A Delaware nursing home for veterans had zero COVID-19 deaths. But did it come at a cost?
The Delaware Veterans Home has accomplished something almost unheard of in the pandemic: It’s prevented anyone there from dying of COVID-19.
The lethal virus made its way into dozens of Delaware's long-term care facilities, killing hundreds and infecting thousands. Yet, in almost a year, only a handful of more than 50 veterans in the state-run facility even contracted the virus.
Those numbers came because the home had extremely conservative visitation policies. At one point, family members could not even visit their loved ones while standing outside at a window.
And it did not allow compassionate visits, in which family members could see relatives who were close to death, or relatives who had stopped eating, for instance.
These policies, despite likely being the cause of the good COVID-19 statistics, resulted in the nursing home failing a federal inspection last fall, documents show.
In recent weeks, as the rate of community spread decreased, the nursing home started to allow some in-person visits. The Department of State oversees the facility and acknowledged that the strict visitation policy created difficulties.
“We have upset residents,” Secretary of State Jeffrey Bullock said during a Joint Finance Committee hearing last month, “we have upset residents’ families, we have upset staff, we have upset management, we have an upset secretary of state because buttoning down that facility to prevent COVID has not been easy.”
“And it has not been enjoyable,” he continued. “I think we have done the right thing. But I haven’t liked it. And I am very much looking forward to getting back to allowing residents to have family visits and other people come visit them and to opening that facility up.”
There is concern among medical experts that nursing homes’ lockdown policies will have an irreversible effect on the physical and cognitive abilities of their clients.
For some families, it’s already too late. Army veteran Gene Thornton saw her husband Donovan Jagger’s health rapidly decline via video chat during the course of the pandemic.
Jagger, a 72-year-old retired lieutenant colonel, lost interest in eating, which ultimately contributed to his death, Thornton said. For months, she requested compassionate care visits and believes she could have helped him.
Thornton was ultimately granted one compassionate visit in August. Wearing full protective gear, she saw her husband lying unresponsive in bed. Not long after, he died.
“They protected him to death,” she said. “He died from the lockdown, not from COVID.”
A failed inspection
Window visits have become an iconic visual of the pandemic. Photos of small children peering into windows to spot their grandparent have flooded the internet. Children camped outside their parent’s hospice room for hours, just to let their father know they were there.
The veterans home was the only Delaware nursing home in recent months to fail a federal Centers for Medicare & Medicaid inspection for not allowing for these types of visits, among other violations, documents show.
Other nursing homes that failed inspections last fall were cited for not properly isolating patients, for not testing on a regular basis and for staff not properly wearing personal protective gear. Inspectors deemed residents at two nursing homes – Cadia Rehabilitation Capitol and Regency Healthcare – to be in “immediate jeopardy,” one of the more serious designations.
The nursing homes that failed their inspections this fall and winter have fixed the errors, and most developed a plan to prevent a relapse.
While these inspections are often just a snapshot in time, they do show how the virus devastated some Delaware nursing homes. Assisted living communities do not undergo these inspections.
A Delaware Online/News Journal analysis published this summer found that, in the early weeks of the pandemic, almost one-third of nursing homes failed to follow protocols to curb the spread of the virus.
An inspector made an unannounced visit to the veterans nursing home on Sept. 30 for a review that lasted about two weeks.
A 49-page report detailed how some veterans’ families made repeated requests to visit, as they felt their loved one’s health was rapidly declining. Yet, for several months, their requests were denied or ignored.
According to a Medicare memo from this fall, nursing homes “should accommodate and support indoor visits, including visits for reasons beyond compassionate care situations.” Compassionate care does not mean only end-of-life situations.
It could also include a person needing encouragement to eat or a resident, who once socialized with others, now experiencing emotional distress.
Yet for several months, residents at the veterans home were denied these visits.
The veterans home also “failed to provide an ongoing program to support the residents in their choice of activities,” according to the report. Multiple residents were spotted not wearing face masks during the course of the investigation. And the facility didn’t have written policies on how to handle an investigation of sexual abuse allegations.
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In one instance, two employees tested positive for COVID-19, creating a staffing issue. This resulted in video calls, window or outdoor visits being canceled for two weeks, according to the report.
When the inspector asked the nursing home administrator why “window visits and compassionate visits were not started sooner since they were never prohibited by the regulations,” the official said the facility was “trying to keep the residents free of COVID-19 and was following the advice” of a consultant and her supervisors, according to the report.
The official wrote in the report that the facility would undergo a series of audits to make sure residents were offered window visits at the minimum and that these visits were completed.
