From her bed in the intensive care unit at Rhode Island Hospital, Lakesha Lopez wanted to send a message to her staff at the nursing home.
The 40-year-old director of nursing at Bannister Center for Rehabilitation and Health Care, in Providence, had been diagnosed with COVID-19, the illness caused by the novel coronavirus. She had pneumonia in both lungs.
One floor above her in the hospital, Bannister’s 70-year-old receptionist lay tethered to a ventilator, fighting for her life.
Lopez raised her cellphone above her head and tapped the record button.
“I just want you to know I did everything right,” Lopez, a mother of five, said in the April 11 video. “I did everything to keep it out of my building … and look, I still contracted it.”
State health officials and Bannister’s operator said the nursing home was following state guidance for protecting residents and employees from infection. An April 14 inspection by the federal Centers for Medicare and Medicaid Services, or CMS, found Bannister in compliance with infection control standards.
But one thing that experts say is key to preventing the spread of the coronavirus in nursing homes — testing all residents and staff — did not begin at Bannister until the day after the first employee diagnosed with COVID-19 had died.
More than three-quarters of all COVID-19 related deaths in Rhode Island are linked to nursing homes and assisted living centers, according to data released Thursday by the nonprofit Kaiser Family Foundation. That’s one of the highest rates of the 35 states and the District of Columbia publicly reporting those deaths. Massachusetts is at 63%.
In Rhode Island, nursing homes account for more than 90% of the deaths linked to long-term care facilities. And if nursing homes are the epicenter of the coronavirus, Rhode Island is ground zero for nursing homes. In 2017, Rhode Island had the second-highest population of nursing home residents per capita of any state in the country, second only to Iowa, according to an analysis by the Kaiser Family Foundation. (Still, nursing home residents account for less than 1% of the state’s population.)
By one measure, Rhode Island has been more aggressive than many states in testing for the coronavirus, performing the highest number of tests per capita in the country.
Gov. Gina M. Raimondo has dispatched National Guard members to swab residents for testing at facilities with outbreaks of the virus and she has partnered with CVS Health to provide rapid testing for health care workers.
But curbing the virus’s spread in Rhode Island nursing homes also has been hampered by national shortages of testing supplies, the time needed to ramp up testing capacity locally, delays in getting test results, and changing protocols about who should be tested.
In nursing homes, “the key vulnerability is the staff,” said Simon H. Johnson, a professor at the MIT Sloan School of Management and co-chair of the COVID-19 Policy Alliance, a faculty-led group focused on senior care facilities. Many workers receive low wages and live in more congested neighborhoods with higher infection rates, Johnson said, so they’re more likely to be exposed to the virus. Moreover, nursing home staff often haven’t had access to N95 masks and other personal protective equipment, he said, as do hospital staff.
Since March 1, Rhode Island has recorded about 1,900 cases of the coronavirus in nursing homes and assisted living centers. An additional 700 cases have been logged among workers at these facilities. And the numbers continue to climb.
Rhode Island began testing all nursing home employees in mid-April — roughly three weeks after the first staff at Bannister had begun experiencing what may have been early symptoms of the virus, according to interviews with about a dozen
employees.
The story of what happened at Bannister offers a window into how even homes that thought they were well-prepared were vulnerable.
Tenneh Nimmo-Powell was among the first to get sick.
She is 50 and works in Bannister’s supplies office. The last week in March, Nimmo-Powell noticed that her throat was sore, but she didn’t think it was anything serious.
An immigrant from Liberia, she hadn’t traveled except to visit her sister in New Jersey one and a half weeks earlier. The sisters attended a funeral at a church in Guttenberg. Not many people were there, she said.
She drove back to Rhode Island and, the next day, went to work. (That was before Raimondo ordered anyone who traveled out-of-state to self-quarantine for 14 days.)
On Friday, March 27, Nimmo-Powell told Lopez, the director of nursing, that she needed to run to the pharmacy to get some lozenges and throat spray. Nimmo-Powell said she didn’t have a fever and assured Lopez it was nothing to worry about.
Just to be safe, Nimmo-Powell said, she was taking some leftover prescription antibiotics. She didn’t want to go to the doctor because she worried she might get exposed to the coronavirus.
Bannister’s 161-bed nursing home sits at the upper edge of Providence’s south side, one of the city’s poorest neighborhoods. Residents include people who have struggled with homelessness and mental illness, said Dawn Martone, a social worker at Bannister. “A lot of them do not have family,” she said. With no visitors allowed and no family calling to check up on them, these residents rely entirely for their care on Bannister’s staff.
