Even before a coronavirus case was confirmed in Hawaii, Wannette Gaylord thought she’d plan ahead by ordering medical supplies for her adult residential care home in the Moiliili neighborhood.

It was already too late. The vendor had already prioritized its masks and other supplies for larger facilities, such as nursing homes and hospitals, not smaller assisted living and foster care home operations.

“I explained we are care homes and we don’t have access like how the hospitals and other long-term care facilities do,” she said. “They said they couldn’t send us anything directly because we’re not their customer.”

As the coronavirus outbreak evolves, administrators of various types of elderly care facilities are not only dealing with equipment and protective gear shortages, they face big challenges adjusting their operations to reduce the potential for the virus to cross their path.

Family visitations have been canceled. Administrators are scrambling to find the protective gear and staff to conduct symptom screening among employees and patients alike. And then there’s coming up with a plan in case a coronavirus diagnosis is made, including figuring out where to isolate an infected resident.

The state of Hawaii is not currently conducting widespread testing among senior care facilities. Care home operators of both small and large facilities say they instead refer patients to be tested when symptoms appear.

But the experience of long-term care facilities on the mainland show that by the time a case is identified, it could have already spread. The federal government has not been releasing a count of its own, but an Associated Press analysis found at least 450 deaths and nearly 2,300 COVID-19 infections have been linked to outbreaks in nursing homes and long-term care facilities across the U.S.

Most Elderly Care Is In The Community

Of the 13,000 long-term care beds across all islands, only about 35% of them are in nursing homes. The rest are in adult residential care homes, assisted living facilities and community care foster family homes.

“Twice as many people are out in the community as there are in nursing homes,” said John McDermott, the state Executive Office on Aging’s long-term care ombudsman.

“Are we making sure that the care home staff, the foster home staff, the assisted living staff, do they have masks? Do they have gloves? Do they have a way of testing the residents? That is my biggest fear. I don’t know for sure if they are getting the help and the training they need.”

Certain facilities, like large nursing homes, already have infection protocol and have an advantage when it comes to implementing federal guidelines.

Smaller care homes don’t have a built-in hospital support structure, so many caretakers may not be equipped with the guidance and instructions on how to prevent the transmission of this virus.

Investigations into coronavirus outbreaks on the mainland have found that sick workers, perhaps non-symptomatic, fueled the spread as they cared for people at multiple facilities. 

Some staff at smaller facilities may not know or understand how to properly protect themselves when interacting with ill patients, and McDermott fears a Hawaii replay. Certified nurse aids often work at more than one facility, he said.

Those who might be on the frontlines of a potential COVID-19 outbreak may be the least prepared in terms of how to prevent an infection.

“As you move from one (job) to another, are you changing your clothes? Can you be bringing in germs from the other facility? Maybe we checked your temperature at the door, that only tells us about you,” he said.

“They need a recipe, a plan of action because I think they’re kind of left to their own devices,” added Jackie Gardner, the long-term care ombudsman for the Big Island. “What they really need is reassurance that they are doing the right thing.”

An Invisible Threat

Seniors are particularly vulnerable to this coronavirus. People 65 and older have a higher fatality rate and many already have compromising medical conditions.

As of Thursday, 124 Hawaii kupuna over the age of 60 have been diagnosed with COVID-19. They represent about 28% of infections to date, and a larger proportion of them — approximately one-fifth — have required hospitalization, according to health department statistics. Their living situation remains unclear.

Department of Health spokeswoman Janice Okubo said Thursday that none of the 124 patients diagnosed with the coronavirus who are 60 and older have lived in nursing homes, adult residential care homes, assisted living facilities or community care foster family homes.

The nation’s first COVID-19 related deaths were tied to a nursing home. The virus infected two-thirds of the residents at the Life Care Center nursing home in Kirkland, Washington, and 35 people have died.

A nightmare in Maryland followed in late March. By the time two cases were identified at a nursing home 40 miles from Washington, D.C., 64 cases burgeoned at the facility almost overnight. The facility now accounts for more than half of Carroll County’s cases. 

In light of these tragedies, federal officials have provided special recommendations for nursing homes. Those guidelines constantly evolve, leaving administrators of elderly care facilities working to keep up.

“It was crazy, the speed at which there was new guidance,” said Wesley Lo, CEO, Hale Makua Health Services on Maui. “For a while it was like every day, and it was guidance from different people. It was a mess.”

To implement mandatory temperature checks among staff and residents, they first had to find enough thermometers. Then came the no-visitor policies and the cancellation of group activities and communal dining.

The Centers for Medicare & Medicaid Services’ specific advice for long-term care facilities is as follows: implement infection control, wear but preserve personal protective equipment, screen everyone for symptoms and conduct daily temperature checks, and wear appropriate protective gear when interacting with patients and residents as long as the state’s State of Emergency remains in effect.

“Because of the ease of spread in long-term care facilities and the severity of illness that occurs in residents with COVID-19, CMS urges State and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests,” state the latest CMS guidelines.

These recommendations may be tricky to follow if facilities don’t have the right resources. According to Gardner, there have been some meetings and trainings conducted by Maui county government, fire department and the state health officials for care facilities.

CMS’ regulatory purview is primarily nursing homes, which is why McDermott worries the hundreds of smaller operations, most of which have five beds or fewer, may not be getting guidance that they might need the most.

