By the time Gov. Bill Lee ordered Tennesseans to shelter in place April 2 – after weeks of strongly suggesting people stay home – 32 Tennesseans had already died from COVID-19, including four residents from an outbreak at a nursing home in Gallatin.

Eleven Gallatin nursing home resident had died through Tuesday, joining about 500 other nursing home/ long-term care patients across the country who have been victims of COVID-19, leaving families and state agencies asking if the precautions, including testing and visitor bans, from the Centers for Disease Control and from the Centers for Medicare and Medicaid Services, came too late or were not strictly enforced.

At the Gallatin Center for Rehabilitation and Healing, 74 residents and 34 staff members tested positive for the virus, causing an evacuation of 95 to local hospitals. The National Guard was called in to help with the evacuation. Another 28 patients and 16 employees at a Cookeville nursing home tested positive for the coronavirus.

And, it was at a nursing home near Seattle in February that 37 resident deaths were linked to the virus, raising an alarm that the virus had taken hold in the U.S.

With nearly 1.4 million people and more than 15,600 facilities in the nation, an outbreak of the virus could decimate a nursing home’s population.

Those who operate nursing homes and assisted living facilities, many of which struggle to maintain staff in normal times, are experiencing concerns in protecting their residents and staff from contracting the coronavirus, including:

• Confusion surrounding constantly changing guidelines

• Mixed messages from government agencies

• Evolving data about the virus

• A disbelieving public

• A strain on resources

And those issues can cost lives.

Sumner County Mayor Anthony Holt says he blames management at the Gallatin nursing home who allowed staff members to come to work despite showing symptoms for COVID-19.

“The staff of the facility was compromised,” Holt says. “I know that over 30 contracted the virus, and then spread it throughout the facility with patients.”

But he also blames the state health department for its response to the crisis and approving residents to move back in the same week.

“They’re the ones that license this place,” Holt points out. “I want to do the right thing. When something’s wrong, if you’re an elected official, you have an obligation to call that out to the public and the press. I’m not blaming the governor. I don’t know who’s involved. But I can tell you the commissioner for the department of health is responsible for letting this happen.”

Tighter restrictions ahead

Don Bivacca has only been the AARP Tennessee state president for a few months but has been in health care for decades, including the development of his own consulting practice, The ARx Group, in 1998.

He says reaction to the virus is not overblown and should help guide future response to medical emergencies.

But because this virus spreads so easily without people even knowing they have it, any systems put in place are less effective if people think they are healthy when they are not.

“You’ll see the Centers for Medicare and Medicaid Services and the Centers for Disease Control are rewriting or adapting (guidelines) to have more authoritative infection control policies that are required to be adhered to, and that’ll be propagated out to the states from a licensure standpoint when the state is coming out for inspections,” Bivacca says. “There’ll be some tighter regulations around infection control policies and procedures, just ensuring that they’re adhering to those.”

Bivacca acknowledges personal protective equipment is hard to find right now, but that is not specific to Tennessee. Still, it’s a shortage that can cost lives.

“Older adults are particularly vulnerable to this and, I think, it actually is even worse bringing it in a communal setting where the virus can spread,” Bivacca explains. “We know that a lot of our senior population in Tennessee and around the state are living in nursing homes or assisted living facilities.

A resident is removed from the Gallatin Center for Rehabilitation and Healing, evacuated after 74 residents and 34 staff members tested positive for COVID-19. Eight have died so far.

-- Photo By Mark Humphrey | Ap Photo

“We need our leaders in those organizations to make sure that they continue to stay informed and practice the CDC guidelines to the letter of the law and if anything, just be diligent.”

Bivacca says he anticipates a whole new set of problems for residents of long-term facilities, especially concerning mental health.

“We’re starting to get more and more socially isolated, which presents additional challenges for seniors in terms of depression,” he says. “AARP as an organization is setting up call lines to ensure that these socially isolated folks have the ability to actually talk to somebody via the phone.”

Those help lines are anticipated to be live in the next few weeks.

Conflicting standards

Wayne Olson, executive vice president of health care operations for Volunteers of America – with offices in nearly every state, including four in Tennessee – says it has 20,000 employees and 75,000 volunteers across the country providing services similar to other large social service agencies.

His division manages nursing homes, assisted living, home health care agencies and other supports for seniors in seven different states.

“We started planning for this probably two and a half months ago, as it was evident something was coming,” Olson says. “And, of course, there was uncertainty of exactly how virulent it was going to be, but we knew it was going to be bad and started preparing right away and educating our staff, educating our residents.”

But there was no way to get all of the masks needed to protect staff and residents, even when they bought above and beyond their typical need.

