by Valerie Morales
In the neighborhood where I live a nursing home is at the bottom of the hill. A brick and stone building on a residential street, it could be a private school for the privileged. But giggles and laughter rarely rattle the sills of this forlorn place. It’s not a vibrant structure. In fact, the joggers who pass on their morning run rarely offer it a glance. Similarly, commuters taking the back road zip by, rarely paying attention to the window boxes and eaves, unless paramedics are tying up traffic.
I remember one year I gave a party and had extra food that went uneaten; I thought about the nursing home. The moment I opened the door, my arms filled with food containers, the weft of loneliness, old age, and urine hit me like a brick. It took a minute to gather myself. Led down the narrow hallway to the kitchen, I peeked in rooms. The doors were open. One aged resident after the next. In bed, television on, or by the window staring out. Silent. It was heartbreaking, that level of suffocating aloneness.
The kitchen staff was welcoming. They wanted to know about the party, and I obliged but only half-heartedly as I passed the containers around, unable to focus, my mind still reeling from what I had seen walking down the hall.
A few years earlier, a beloved uncle had a stroke and was sent to a nursing rehab center. A day before his release, he was rushed to the hospital and put on a ventilator. He had contracted a virus of some unknown origin. On my first visit, he wasn’t completely sedated. I’m not sure why. His eyes begged me to save him. Help me Valerie. Help me. He flailed against the pillows, his nails digging into my flesh. But. There was nothing I could do. I held his hand and lied. I said it was going to be okay. He was going to be home soon.
He died within the week and I have carried the guilt of not being able to save him for many, many years. At the time, no one outside his family gave much thought to his death. It was one of those nursing home things. Because he was a 45-year smoker and his lungs were in terrible condition, he couldn’t manage the consequences of pneumatic fluid. I wonder now about the virus that killed him so efficiently. Who brought it in? Was it the physical therapist? The occupational or cognitive therapists? Or, was it me? I had a young child at the time. Did I accidentally pass on a second grader’s contagion?
Nursing homes horde chattel. The bodies within curate a high volume of sickness. Not surprisingly, the elderly cannot fight the tenacious grip of a virus in the lungs or brain. My uncle succumbed to an ordinary virus that didn’t have the contagion properties of Covid-19. But it was deadly just the same.
The Los Angeles Times recently listed all the local (L.A. County) nursing homes with Covid cases. The skilled nursing center where my uncle had been placed was on the list. But how is it that my uncle died from a virus 24 years ago and in the two decades since a plan hasn’t been in place to control the infectious spaces where the elderly breathe?
A Chinese law requires adult children to visit their elderly parents who are over the age of 60, and to make sure their needs- both financial and spiritual- are met. The law further states that children should pay an allowance to their parents if they won’t take care of them. In China, the elderly are allowed to sue their children. America doesn’t mythologize older Americans as much, doesn’t see them as wise or valuable, doesn’t honor their history and longevity, nor their social and economic contributions. In a culture that fetishizes the young, the worker, and personal pleasure, we toss away the old with polite neglect.
The United States used to place the elderly in the same facilities with the mentally insane. They were called poorhouses. After the Depression of the 30’s, poorhouses were out, and convalescent homes were in. Convalescent homes provided shelter and meals for a price. As the years passed, nursing homes were the standard. In the 1960s, they cared for the disabled and the elderly and offered shelter and meals. Some homes were private while others were run by the state, funded by federal and state dollars, Medicare, and Medicaid. It was a drastic upgrade over the poorhouse because now there were legal restrictions. A registered nurse had to be on duty at all times. There were cleanliness requirements.
The Nursing Reform Act and the Residents Bill of Rights reshaped the care and industry. Across the country nursing homes look incredibly different. Some are designed like a hospital, others look like an awkward apartment complex.
Before Covid-19, most relatives feared nursing home abuse. Overworked and underpaid nursing home caregivers, for a variety of reasons, have neglected those they are paid to care for. Right or wrong, nursing home caregivers aren’t trained like physicians and nurses. They are not saving lives but prolonging them. Their abuse goes unnoticed for weeks, and even months in the most severe cases. To interrupt the cycle many adult children of parents in nursing facilities aggressively check for wounds in concert with a host of other skeptics. The children suffer from anticipatory anxiety as they wait for the phone to ring with news about a fall or a virus or a sudden death they don’t believe is normal.