During the last three years, Bannister Center had the highest number of deficiencies cited of any nursing home in Rhode Island, according to inspection reports compiled by ProPublica from CMS.
In 2017, Bannister was fined $13,627 for failing to provide basic life support, including CPR, to a resident who died at the facility.
Bannister staff members were “deeply saddened by what transpired in 2017,” Jeffrey Jacomowitz, a spokesman for Centers Health Care, which operates Bannister, said in an email. In addition to paying the fine, he said, Bannister retrained its staff in CPR and other areas of first aid. “The safety of our residents and staff have always been first and foremost our No. 1 priority.”
In late March, none of Bannister’s residents were showing any COVID-like symptoms. And since state health officials were only advising testing for people who had telltale symptoms, nobody at the nursing home had been tested.
But on March 25, state health officials learned of the first case of the virus at Oak Hill Center in Pawtucket, 6 miles from Bannister and also operated by Centers Health Care of the Bronx in New York City.
Staff at the two nursing homes often crossed paths. Lopez, the director of nursing, had come to Bannister in late January after working at Oak Hill. And since February, a nurse on the afternoon shift at Oak Hill had been working the early shift at Bannister, training to be Lopez’s assistant.
State health officials have advised nursing home operators that it’s “best practice” to limit workers to one site to reduce the risk of spreading infection But it’s not uncommon for nursing home staff to work at more than one facility. During the pandemic, with many nursing homes facing staff shortages, it’s up to nursing home administrators to balance infection control measures with “the need for facilities to be adequately staffed,” said Joseph Wendelken, a spokesman for the state Health Department.
Shirley Lomba was worried. If the virus had hit Oak Hill, Bannister could be next.
Lomba, 51, works as a nurse assistant at Bannister. She helps support her husband, an unemployed truck driver, and their children, ages 14 and 20, on her $15.30-an-hour paycheck.
A union delegate, Lomba said she’d raised concerns about the lack of testing of staff with two of Center Health Care’s regional administrators during the last week of March.
“Shouldn’t we be tested?” Lomba recalled asking. “And that’s when they told us that they were being directed by the Department of Health (and) that we didn’t need to be tested at that time.”
Ray Talamona Jr., regional director of operations for Centers Health Care, said he couldn’t comment on what happened during the meeting because he wasn’t there. But he said, “We followed the state’s direction as to who to test and when to test.”
The Health Department’s guidance was based on the state’s effort to allocate scarce testing supplies and prioritize patients who were sick, as well as an evolving understanding of how the virus is transmitted, Wendelken said.
To prevent widespread infection in nursing homes, experts say, it’s not enough to wait for people to become symptomatic to be tested. In one skilled nursing facility in King County, Washington, public health researchers found that more than half of the residents who tested positive for COVID-19 did not have symptoms at the time of testing and most likely contributed to transmission of the virus, according to a study published April 24 in The New England Journal of Medicine
States were only testing people with symptoms mainly because they didn’t have enough tests, said Dr. Morgan J. Katz, an assistant professor at Johns Hopkins University School of Medicine. But now, Katz said, states need to do “more widespread testing of exposed staff members, even if they are asymptomatic.”
Lomba, the CNA who asked about testing staff in late March, said administrators tried to reassure workers that it wasn’t necessary. Just wear your PPE, or personal protective equipment, she said they were told, and you’ll be fine. At the time, Lomba said, she had only a surgical mask to bathe and feed residents.
“We didn’t have the gowns. We didn’t have the goggles. We didn’t have the face shields,” Lomba said. “I felt like they were just trying to reassure workers to make sure that they come to work.”
Nimmo-Powell, who worked in the supplies office, was walking by the front reception desk on the last Monday in March when she noticed that Virginia, the receptionist, was wearing a sweater. (We’re not using her last name at the request of her family, who declined to be interviewed.)
When Nimmo-Powell asked her why, she said, Virginia replied that she “had the chills.”
Known affectionately by some of her co-workers as Ms. Virginia, she punched in precisely on time each morning and doubled as the front office’s security desk which, since mid-March, included keeping out most visitors and deliveries. She also was the person assigned to screen employees for symptoms as they arrived for work each day.
Virginia showed up for work cheerfully as always, well dressed and perfumed. Before her shift, she’d often stop by the nursing home’s chapel to pray.
