Nurses at Alta Bates Summit Medical Center in Oakland, Calif., were on edge as early as March, when patients with COVID-19 began to show up in areas of the hospital that were not set aside to care for them.
The Centers for Disease Control and Prevention had advised hospitals to isolate COVID-19 patients to limit staff's exposure and help conserve high-level personal protective equipment that's been in short supply.
Yet COVID-19 patients continued to be scattered throughout the Oakland hospital, according to complaints to California's Division of Occupational Safety and Health. The concerns included the sixth-floor medical unit where veteran nurse Janine Paiste-Ponder worked.
Patients on that floor who had the coronavirus were not staying in their rooms, either because they were confused or disinterested in the rules. Hospital employees were not provided highly protective N95 respirators, says Mike Hill, a nurse in the hospital intensive care unit and the hospital's chief representative for the California Nurses Association, which filed complaints to Cal/OSHA, the state's workplace safety regulator.
"It was just a matter of time before one of the nurses died on one of these floors," Hill says.
Two nurses fell ill, including Paiste-Ponder, 59, who died of complications from COVID-19 on July 17.
The concerns raised in Oakland also have swept across the U.S., according to interviews, a review of government workplace safety complaints and health facility inspection reports. A Kaiser Health News investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate COVID-19 patients from those not infected with the coronavirus, in some places fueling its spread and leaving staff unprepared and infected or, in some cases, dead.
As recently as July, a National Nurses United survey of more than 21,000 nurses found that 32% work in a facility that does not have a dedicated COVID-19 unit. At that time, the coronavirus had reached all but 17 U.S. counties, data collected by Johns Hopkins University shows.
Our investigation discovered that patients with COVID-19 have been commingled with uninfected patients in health care facilities in states including California, Florida, New Jersey, Iowa, Ohio, Maryland and New York.
A COVID-19 outbreak was in full swing at the New Jersey Veterans Home at Paramus in late April when health inspectors observed residents with dementia mingling in a dayroom — coronavirus-positive patients as well as others awaiting test results. At the time, the center had already reported coronavirus infections among 119 residents and 46 virus-related deaths, according to a Medicare inspection report.
The assistant director of nursing at an Iowa nursing home insisted on April 28 that they did "not have any COVID in the building" and overrode the orders of a community doctor that several patients who had fevers and falling oxygen levels be isolated, an inspection report shows.
By mid-May, the facility's COVID-19 case log showed 61 patients with the virus and nine dead.
Federal work-safety officials have closed at least 30 complaints about this sort of mixing of patients in hospital units nationwide — without issuing a citation. The complaints include a claim that a Michigan hospital kept patients who tested negative for the virus in the COVID unit in May. An upstate New York hospital also had COVID-19 patients in the same unit as those with no infection, according to a closed complaint to the federal Occupational Safety and Health Administration.
Federal Health and Human Services officials have called on hospitals to tell them each day if they have a patient who came in without COVID-19 but developed an apparent or confirmed case of the coronavirus 14 days later. Hospitals filed 48,000 reports from June 21 through Aug. 28, though the number reflects, in some cases, multiple reports on the same person.
Patients infected with the coronavirus have been mixed in with others for a variety of reasons. Some hospitals say they have limited tests, so patients carrying the virus were identified only after they had already exposed others. In other cases, they had false-negative test results or their facility was dismissive of federal guidelines, which carry no force of law.
And while federal Medicare officials have inspected nearly every U.S. nursing home in recent months — and states have occasionally levied fines and cut off new admissions for isolation lapses — hospitals have seen less scrutiny.
The scene inside Sutter
At Alta Bates in Oakland, a hospital in the Sutter Health network, the nursing staff made it clear in official complaints to Cal/OSHA that they wanted administrators to follow the state's stringent legal requirements in the way it handles people who have aerosol-transmitted diseases. From the start, some staffers wanted all the state-required protections from a virus that has been increasingly shown to be transmitted by tiny particles that float through the air.
The regulations call for patients with a virus like the one that causes COVID-19 to be moved to a specialized unit within five hours of identification — or to a specialized facility. The rules say those patients should be in a room that includes air purification via HEPA filtration or that has negative air pressure, meaning circulating air in the room is pulled out via an exhaust system, instead of drifting into the hallway when a door is opened.
Initially, in March, Alta Bates hospital outfitted a 40-bed COVID-19 unit at its Oakland campus, according to Hill. But when a surge of patients failed to materialize, that unit was pared to 12 beds.