Inheritance has privileges but Wanda Prince was an outlier. She didn’t have children to hold her hand when she collapsed from a stroke, and even if she had children to love, her stroke happened during a pandemic; children would have been turned away from the hospital.
Wanda wasn’t financially comfortable nor inherently special. She was a woman who went to work every day then came home to her apartment with a balcony and a view. Overweight, diabetic, drowning in high cholesterol with an equally spiked blood pressure, she was immediately rushed to the ICU. Her stroke did major damage to language, cognitive skills, and mobility. Two weeks after her collapse, she was non-responsive. Pre-stroke her professional life was dedicated to helping juveniles in trauma but her good works no longer mattered. She was another casualty of the didn’t take care of her health as she should club of black women.
Although Wanda survived brain trauma, living on her own outside of a skilled nursing facility was unlikely. Her hospital stay was isolated because of Covid-19. Visitors and flower deliveries were not allowed. Wanda was moved to a skilled nursing center without her sister's company.
It started with oxygen. She couldn’t get enough into her lungs. Then she started coughing. Her fever rose. Not long after, she was transferred to the hospice care wing of the nursing center. Her body was failing. Did she have Covid? Her skilled nursing facility had 7 employees who tested positive for the virus. The tests on Wanda haven’t come back yet and she hasn’t been moved to the Covid floor either.
When she dies- sadly, it’s a matter of when- and if the autopsy reveals Covid-19, the nursing home will be shielded from litigation. Almost all states are giving nursing homes immunity. On the one hand nursing homes have become infestation hothouses; residents and staff at risk. But the cure is nearly as devastating a trajectory as the disease. Closing nursing homes put the elderly more at risk, not less. There is no Solomon dividing the baby in half in this very tragic situation of blame on multiple sides.
What we didn’t know until now was that many nursing homes are lazy when it comes to infection control. Because nursing homes are grossly understaffed, the problem worsens over time. In California, a spokesperson for the Dept of Public Health acknowledged that inspections are on hold. Whatever inspections are taking place are being done through virtual means. That comforts no one, particularly families who have relatives in nursing care.
Infection control violations include not washing hands. Not putting on protective gowns before entering the room of an infected resident. Sending infected residents to outside labs without informing the labs the resident is under “contact precautions”. Not cleaning chairs or portable respirators that are in hallways. Leaving drink containers in carts with clean linens. Haphazardly cleaning bedpans.
Nursing home administrators insist they are not to blame. You can’t correlate the number of infections from the Covid virus with past violations at a particular facility. But families see it differently.
I kept my father out of skilled nursing after his stroke last October which set up an epic hallway showdown with his neurological and physical therapy team. If he died, I insisted, he would be at his house. Some five months later, nursing homes are inundated with Covid and my father, at his house, has recovered.
“The understaffed homes don’t do handwashing and don’t have time for infection control. They also don’t have enough RN’s to oversee the infection control”, said UC San Francisco School of Nursing professor emeritus Charlene Harrington.
Nursing home ratings matter. Except, the Life Care Center in Kirkland, Washington where 37 died of coronavirus had a five-star rating. Soon after, details emerged. They didn’t have an adequate infection control system. “They failed to ensure timely interventions for a respiratory outbreak resulting in multiple acute changes leading to hospitalization and resident deaths” according to the State Department of Social and Health Services.
The Life Care Center was negligent, five stars or no. Their violations were numerous. They didn’t notify officials about the increase in respiratory distress among residents and didn’t have a back-up plan just in case the worst happened.
In California, 1,800 have died from Covid-19. Over 500 of those deaths are attributed to nursing home infections that were fatal. One nursing assistant at the Brier Oak Nursing facility told the LA Times that administrators discouraged the use of masks and protective equipment. “I was infected because of that idiot woman [administrator] told us we couldn’t wear masks…everyone is infected because of her.”
