On Oct. 12, the Burbank Healthcare and Rehabilitation Center popped up on the Los Angeles County Department of Public Health coronavirus dashboard — an outbreak had been reported.
It started with a handful of cases: four workers, two residents. But, as has been seen at nursing homes across the country, the virus, whose symptoms can sometimes be undetected for weeks, spread quickly.
By Wednesday, Nov. 4, 19 staff members and 54 residents had tested positive for COVID-19 at the facility, according to the county department. Eight people had died. Elizabeth Tyler, a media contact for the Burbank center, said that by Thursday, that number was 10 — all residents.
This is not the center’s first outbreak. An earlier outbreak that ended in July killed two dozen people — again, all residents — with a combined total of more than 100 workers and residents testing positive for the coronavirus, Tyler said in an interview in August.
In total, as of Tuesday, 120 residents and 58 staff members at the facility have contracted the coronavirus this year, according to the California Health and Human Services Agency. The department also reported 30 resident deaths and no worker deaths at the facility, though combining the number of fatalities cited by Tyler for each outbreak yields a different sum — 34.
Tyler, whose clients include the Burbank center, said a staff member who was infected with the virus outside the facility unknowingly brought it inside. The worker had tested negative for the virus on Oct. 1 and positive on Oct. 6, with the first patient testing positive four days later.
Tyler added that all residents with COVID-19 have been contained in one unit of the facility, and that the majority of patients who tested positive for the virus were asymptomatic. The county and state public health departments are working with the facility to contain the outbreak, she explained.
“I can tell you everybody’s doing the best they can, and facilities are in the business of taking care of people,” Tyler said by phone, explaining that the Burbank center went from having more than 180 residents to 134. “If people die, they don’t have people to take care of.”
TESTING, CITATIONS EXAMINED
Nursing facilities have been reported as hotspots for the coronavirus since the early days of the pandemic. According to the Centers for Medicare and Medicaid Services, or CMS, more than 60,000 residents at nursing homes have died from COVID-19 across the nation.
Testing, Tyler emphasized, remains facilities’ best protection against outbreaks. But there are issues. While testing at nursing facilities is mandated, she said, there are not enough tests for everyone every day, and results can take days to come in. At the Burbank facility, there has been testing twice a week for staff members and residents since the first positive case was identified, Tyler added.
“Are you going to catch it on the first day somebody had it? It just depends on how much virus they shed,” Tyler said via phone. “They don’t know they had it. We don’t know they had it. They got it at the gas station or the grocery store.”
She added that, for nursing facilities, tests can cost anywhere from $80 to $200 each, though the government subsidizes some of the cost.
Patricia McGinnis, executive director for the nonprofit organization California Advocates for Nursing Home Reform, agrees that lack of access to tests remains a major issue for facilities. But that is also partly because she believes they were generally “not at all” prepared for the pandemic.
She pointed out that the Burbank Healthcare and Rehabilitation Center has a health inspection rating of one star out of the possible five by CMS.
“It’s very insufficient to judge a facility [with], but that should have given them some indication right there,” she said in a phone interview. “They have problems with quality of care, they have problems with staffing, and this has been going on. [It] didn’t start with the pandemic.”
In 2019, of the Burbank facility’s 26 citations, also called health deficiencies, most were ranked two out of four in terms of severity: “minimal harm or potential for actual harm,” according to CMS. None had a ranking of three or four, representing the more severe cases.
Only one citation seemed to regard infection control; according to the inspection report, in 2019 a staff member at the nursing home didn’t follow hand-washing protocols between feeding two residents.
But complaints and facility-reported incidents at the Burbank center have often exceeded statewide averages for facilities of similar sizes and types. In 2018, according to California Department of Public Health data, there were 71 such incident reports, compared to a California average of 41, though only 28 led to citations. That gap was closed in 2019, with the facility matching the statewide average of 41 reports.
To date of this year, however, the facility has 51 incident reports, compared to the statewide average of 12. Of those reports, six were related to noncompliance with COVID-19 protocols — and none were found to be substantiated by investigators.