Since then, a steady stream of patients infected with the virus have been admitted, he says, many testing positive only days after admission — and after they'd been housed in regular rooms in the facility.
From March 10 through July 30, Hill's nurses union and others filed eight complaints to Cal/OSHA, including allegations that the hospital had failed to follow isolation rules for COVID-19 patients, some on the cancer floor.
So far, regulators have done little. California Gov. Gavin Newsom had ordered workplace safety officials to "focus on ... supporting compliance" instead of enforcement, except as regards the "most serious violations."
According to Frank Polizzi, a spokesman for Cal/OSHA, officials in his agency responded to the employee complaints by reaching out by mail and phone to "ensure the proper virus prevention measures are in place." Two investigations are ongoing, Polizzi says.
Meanwhile, Cal/OSHA records show that a third investigation — related to transport workers not wearing N95 respirators while they moved COVID-19-positive patients (and others who had a suspected coronavirus infection) at a Sutter facility near the hospital — resulted in a $6,750 fine.
The string of complaints also says the hospital did not give staff the necessary personal protective equipment (PPE) that's required under state law — an N95 respirator or something more protective — for caring for virus patients.
Instead, Hill says, employees working on the hospital floors where some patients infected with COVID-19 were being treated were provided lower-quality surgical masks — a concern reflected in complaints filed with Cal/OSHA.
Hill believes that Paiste-Ponder and another nurse on her floor caught the virus from COVID-19 patients who did not remain in their rooms.
"It is sad, because it didn't really need to happen," Hill says.
Polizzi says investigations into the July 17 death and another staff hospitalization are ongoing.
A Sutter Health spokesperson says the hospital takes allegations, including Cal/OSHA complaints, seriously, and its highest priority is keeping patients and all members of the health team and other workers safe.
The hospital system's statement also says that the practice of grouping together patients who have the virus is a tool that "must be considered in a greater context, including patient acuity, hospital census and other environmental factors."
Concerns at other hospitals
CDC guidelines are not strict when it comes to the topic of keeping COVID-19 patients sectioned off, noting that "facilities could consider designating entire units within the facility, with dedicated [staff]," to care for these patients.
That approach succeeded at the University of Nebraska Medical Center in Omaha. A recent study reported "extensive" viral contamination around COVID-19 patients there, but noted that with "standard" infection control techniques in place, staffers who cared for COVID-19 patients did not get the virus.
The hospital set up an isolation unit with air pumped away from the halls, restricted access to the unit and trained staff to use well-developed protocols and N95 respirators — at a minimum. What worked in Nebraska, though, is far from standard elsewhere.
Cynthia Butler, a nurse and National Nurses United member at Fawcett Memorial Hospital in Port Charlotte, on Florida's west coast, says she actually felt safer working in the COVID-19 unit — where she knew what she was dealing with and had full PPE — than on a general medical floor.
She believes she caught the virus from a patient who had COVID-19 but was housed on a general floor in May. A similar situation occurred in July, when another patient had an unexpected case of COVID-19 — and Butler says she got another positive test then herself.
She says both patients did not meet the hospital's criteria for testing admitted patients, and the lapses leave her on edge — concerns she relayed to an OSHA inspector who reached out to her about a complaint her union filed about the facility.
"Every time I go into work it's like playing Russian roulette," Butler says.
A spokesperson for HCA Healthcare, which owns the hospital, says it tests patients coming from long-term care facilities and any patient going into surgery, as well as those with virus symptoms. She says all medical employees and other workers on staff have access to PPE and practice vigilant sanitation, universal masking and social distancing.
Social distancing from patients is not an option for Butler, though, who says she cleans, feeds and starts IVs for patients and offers reassurance when they are isolated from family.
"I'm giving them the only comfort or kind word they can get," says Butler, who has recently gone on unpaid leave over safety concerns. "I'm in there doing that and I'm not being protected."
Given research showing that up to 45% of COVID-19 patients are asymptomatic, the University of California, San Francisco Medical Center is now testing every patient who is admitted, says Dr. Robert Harrison, a UCSF professor who consults on occupational health at the hospital.
The testing is done for the safety of staff and to reduce spread within the hospital, he says. Patients who test positive are separated into a COVID-19-only unit.
And health care workers who learn they've spent more than 15 minutes within 6 feet of a patient later determined to have COVID-19 are typically sent home for two weeks, he says, if they didn't have an N95 respirator on at the time.