So Lopez, the nursing director, was caught off-guard that same day when Virginia asked Lopez if she thought Virginia should stop working because she was at high risk due to her age (she was 70).
“What if you wait until we get a positive case here?” Lopez said she told Virginia. “You’re really not that much (at) risk here because there’s no positives.”
Lopez said she thought staff members were just anxious because of the rising number of positive cases at Bannister’s sister nursing home, Oak Hill, in Pawtucket.
“OK,” Lopez said Virginia replied. “I’ll let you know by the end of the day.”
That afternoon, Lopez said, Virginia told her supervisor that she had a fever and wasn’t feeling well. Lopez said she tried calling Virginia that night but there was no answer, so she left a message.
When Lopez called back Tuesday morning, she said, Virginia said that she’d had a fever the night before, but that morning it was normal. “She said that she was fine,” Lopez said. “Get well,” Lopez said, and “keep me updated.”
A week passed. Lopez didn’t hear from her.
The afternoon shift had already started when Bannister’s administrators called an emergency staff meeting in the residents’ dining hall on Monday, April 6.
The night before, Virginia had been rushed to Rhode Island Hospital. She was in the ICU on a ventilator. She’d tested positive for COVID-19.
Virginia was the one who screened everyone who came into the building. She’d slide open the plexiglass window in front of the reception desk and hold a “no-touch” thermometer a few inches from their foreheads. She’d also pass out forms employees had to sign stating they didn’t have any symptoms. She handed out pens, too. Virginia always wore a surgical mask, employees said, but they couldn’t recall if she also wore gloves. (Talamona, the company’s regional director of operations, said receptionists don’t wear gloves when screening.)
Lomba, the CNA, said workers again asked whether all the staff should get tested.
Bannister administrators again said they were following the state Health Department’s guidance on testing.
But it’s unclear whether state health officials knew at the time that an employee had been hospitalized with the coronavirus. Talamona said the hospital would have notified state health officials about the case. However, it wasn’t until three days later, on April 9, that the Health Department first learned that a Bannister employee tested positive for COVID-19, Wendelken said.
At the meeting, Bannister administrators talked about the importance of showing up for work unless you were sick. At other nursing homes where there were outbreaks, some employees, fearing they’d become infected, had stopped showing up for work, leaving homes critically understaffed.
“This is what we choose to do for a living and our patients depend on us, so you guys need to come to work,” Lomba recalled one of the administrators saying. “You’re gonna be safe as long as you have your PPE.”
The administrators also assured workers that they had plenty of PPE. “Don’t worry,” Lomba recalled one of them saying, “if it comes down to it we have everything. We have all the supplies, we’re just rationing them.”
Said Lomba: “It’s like now they’re worrying about making sure they have staff here and not really worrying about, you know, us.”
Bannister has been following state and federal guidelines for using PPE, Talamona said. The nursing home has always had a sufficient supply, he said, including gowns, face shields and N95 respirator masks. And contrary to statements by several workers interviewed, Talamona said that all staff, including the receptionist, had access to N95 masks.
Lopez was exhausted. She’d been working about 70 hours a week. If she wasn’t talking with other staff she was on her laptop or cellphone.
On Wednesday, April 8, Nimmo-Powell, who worked in supplies, said she called Lopez and told her that she’d been running a fever and her doctor told her to stay home and get tested.
By late afternoon, Lopez said, she wasn’t feeling well either. Her lower back ached and her legs felt like “I just ran a mile.”
Lomba, the CNA, said she saw Lopez coming out of a meeting with a package of cough drops in her hand. “Boy, you sound like crap!” Lomba said she told her. “What are you doing here? You should be home!” She said Lopez replied, “I’m going home right now.”
That night, Lopez took her temperature. It was 100.8. She popped some Tylenol and went to bed.
The next morning, Lopez drove to Bannister. She used her key to unlock a back door and went straight to her office to retrieve her laptop, so she could work from home. She told her boss, the corporate director of nursing, that she wasn’t feeling well. Are you going to get tested, Lopez said her boss asked.
Lopez said she’d get tested if she didn’t feel any better by Monday.
Lopez wouldn’t learn until later that the nurse from Oak Hill who until one and a half weeks earlier had been training to be her assistant at Bannister had received a call that day from the Health Department. Oak Hill had started screening its employees after the outbreak. The nurse said she had no symptoms. But she’d tested positive for COVID-19. She was instructed to self-quarantine for 14 days.
