of need to protect the well-being of patients and the general public.”

Carvajal has already seen school closure disrupt operations at her facilities.

“Now we are living with staff showing up with kids in some cases to the property saying ‘What am I supposed to do with them? They’re out of school, and I need to come to work,’ ” she said. “We’re having to consider potentially mock day care centers to a certain degree.”

“It’s all just compounding,” she said. “It’s one thing compounding on top of the other on top of the other.”

CONTINGENCY PLANS

Knapp, from the Florida Health Care Association, says facilities are making plans to fill in staffing gaps if there are coronavirus-related reductions.

“We are asking our facilities to develop contingency plans, and what they will do if either their workers are sick, and they can’t come to work or they have childcare challenges,” she said.

In past crises, most of them hurricane-related, facilities have been able to temporarily bring in workers from nearby states, but that might not be an option this time around.

“In a hurricane traditionally you have an end point in time, and you also only might have a specific area that’s impacted,” Knapp said. “But this is a completely different situation because you may not have the ability to do that if there’s an impact in Georgia, in Alabama in other southern states with the virus.”

Potential solutions include turning to per-diem workers or making staff already in place put in longer hours.

“Maybe we’re looking at just asking staff to work longer shifts,” said Knapp.

Per-diem workers can rattle patients, Canales says.

“Per-diem workers are temporary; they don’t have the type of relationship or connection with some of these patients,” she said. “And if you have a resident with Alzheimer’s or dementia who has a hard time identifying people, constantly throwing strangers into their environment is a total and complete disruption.”

PUSH FOR PAID LEAVE

An irony in elder care, as some inside the industry point out, is that caregivers have little access to care themselves.

“There’s no paid sick leave in our industry. Nothing,” Carvajal said. “It’s funny. We are in health care, but we do not as an industry broadly offer health benefits or paid leave. . . . Extended time off paid is unheard of in our industry.”

Canales would like to see that change, especially in a time of crisis.

“If any of our members end up being part of the population who are at risk, and they have to be quarantined, we are asking our employers to make sure that they are getting the proper care, quarantine and compensation while that happens,” she said. “A lot of workplaces have attendance policies, and we don’t want our members to suffer any negative disciplinary action because they are homesick as a result of trying to carry out their duties in a healthcare facility.”

According to Canales, workers “can’t afford to be off, and they can’t afford to be sick.”

She added: “We would want folks to try to think about their short term needs and the long term health of the community. We really think that employers who are being more willing and flexible to work with us can help beef up the immunity that our communities need.”

Carvajal is wary of the push to extend paid leave: “What happens to us and our staffing needs?” she said.

Knapp echoed that sentiment, noting that employers have more pressing needs to address.

“I think that’s a good discussion that needs to be had but first and foremost we want to make sure we keep this virus from getting into our nursing homes,” she said. “The priority right now is to try to mitigate the spread of the virus. That’s really first and foremost our top priority.”

Added Carvajal: “It’s all very scary to be perfectly honest. We are hoping for the best, and we are preparing for the worst. But I don’t think we even know what the worst would be in this case.”