California isn’t unique. Half of the Washington coronavirus dead are from nursing facilities. 1,700 in New York died from nursing facility infections. Nursing staff are frightened. The scarcity of staff and equipment creates a culture of fear. Will they be next? Will their nursing home lose Medicare and Medicaid funding, which will in turn affect staffing? Will they be dead by the time all of this is sorted out? Already, many nursing home staffers work two jobs. $14/hr isn’t enough to take care of financial responsibilities. If it isn’t one infected nursing home, it’s another.
We are not skilled in the area of elderly care. We throw a lot of junk at the problem and hope it sticks. We rationalize that it is someone’s mother, and then exhale because it is not our mother. It is someone’s father, but it is not our father. We would never treat children the way we treat the grandmothers and grandfathers of children.
One month into my father’s stroke recovery, we got into an argument. He called me mean because I kept telling him to stop reaching for things he dropped on the floor. (He lost part of his eyesight). It put him in danger of a fall. In response to the “mean” comment I told him he could go to skilled nursing if he didn’t like the care I was providing. He was horrified. “No. I won’t go there. They will tie me up and beat me with a rubber hose.” I laughed at the imagery. He must have seen an old ‘30s flick where some older person was tortured. Later in the day, when I thought about what a nursing home meant to him, that it was abuse and nothing else, I felt sad. But was he that far off?
We cling to stereotypes the way we cling to oxygen. Every night, to start off her show, Rachel Maddow opens with a hospital nurse talking about her experience on the front line of Covid-19. It is tragic, courageous, painful, and hopeful. To die in a hospital, in many ways, is seen as a failure of the system. I’m waiting for Rachel Maddow to show a nurse at a nursing home. Her days are equally tragic, courageous, painful, and hopeful. But to die in a nursing home is seen as expected. Normal. Ordinary.
Why do we have disdain for nursing homes? Why do we pay their staff less? Why don’t we require a more skilled workforce who embraces the ethos of do no harm? Why does it matter only when a pandemic is at the gate like a rabid barbarian?
Coronavirus has reminded us that the nursing home population is vulnerable to every infected crumb the world has to offer. Usually, the elderly residents of nursing homes are ignored, unless a catastrophe like Hurricane Katrina or a catastrophe like the novel Coronavirus is on the shore, lapping at their garments. We haven’t done much to confront this challenge of the old and lonely and the often dour. What are we doing to our parents? How are we treating them?
When I made the decision to put my life on hold to take care of my father it wasn’t because we had some great love affair of adoration and admiration. My father left my mother, and I probably haven’t forgiven him. He wasn’t interested in fatherhood for most of my childhood, and he had episodes of cruelty to me. But, years later I had a responsibility to care for him, to make sure he survived a stroke, that he could recapture his independence. I put on the back burner thoughts of reciprocity- that he would not on his best day do the same for me.
Old people remind us of a morbid concept: where they are now we will be one day. The idea of old age is fundamentally absurd, and the idea of dementia is fundamentally frightening so we ignore the problem. We shovel government funding at it and pretend we care. We make jokes about Bingo and losing your memory. We aren’t even curious about the old and where they live, that their home is often a building with water, lights, and strangers in and out of their rooms. Saving them or neglecting them, or some hybrid of the two is the alpha and omega of geriatric care.
I wish I could blame it on the complexity of aging, but aging isn’t a mystery like it used to be. High school science fills in most of the gaps of the aged brain, the failing body, and time. Patronizingly, we behave like the children we once were. We fail humanity’s most basic test when we push the old somewhere we don’t want to see and expect them to survive off of crumbs. We punish nursing home caregivers with skepticism and low salaries while we turn our apathetic gaze on the residents who are weak and vulnerable.
Our neglect of the elderly in this time of great stress and tragic death is the collateral damage of a pandemic we still don’t have under control. It’s anti-climatic at the moment, the infected dead piling up like a cold mountain. Bodies of the old who once upon a time held the hand of a child, or a friend, or a neighbor- they used to belong somewhere, to someone- consume the earth. The aged sick have no neighbors now in this epic fall from grace that is Covid-19. And rarely, sadly, do they have us either.