Another problem, Olson says, is every county they deal with, even in the same state, is approaching the outbreak differently, with their own rules. And that puts extra strain on already limited resources.

“Some follow CDC. Some say, ‘Well that’s not good enough. We’re going to be tougher than CDC.’ But if you’re going to be tougher than the CDC, you’re keeping my workforce out of the building an extra three or four days.

“If they need to be out, fine. But if the CDC says they only have to be out four days, and you’re saying they have to be out seven days, I just lost a part of my workforce for three more days.”

Moving forward Olson says residents would be better protected with a better planning process directed by the federal government that advised the states to coordinate with counties.

“Hospital systems around the country, they’re all dealing with it differently. And I don’t know what’s right and wrong. All I see is they’re all doing it differently. And next time we have got to be better prepared. There has got to be more coordination and there’s got to be more basic PPE, and there’s got to be an earlier acceptance that this is going to be an issue.

“The Spanish flu happened and this happened,” Olson says. “It can happen.”

Timeline of an outbreak

The Gallatin Center for Rehabilitation and Healing first posted about COVID-19 on its Facebook page March 8, three days after the first case of the virus was reported confirmed in the state. In that post, officials stated they did not have any cases at the center at that time, and that the CDC had recommended a variety of steps that were being implemented to help reduce the potential for the virus to enter the building.

Officials also asked the community to do its part at that time by not visiting the center if they had symptoms of cough, fever, sore throat, runny nose or shortness of breath; to cover their mouth and nose with a tissue when coughing or sneezing; and to let someone at reception know if they had recently visited another country or seen someone who had. They also asked visitors to practice proper handwashing.

The Gallatin Center for Rehabilitation and Healing did not respond to multiple attempts for an interview. Bill Christian, associate director of communications with the Tennessee Department of Health, said his department messaged facilities numerous times dating back to early March about developing guidance and enhanced measures to protect facility residents.

Gov. Bill Lee, right, answers questions concerning the state’s response to the coronavirus during one of his daily briefings.

-- Photo By Mark Humphrey | Ap Photo

The center did not post on Facebook when it started following the CDC guidelines, which were released to long-term living facilities March 10 and are updated almost daily.

On March 11, the center posted again there were no cases at the facility but visitation would be limited to emergency situations, as well as staff, patients and staff from the local and state health departments.

On March 13, the Centers for Medicare and Medicaid Services announced new measures designed to protect long-term care facilities, based on updated guidance by the CDC. Those guidelines were to restrict all visitors and nonessential personnel, with some exceptions, such as for end-of-life care.

Facilities were told to cancel all group activities and communal dining, remind residents to practice social distancing and frequent hand hygiene, and to start active screening of residents and health care personnel for fever and respiratory symptoms.

The American Healthcare Association and the National Center for Assisted Living also advised nursing homes to restrict nonessential visits to protect residents.

On March 23, the center posted that one of its team members had tested positive for COVID-19 but had been wearing appropriate personal protective equipment and did not return to work after showing symptoms. It further stated its intention to go above and beyond what was recommended by regulatory bodies.

By March 27, the Sumner County Unified Command Post had been notified by state officials that 24 patients needed to be transported to hospital. Another 17 patients were transported the next day. Later that night, 54 more transports were made. Seventy-four residents tested positive; the others were staffers.

On March 28, the Gallatin Center posted on Facebook that it was “proud of the precautionary measures that we have put in place since the beginning of March in efforts to prepare for what is now unfolding in Sumner County, our beloved state, and nation.”

The post went on to state the nursing home had an ample supply of PPE, a restricted visitation policy and had conducted employee and patient screening to fight COVID-19, but since several followers were sharing HIPAA protected information through messaging and tagging, in addition to using vulgar language, the decision was made to temporarily disable its page.

“The last 12 hours have been spent transporting these patients safely to our local hospital for continued care and monitoring in addition to supporting those patients currently under our care here at Gallatin Center. Our families deserve peace, support and understanding at this time, not hysteria driven by select language such as “evacuated” and the like,” the post read.

On March 29, the Facebook post stated the center had worked with the Tennessee Department of Health and emergency management systems of Gallatin to test all patients and staff. A subsequent post stated the center was performing a facility wide cleaning, transferring patients to a local hospital for two to three days during the cleaning and would let families know which hospital when they could.

On April 2, the center posted the facility had been cleaned, described the cleaning process and that officials were working with the Department of Health for final inspections before transferring patients back. Dr. Lisa Piercey, commissioner of the TDH, addressed the cleaning at the governor’s press conference later that day.