There’s no way to know if Hawaii facilities are actually doing these things until the state can inspect them.

Keith Ridley, chief of the state Office of Health Care Assurance, said random inspections for COVID-19 compliance among senior care facilities will begin soon.

Before the pandemic, the department was already limited in its capacity to cover the thousands of facilities, he said. Now, the office is shifting its resources to make room for inspections of facilities that were otherwise not due for a visit.

“We’ll do them as we are able, and they are high priority, but we have other work such as complaint investigations and high priority case investigations in addition to our COVID-19 work,” he said. “We’re really trying to put the puzzle together, what work there is to do, what to prioritize, what resources we have and schedule it out accordingly.”

‘Doing The Best We Can With What We Have’

These days, supplies like gowns, gloves and masks are even harder to come by, even at local stores. And as supplies dwindle, tensions are growing. Last week, thousands of dollars worth of N95 masks, face shields and gloves were stolen from Wilson Care Group, which operates assisted living centers for seniors and is caring for some COVID-19 patients in their homes.

Hilton Raethel, the president and CEO of the Healthcare Association of Hawaii, said the Hawaii Healthcare Emergency Management is distributing personal protective equipment and supplies to facilities on an as-needed daily basis, depending on how quickly each facility burns through their supplies.

There have been “significant challenges” in acquiring enough PPE for the state, he said.

“It would be great if we had a lot more PPE, but there’s decisions being made on a daily basis, doing the best we can with what we have,” he said at a press conference last Friday.

Gaylord, the president of the Hawaii Alliance of Residential Care Administrators, said she has received pleas for help from other home care operators.

“My members have been calling and asking me for face masks, gloves, diapers, under pads, pads and face shields,” she said. “I’m only able to give them what I can.”

Back Up Plans

Hawaii has yet to identify a specific facility for COVID-19 care in case hospitals need to expand their capacity.

“Nursing homes aren’t really prepared for acute COVID-19 care — we don’t all have ventilators,” Lo said. “But if there is COVID, we all have our plans about how to deal with it in our facilities.”

An official with Leahi Hospital in Honolulu said the hospital will only be used as a quarantine facility, as had been discussed, as an absolute last resort if Hawaii really needs more beds and maxes out all its other options. It already has nursing care residents to protect, and has cleared an entire floor to isolate anyone who comes down with coronavirus-like symptoms.

“Every nursing facility will probably have to come up with their own contingency plan,” said Darlene Nakayama, a registered nurse and CEO of Palolo Chinese Home, which like most facilities Civil Beat has spoken with has designated space that could be used to isolate potential future COVID-19 patients.

“Every one of us has the potential of having a COVID-19 patient,” she said. “Anything can happen, right? You try to do the best you can to mitigate the risk.”

Nearly all senior care facilities have ended day care programming. Some companies have been able to reassign employees as their operations evolve.

“The nice thing is we have staff we can deploy,” said Suzie Schulberg, president and CEO of The Arcadia Family of Companies, noting 18 staff members moved from the day care operation to other wings. They’re among the lucky ones.

The invisible threat that a COVID-19 infection poses means many employees can be out of the office for two weeks, such as when a family member has a suspected case.

Schulberg says that scenario has occurred at Arcadia, and multiple employees have been placed on home quarantine until they or their close contacts get test results.

To date, Arcadia has tested 10 residents, a dozen staff, and one home health care client for the coronavirus. All had negative results.

Testing Availability

At Hale Makua on Maui, residents have waited two to four days for their COVID-19 test results, according to Lo. In light of the recent cluster of cases confirmed at Maui Memorial Hospital, seniors who were admitted to Hale Makua campuses after hospitalization there have been assigned to a separate area to be quarantined for two weeks and are awaiting test results.

DOH Director Bruce Anderson said this week that faster testing kits will arrive in Hawaii soon, but only about five kits are due to arrive with the capacity to test 120 people. The tests will be rationed to those who need rapid results most, he said.

In an emailed notice to facilities, Healthcare Association of Hawaii has indicated long-term care patients can access more rapid results from the State Laboratories Division if they request it.

The need is urgent. Without diagnostic proof, symptoms could be dismissed, as they were in Washington state.

Many senior care facilities have already had to test multiple residents and staff members for suspicious cases. Ultimately they’ve all come back negative, the facilities told Civil Beat.

Multiple care home operators told Civil Beat that the state has declined to test new admissions because the new residents don’t have symptoms.

As a result, some smaller facilities and caretakers may be limiting admissions out of fear, not knowing for sure the medical or travel history of new residents, since COVID-19 sometimes doesn’t show symptoms for as many as two weeks after exposure. according to some caregivers.

“I thank God I haven’t been in the situation where I have not needed to test anyone,” said Gaylord. “I’m actually bringing in a new resident today. He’s going to be put in a room and isolated for the next 14 days because that’s the only way I can do this admission.”

Nakayama said she’d be in favor of having quick-testing available when admitting new residents.

“We could know everybody is clear instead of this continuous fear of ‘you’re a possibility, you’re a possibility,’’’ she said. “It would be so great if everybody could be tested and cleared. But I don’t think it’s going to be possible because there’s such a limited supply of test kits.”

Civil Beat reporter Brittany Lyte contributed to this report.