As COVID-19 cases rise again in nursing homes, a few states have begun requiring visitors to present proof that they're not infected before entering facilities, stoking frustration and dismay among family members.
Officials in California, New York, and Rhode Island say new COVID testing requirements are necessary to protect residents — an enormously vulnerable population — from exposure to the highly contagious omicron variant. But many family members say they can't secure tests amid enormous demand and scarce supplies, leaving them unable to see loved ones. And being shut out of facilities feels unbearable, like a nightmare recurring without end.
Severe staff shortages are complicating the effort to ensure safety while keeping facilities open; these shortages also jeopardize care at long-term care facilities — a concern of many family members.
Andrea DuBrow's 75-year-old mother, who has severe Alzheimer's disease, has lived for almost four years in a nursing home in Danville, California. When DuBrow wasn't able to see her for months earlier in the pandemic, she said, her mother forgot who she was.
"This latest restriction is essentially another lockdown," DuBrow said at a meeting last week about California's new regulations. "The time that my mom has left when she can recognize in some small locked-away part of her that it is me, her daughter, cleaning her, feeding her, holding her hand, singing her favorite songs — that time is being stolen from us."
"This is a huge inconvenience, but what's most upsetting is that no one seems to have any kind of long-term plan for families and residents," said Ozzie Rohm, whose 94-year-old father lives in a San Francisco nursing home.
Why are family members subject to testing requirements that aren't applied to staffers, Rohm wondered. If family members are vaccinated and boosted, wear good masks, stay in a resident's room, and practice rigorous hand hygiene, do they pose more of a risk than staffers who follow these procedures?
California was the first state to announce new policies for visitors to nursing homes and other long-term care facilities on Dec. 31. Those took effect on Jan. 7 and remain in place for at least 30 days. To see a resident, a person must show evidence of a negative COVID rapid test taken within 24 hours or a PCR test taken within 48 hours. Also, COVID vaccinations are required.
In a statement announcing the new policy, the California Department of Public Health cited "the greater transmissibility" of the omicron variant and the need to "protect the particularly vulnerable populations in long-term care settings." Throughout the pandemic, nursing home residents have suffered disproportionately high rates of illness and death.
New York followed California with a Jan. 7 announcement that nursing home visitors would need to show proof of a negative rapid test taken no more than a day before. And on Jan. 10, Rhode Island announced a new rule requiring proof of vaccination or a negative COVID test.
Patient advocates are worried other states might adopt similar measures. "We are concerned that omicron will be used as an excuse to shut down visitation again," said Sam Brooks, program and policy manager for the National Consumer Voice for Quality Long-Term Care, an advocacy group for people living in these facilities.
"We do not want to go back to the past two years of lockdowns in nursing homes and resident isolation and neglect," he continued.
That's also a priority for the federal Centers for Medicare & Medicaid Services, which has emphasized since Nov. 12 residents' right to receive visitors without restriction as long as safety protocols are followed. Nursing homes could encourage but not require visitors to take tests in advance or provide proof of COVID vaccination, guidance from CMS explained. Safety protocols included wearing masks, rigorous hand hygiene, and maintaining adequate physical distance from other residents.
With the rise of omicron, however, facilities pushed back. On Dec. 17, an organization representing nursing home medical directors and two national long-term care associations sent a letter to CMS' administrator asking for more flexibility to "protect resident safety" and "place temporary visitation restrictions in nursing homes." On Jan. 6, CMS affirmed residents' right to visitation but said states could "take additional measures to make visitation safer."
Asked for comment about the states' recent actions, the federal agency said in a statement to KHN that "a state may require nursing homes to test visitors as long as the facility provides the rapid antigen tests, and there are enough testing supplies. … However, if there are not enough rapid testing supplies, the visits must be allowed to occur without a test (while still adhering to other practices, such as masking and physical distancing)."
Some relief from test shortages may be at hand under the Biden administration's new plan to distribute four free tests per household. But for family members who visit nursing home residents several times a week, that supply won't go very far.
Since the start of the year, tension over the balance between safety and residents' rights to visitation has intensified. In the week ended Jan. 9, 57,243 nursing home staffers reported COVID infections, almost 10 times as many as three weeks before. During the same period, resident infections rose to 32,061, almost eight times as many as three weeks earlier.
But outbreaks are occurring against a different backdrop today. More than 87% of nursing home residents have been fully vaccinated, according to CMS, and 63% have also received boosters, reducing the risk that COVID poses. Also, nursing homes have gained experience handling outbreaks. And the toll of nursing home lockdowns — loneliness, despair, neglect, and physical deterioration — is now far better understood.
"We have all seen the negative effects of restricting visitation on residents' health and well-being," said Joseph Gaugler, a professor who studies long-term care at the University of Minnesota's School of Public Health. "For nursing homes to go back into a bunker mentality and shut everything down, that's not a solution."
Amid egregious staffing shortages, "we need people in these buildings who can take care of residents, and often those are visitors who are basically functioning as unpaid certified nursing assistants: grooming and toileting residents, turning and repositioning them, feeding them, stretching, and exercising them," said Tony Chicotel, a staff attorney at California Advocates for Nursing Home Reform.
Nearly 420,000 staffers have left nursing homes since February 2020, according to the U.S. Bureau of Labor Statistics, worsening existing shortages.
When DuBrow learned of California's new testing requirement for visitors, she arranged to get a PCR test at a testing site on Jan. 6, expecting results within 48 hours. Instead, she waited 104 hours before getting a response. (Her test was negative.) Eager to visit her mother, DuBrow called every CVS, Walgreens, and Target in a 25-mile radius of her home asking for a test but came up empty.
In a statement, the California Department of Public Health said the state had established 6,288 COVID testing sites and sent millions of at-home tests to counties and local jurisdictions.
In New York, Democratic Gov. Kathy Hochul has pledged to deliver nearly 1 million COVID tests to nursing homes, where visitors can take them on the spot, but that presents its own problems. "We don't want to test visitors who are lining up at the door. We don't have the clinical staff to do that, and we need to focus all our staff on the care of residents," said Stephen Hanse, president and CEO of the New York State Health Facilities Association, an industry organization.
With current staff shortages, trying to ensure that visitors are wearing masks, physical distancing, and adhering to infection control practices is "taxing on the staff," said Janine Finck-Boyle, vice president of regulatory affairs at Leading Age, which represents not-for-profit long-term care providers.
"Really, the challenges are enormous," said Gaugler, of the University of Minnesota, "and I wish there were easy answers."
Kaiser Health News is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.