That evening, Lopez started having trouble breathing. Her son called 911, and she was rushed to Rhode Island Hospital.
On April 14, her fifth day in the hospital, Lopez lay in her bed on the ninth floor and tried to make sense of what had happened. A tube blew oxygen into her nostrils. As she talked on her cellphone, the noise from the room’s negative air pressure system, which ensures air doesn’t leave the room, sounded like snow on an old black-and-white TV screen.
Lopez thought about Virginia, who she’d heard was just above her, on the hospital’s 10th floor. She recalled the conversation she’d had with her the week before Virginia had gone into the hospital, and how she’d told Virginia to wait to go on leave until Bannister had its first positive case.
“I kind of feel bad,” Lopez said, weakly, “...not even knowing she was our first positive.”
Lopez had heard that Nimmo-Powell, who works in supplies, also had tested positive for the virus. So had a maintenance worker. Lopez posted video updates on her progress on Facebook. Co-workers responded with words of encouragement and prayers.
Lopez was feeling better each day. She missed her kids; she wanted to get back to work.
But Virginia never made it back to work. On April 16, the popular receptionist — the one known to remind department heads to return their calls and to offer Hershey’s chocolates to staff members who stopped by her desk — had lost her battle with COVID-19.
At Bannister, the news landed like a grenade. Some people screamed. Others cried.
Photos appeared of Virginia on Facebook. “RIP Ms. Virginia, miss you already. Always a rockstar and class act.”
Martone, the social worker, printed a photograph of Virginia and placed it in the chapel where she used to pray, next to a bouquet of white flowers.
The union representing nursing home workers organized a drive-by protest outside Bannister demanding workers receive on-site testing, proper PPE and hazard pay.
A union official accused Bannister of repeatedly ignoring workers’ requests for testing.
“They have intentionally, since the first case has been known ... told workers that they don’t have to go get tested,” said Adanjesus Marin, of Local 1199 of the Service Employees International Union New England. “What they have done to the workers there, I believe it’s criminal.”
Nursing home industry officials say they need on-site testing of staff as well as residents to quickly identify and isolate people who are infected.
“We need the testing that will have almost immediate results in the homes, and we need to have a repeat testing every four to seven days,” said Scott Fraser, president and CEO of the Rhode Island Health Care Association, which represents for-profit nursing homes.
Fraser said nursing homes also are reporting scheduling problems and inconsistent test results. “You’re seeing cases where someone will go from positive to negative to positive,” he said, “and that makes it very hard to just determine the best way to treat inside a facility.”
Raimondo has said she is working to get rapid testing into nursing homes. Her administration also has granted pay raises to front-line workers earning less than $20 an hour and help with personal protective equipment and staffing.
As of May 6, about half of Rhode Island’s 85 licensed nursing homes had reported COVID-19 infections, according to state Health Department data.
By then, testing had been completed at 60 of the 85 nursing homes, state health officials said.
“You’re talking about testing 7,100 residents plus the staff,” said Dr. James McDonald, a medical director at the state Health Department.
Considering it had been just 67 days since Rhode Island’s first patient had tested positive for the virus on Feb. 29, McDonald said, testing in nursing homes has “scaled really quite extensively and, I think, rather quickly.”
Raimondo said during her May 6 daily news briefing that her goal was to have tested “every resident and every worker in every nursing home” in the state. The goal was met Monday.
As of Thursday, the state Health Department reported that five to nine residents and 10 to 14 staff members at Bannister have tested positive for the virus. (The department reports numbers of COVID-19 cases and deaths at individual sites as ranges.)
Talamona, the company’s regional director, disputed the state’s figures, saying that some of the people who tested positive had been retested and were negative. He said last week that about six employees have tested positive for COVID-19. None of Bannister’s residents, he said, have tested positive for the virus.
The Health Department has no way to classify someone as a “false positive,” Wendelken said.
Some of the employees who contracted the virus have recovered, Talamona said, and returned to work. Bannister has been lucky, he said, because they haven’t had problems with staffing shortages. The employees, he said, have continued to show up for work.
On May 4 — three weeks after she was released from the hospital and after twice testing negative for COVID-19 — Lopez returned to work.
This time, she said, she was taking extra precautions. She went on Amazon and spent about $70 on her own set of PPE: Masks. Face Shield. A gown that, she said, looked more durable than the papery, thin ones they had at work. For her, she said, it’s about peace of mind.