Tyler expressed surprise at those numbers, saying they were higher than the center had recorded and she was not sure what the CDPH had included in the data. She added that the center would contact the CDPH for clarification.
CMS figures, which Tyler said is more accurate to the Burbank center’s in-house numbers, shows that there were 32 complaints in the last three years at the facility that led to a citation. The most recent standard health inspection, in 2019, resulted in 26 health deficiencies, compared to the state average of 13.5, though Tyler noted that that the Burbank center has more residents than many facilities whose data is included in that average.
The Burbank facility has only four deficiencies for 2020 listed on the CDPH website — all “level two” citations. Two concerned the facility’s failure to report residents’ injuries or skin discoloration, according to federal investigators, one had to do with a months-long delay in a family’s records request, and one regarded improper food storage.
Tyler suggested the facility’s history of deficiencies is not connected to its COVID-19 outbreaks. To the contrary, she said the citations prompted staff to increase training and monitoring to make sure the issues didn’t reappear.
“It’s not like a traffic ticket, where you’ve got to pay a fine but you don’t have to prove to anybody you’ve corrected your bad behavior,” she explained. “When you get a deficiency in a health-care facility, you have to submit a plan to the government about how you’re going to correct that deficiency and they have to approve it.”
FEWER REPORTS SEEM SUBSTANTIATED
But McGinnis questions that stance, arguing that the CDPH treats citations as “minor issues” and that little usually comes of them. She added that many investigations this year have been of singular complaints rather than surveys of the whole facility.
“I doubt they even went in. They probably called,” McGinnis said. “Seventy percent to 80% of the claims that people file against nursing homes are found to be unsubstantiated — not because they didn’t happen, but because no one goes there.”
However, the California department told the Leader in an email that in-person investigations are continuing, and that the last in-person investigation at the Burbank Healthcare and Rehabilitation Center was on Monday, Nov. 2.
McGinnis’ colleague at the advocacy group, Michael Connors, pointed to a report by the Voice of San Diego, a nonprofit news organization. The organization said CDPH found that 21 of 739, or 2.8%, of complaints at nursing homes from March to June were substantiated, according to data recently obtained by Voice of San Diego. The state agency had substantiated 1,276 of 3,240 nursing home complaints, or 39%, during the same period in 2019.
CDPH’s department of public affairs told the Leader in an email that there were just over 17,000 intakes — the combined number of complaints and facility-reported incidents at skilled nursing facilities — from March to October 2019, compared to about 15,100 intakes during the same period in 2020.
Of the intakes during that period in 2019, 20,222 deficiencies were found. In 2020, that number was only 3,509.
The public affairs department also noted that, in March, CMS told states to pivot from regulatory enforcement to infection control assistance — a change that has since somewhat reverted.
McGinnis also pointed out that the CDPH has a substantial backlog. The agency’s department of public affairs told the Leader in an email that there were 9,492 complaints and facility-reported incidents as of Nov. 2 that had been logged more than 60 days ago, though the department added that the CDPH made “significant strides” to reduce the backlog last year.
FACILITIES STRUGGLE WITH COVID
Tyler said nursing homes and the government agencies that advised them, had little information about how to identify or contain the virus — particularly one that can spread quickly and asymptomatically — during the early months of the pandemic.
“I think the biggest challenge they had was the evolving guidance from the government and evolving rules on testing. If they had been able to test sooner, they could have responded sooner,” Tyler said. “And at the same time, the government is trying to do the best it knows how to do.”
And testing of asymptomatic carriers can have a major impact. In the first outbreak at the Burbank center, the virus spread through asymptomatic infections, and administrators realized it had an outbreak only when a patient and a staff member were tested in early April.
As for families concerned about their loved ones in a nursing home, Tyler acknowledged that many have to make a decision about whether it is better to keep them at home or to have them in a facility offering medical care.
“It is a trade-off, and it’s a hard decision for anyone to make,” she said. “Because there are no guarantees, there is no facility that can tell you for sure, ‘Your loved one will not get [COVID-19] here.’”