In a statement, Secretary of State Bullock said limiting visits was “difficult” but credited it to why the Delaware Veterans Home had zero COVID-19 deaths.
The department, who did not make anyone available for an interview, outlined in a statement the series of corrective actions the home has taken since the inspection report.
It initiated monthly meetings with families to “open the lines of communication between the veterans home administration and family members, said David Mangler, department spokesman.
By early January, the nursing home had vaccinated all of its residents who were medically cleared, Mangler said. The state also approved the veterans home’s plan to reopen aspects of the facility. Last month, residents could again move freely within the nursing home, he said.
Residents can also now meet with a visitor once this person has been “screened and cleared,” Mangler said. More than 20 visits have occurred in the last two weeks.
Many medical experts are concerned that the damage to residents in facilities like this nationwide who were prevented from having visitors for months may be irreversible.
“It’s a vital piece of being human, to interact with other people,” said Ashley Ritter, a geriatric nurse practitioner and a postdoctoral fellow in the National Clinician Scholars Program at the University of Pennsylvania.
“When you take away group meals, the recreational activity and the visitation with family members," she said, "those risks are magnified and drastically increased for a declining population.”
The final goodbye
It was almost one year ago, the first Saturday in March 2020, when Gene Thornton last touched her husband of 42 years. It was the last day Donovan Jagger saw his wife or really understood that she was there. It was the last day he smelled her familiar smell.
The couple met while in the Army, both serving for nearly 30 years. Jagger was a highly decorated veteran who graduated at the top of his West Point class.
Jagger first began living at the Delaware Veterans Home in 2015 after being diagnosed with dementia two years earlier. Before the pandemic, if Thornton missed a scheduled visit for whatever reason, her husband would be visibly cold to her the next time she saw him.
Jagger had difficulty following shows and movies on television before he began living in a nursing home. So despite efforts to do video calls with him during the pandemic, Thornton feels he was unable to understand her.
Isolation among older adults can be incredibly detrimental, Ritter said. Physical touch has shown to provide a positive psychological response to older Americans, while having constant conversations with others is key to maintaining cognitive health.
Social connection, she said, helps many feel they have meaning and purpose in the world.
“I think of it as the reason you wake up in the morning,” Ritter said. “You can have an entire life entwined with someone else, and those interactions with another person give you strength. When you take that away, the days look very similar.
“And there’s not a lot of reason to get up in the morning when the days look similar.”
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Ritter has found that many nursing home administrators “bend over backwards” to facilitate visits. But in some ways, their hands are tied: They are working to keep the virus out while also being obligated to follow both federal and state guidelines.
Yet it is possible to do in-person visits safely at nursing homes amid the pandemic, according to some studies. Ritter said it is dependent on community spread, staffing levels and proper financial investment.
In the Delaware Veterans Home inspection report, family members expressed concerns about the lack of visits.
For one veteran, referred to in the report as “R1,” his son requested to have weekly in-person meals with him but was told that would not be possible, according to the report. This family member later revealed in the report that he had “concerns about lack of visitation, neglect, weight loss, and resident rights.”
The son frequently “voiced and emailed'' these concerns to the nursing home administrator since June “without acceptable response from the facility,” according to the report.
The family of another veteran, “R6” in the report, noticed their loved one was declining and losing weight. The man had also become weak and depressed, according to the report.
A family member filed a complaint to the state because they had not been able to visit R6 since mid-March. After requesting window visits multiple times since April, she recently had two window visits, according to the October report.
Since those two visits, the family member said she saw “an improvement in R6's demeanor,” according to the report.
Thornton, the Army veteran, said she made repeated attempts to have compassionate visits with her husband. She felt her husband wasn’t eating enough, which had been an issue for him before the pandemic.
She said she would have worn full PPE for outdoor visits at the facility’s porch, but that was denied.
In August, the Delaware Veterans Home officially approved her for a single compassionate care visit, Thornton said. She wore gloves, a gown and a mask. She was told she couldn’t be within 6 feet of Jagger.
The visit lasted one hour. A staff member stayed with Thornton to make sure she followed the rules.
But by then, he was already gone. He was unresponsive and on a morphine drip. He was dying.
“My husband just thinks I never came back to see him again,” Thornton said, “and no one could explain to him anything about it.”
“And so, just as far as he knows, I just didn't love him anymore.”
Contact Meredith Newman at (302) 324-2386 or at firstname.lastname@example.org. Follow her on Twitter at @MereNewman