“The Gallatin nursing home situation is starting to resolve,” she said. “As of today, we have surveyed and inspected and ensured disinfection based on CDC recommendations. All of the negative patients will be transferred as well as those who meet the definition of recovered. Any patients in infectious risk will not go back until clear of infection.”

Piercy also discussed contact tracing and how asymptomatic spread seemed to be even more prevalent among the elderly.

“We are waiting to see what role this has to play,” she said.

Back too soon?

Concerns were immediate about how quickly the facility was bringing residents back in after so many had tested positive. Christian, the Tennessee Department of Health spokesman, stated in an email that the state began facilitation of a contractor to perform a deep clean and disinfecting procedures at the Gallatin Center Sunday, March 29, in accordance with Centers for Disease Control protocols.

“As an additional precaution, a state surveyor inspected the facility on April 1 to ensure the facility is safe for residents to reenter,” he added. “Residents who had tested negative or who had tested positive and since recovered will be allowed to reenter the facility. Residents who tested positive and have not recovered will remain at Sumner Regional Medical Center and other area hospitals for quarantine and monitoring.”

But that wasn’t a good enough response for Sumner County Mayor Holt, who says he struggles with the health department’s initial response with removing patients, the lag in test result returns and their insistence that the facility was deemed safe for patients to return days after being removed.

“Here’s the real problem – when that many of their staff members contracted the virus, that means just about every one of their staff members were exposed under CDC guidelines,” Holt says. “Then one day after we evacuated, we got a call from the health department and it says they’re going to move patients back.”

Backed by the CEO from Sumner Regional Medical Center, the hospital’s medical director and the county EMA chief, Holt says he responded to the health department that it was too premature to bring residents back into the Gallatin nursing home. He says he wanted to wait a few more weeks to make sure no one developed symptoms after previously testing negative.

“The state health department pretty much ignored everything we said,” Holt explains. “To put patients back in now? I hold the state health department responsible for that, too. I think it is totally irresponsible.

“I am infuriated with this whole process. I am sick of what’s going on, and I think that this facility is irresponsible. Now, I’m not saying they could have prevented this from happening, but rather the spread and the way it was handled after the facility became compromised.”

An email from the state health department states facilities across the state need to reach out for help if there are any issues in the future.

“If there is concern about illness among staff or residents of a facility, TDH is happy to consult about performing testing at the State Public Health Laboratory,” Christian’s email states.

Evolving guidelines, PPE shortages

The Gallatin nursing home was not the first facility of its kind to suffer a COVID-19 outbreak in this country, and won’t be the last.

Dr. James E.K. Hildreth, president and CEO of Meharry Medical College, said last week that four out of the five cases in the state seemed to have been contracted from someone with no symptoms.

None of the 28 patients at the Cookeville nursing home who tested positive had a temperature more than 100 degrees or appeared symptomatic. Earlier guidelines released to long-term care facilities restricted only visitors showing symptoms.

“TDH has provided extensive guidance to all long-term care facilities, nursing homes and assisted living facilities in the state regarding COVID-19,” Christian says. “There are important steps that these facilities can take, including screening all staff for fever and respiratory symptoms before each shift and sending ill staff home.”

Christian says the department of health also stipulates facilities should be restricting all visitors except for compassionate care. Facilities should also:

• Have an emergency response plan in place for increased staffing needs

• Ensure adequate supplies of PPE

• Canceling all field trips outside of the facility

• Have residents who must regularly leave the facility for medically necessary purposes wear a facemask, if possible.

Christian says personal protective equipment is readily available to the state’s long-term care facilities through their regional health care coalition or their county EMA.

Jesse Samples, executive director of the Tennessee Health Care Association, says long-term care facilities – both nursing facilities and assisted living facilities – are following CDC guidelines for combating the COVID-19 virus and have been since the guidance was released in early March.

But as the virus has proven to infect without symptoms, the guidance is continuously being updated.

Also, Samples says facilities do not have enough personal protective equipment.

“Adequate supply of personal protective equipment has been a challenge for long-term care facilities, and THCA/TCAL has been working with state officials to try to make these resources available,” Samples says. “With individuals able to spread this virus before they exhibit signs of having it – if they ever show signs of having the virus – mitigating the spread of coronavirus is an extremely tough task, particularly in a long-term care facility where so many already have compromised health conditions.”

But Samples says he is confident the staff at long-term care facilities across the state are doing everything they can to care for and protect their residents. He also says he is confident there will be a vaccine in the near future. But the immediate concern is a potential surge of infections they will need to deal with.

“Caregivers in long-term care facilities are doing an exceptional job under these circumstances, and we hope everyone will take a moment to thank them for what they are doing,” Samples says. “But if you ask me what we need, I would say we need to have resources for staff and supplies to be able to provide care. We need access to PPE.”