Outside of academic medicine, though, front-line nursing staff and other health care workers have turned to union leaders to push for such protections.
In Southern California, leaders of the National Union of Healthcare Workers filed an official complaint with state hospital inspectors about the risks posed by intermingled COVID-19 patients at Fountain Valley Regional Hospital in Orange County.The hospital is part of for-profit Tenet Health. There, according to the complaint, patients were not routinely tested for the coronavirus upon admission.
One nursing assistant spent two successive 12-hour shifts caring for a patient on a general medical floor who required monitoring. At the conclusion of the second shift, she was told the patient was just found to be positive for the coronavirus.
The worker had worn only a surgical mask — not an N95 respirator or any form of eye protection — according to the complaint to the California Department of Public Health. The nursing assistant was not offered a coronavirus test or quarantined before her next two shifts, the complaint says.
The state health department says it can't comment on a pending inspection.
Barbara Lewis, Southern California hospital division director with the union, says COVID-19 patients at the hospital were on the same floor as cancer patients and post-surgical patients who were walking the halls to speed their recovery.
She says managers took steps to separate the patients only after the union held a protest, spoke to local media and complained to state health officials.
Hospital spokesperson Jessica Chen says the hospital "quickly implemented" changes directed by state health authorities. Sometimes, when there's a surge in COVID-19 cases, her facility does place some COVID-19 patients on the same nursing unit as other patients, she says, but patients infected with the virus are placed in single rooms with closed doors.
Patients can get a test for the coronavirus via a physician's order, Chen says, and employees can get the test in the community.
That's in contrast, Lewis says, to high-profile examples of the stricter precautions now being taken in professional sports.
"Now we're seeing what's happening with baseball and basketball — they're tested every day and treated with a high level of caution," Lewis says. "Yet we have thousands and thousands of health care workers going to work in a very scary environment."
Nursing homes face penalties
More than 40% of the people who have died of COVID-19 have lived in nursing homes or assisted living facilities, researchers have found.
The mixing of patients in close quarters — people who have the coronavirus with those who don't — has been a concern at some nursing homes, too, which Medicare officials discovered when they reviewed infection control practices at more than 15,000 facilities.
News reports this summer have highlighted the problem at an Ohio nursing home and at a Maryland facility where the state levied a $70,000 fine for its failure to keep infected patients away from those who weren't sick.
Fair Havens Center, a Miami Springs, Fla., nursing home, also faced penalties when inspectors discovered 11 roommates of patients who tested positive for COVID-19 were moved to rooms with other residents — putting those new roommates at heightened risk.
Florida regulators cut off admissions to the facility, records show, and Medicare authorities levied a $235,000 civil monetary penalty.
The vice president of operations at the nursing home told inspectors that isolating exposed patients would mean isolating the entire facility: Everyone had been exposed to the 32 staff members who tested positive for the virus, the report says.
Fair Havens Center did not respond to our request for comment.
In Iowa, Medicare officials declared a state of "immediate jeopardy" at Pearl Valley Rehabilitation and Care Center in Muscatine, Iowa in late April. Against the orders of a community doctor, the assistant nursing director had kept patients who had COVID-19 in the facility, citing a general order by Pearl Valley's medical director to avoid sending patients to the ER "if you can help it."
Meanwhile, several patients were documented by facility staff to have fevers and falling oxygen levels, the Medicare inspection report shows. Within two weeks, the facility discovered it had an expanding outbreak, with 61 residents infected and nine dead, according to the report.
Medicare officials also are investigating Menlo Park Veterans Memorial Home in New Jersey, state Sen. Joseph Vitale said during a legislative hearing in mid-August. Glenn Osborne, president of the facility's residents council, testified during the hearing that people living there were returned to the same shared rooms after hospitalizations — a breach in safety protocols during the pandemic
Osborne, an honorably discharged Marine, said he saw more fellow residents of the skilled nursing facility die than fellow service members during his military service. The Menlo Park and Paramus veterans home — where inspectors saw dementia patients with and without the virus commingling in a day room — have each reported more than 180 COVID-19 cases among residents, 90 among staff and at least 60 deaths from the disease.
A spokesperson for the homes says he could not comment for this story, because of pending litigation.
"These deaths should not have happened," Osborne told the assembled New Jersey legislators in his testimony. "Many of these deaths were absolutely avoidable, in my humble opinion."
Kaiser Health News is a nonprofit, editorially independent program of the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente.
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