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Nurses at Alta Bates Summit Medical Center 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 patients to limit staff exposure and help conserve high-level personal protective equipment that's been in short supply.
Yet COVID patients continued to be scattered through 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.
COVID patients on that floor were not staying in their rooms, either confused or uninterested in the rules. Staff was not provided highly protective N95 respirators, said 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 said.
Two nurses fell ill, including Paiste-Ponder, 59, who died of complications from the virus 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 KHN investigation found that dozens of nursing homes and hospitals ignored official guidelines to separate COVID patients from those without 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 unit. At that time, the coronavirus had reached all but 17 U.S. counties, data collected by Johns Hopkins University shows.
California Nurses Association members had complained to Cal/OSHA about COVID patients being spread throughout Alta Bates Summit Medical Center and say the practice was a factor in Janine Paiste-Ponder’s illness and death.
KHN discovered that COVID victims 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 day room — COVID-positive patients as well as others awaiting test results. At the time, the center had already reported COVID 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 April 28 that they did "not have any COVID in the building" and overrode the orders of a community doctor to isolate several patients with fevers and falling oxygen levels, an inspection report shows.
By mid-May, the facility's COVID log showed 61 patients with the virus and nine dead.
Federal work-safety officials have closed at least 30 complaints about patient mixing in hospitals nationwide without issuing a citation. They 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 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 had 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 some double or additional counting of individual patients.
COVID patients have been mixed in with others for a variety of reasons. Some hospitals report having limited tests, so patients carrying the virus are 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, part of the Sutter Health network, hospital staff made it clear in official complaints to Cal/OSHA that they wanted administrators to follow the state's unique law on aerosol-transmitted diseases. From the start, some staffers wanted all the state-required protections for 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 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 with a HEPA filter or with negative air pressure, meaning that air is circulated out a window or exhaust fan instead of drifting into the hallway.
Initially, in March, the hospital outfitted a 40-bed COVID unit, 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 virus patients have been admitted, he said, many testing positive only days after admission — and after they'd been in regular rooms in the facility.
From March 10 through July 30, Hill's union and others filed eight complaints to Cal/OSHA, including allegations that the hospital failed to follow isolation rules for COVID patients, some on the cancer floor.
So far, regulators have done little. Gov. Gavin Newsom had ordered workplace safety officials to "focus on … supporting compliance" instead of enforcement except on the "most serious violations."
State officials responded to complaints by reaching out by mail and phone to "ensure the proper virus prevention measures are in place," according to Frank Polizzi, a spokesperson for Cal/OSHA.
A third investigation related to transport workers not wearing N95 respirators while moving COVID-positive or possible coronavirus patients at a Sutter facility near the hospital resulted in a $6,750 fine, Cal/OSHA records show.
The string of complaints also says the hospital did not give staff the necessary personal protective equipment (PPE) under state law — an N95 respirator or something more protective — for caring for virus patients.
Nurse Janine Paiste-Ponder died July 17 of COVID-19. Her colleagues held a vigil for her on July 21.
Instead, Hill said, staff on floors with COVID patients 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 patients who did not remain in their rooms.
"It is sad, because it didn't really need to happen," Hill said.
Polizzi said investigations into the July 17 death and another staff hospitalization are ongoing.
A Sutter Health spokesperson said the hospital takes allegations, including Cal/OSHA complaints, seriously and its highest priority is keeping patients and staff safe.
The statement also said "cohorting," or the practice of grouping virus patients together, 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 on the topic of keeping COVID patients sectioned off, noting that "facilities could consider designating entire units within the facility, with dedicated [staff]," to care for COVID patients.
That approach succeeded at the University of Nebraska Medical Center in Omaha. A recent study reported "extensive" viral contamination around COVID patients there, but noted that with "standard" infection control techniques in place, staffers who cared for COVID 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, said she actually felt safer working in the COVID 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 — and Butler said she got another positive test herself.
She said 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 said.
A spokesperson for HCA Healthcare, which owns the hospital, said it tests patients coming from long-term care, those going into surgery and those with virus symptoms. She said staffers have access to PPE and practice vigilant sanitation, universal masking and social distancing.
The latter is not an option for Butler, though, who said 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," said Butler, who has since 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 patients are asymptomatic, UCSF Medical Center is testing everyone who's admitted, said Dr. Robert Harrison, a University of California-San Francisco School of Medicine professor who consults on occupational health at the hospital.
It's done for the safety of staff and to reduce spread within the hospital, he said. Those who test positive are separated into a COVID-only unit.
And staff who spent more than 15 minutes within 6 feet of a not-yet-identified COVID patient in a less-protective surgical mask are typically sent home for two weeks, he said.
Outside of academic medicine, though, front-line staff 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 patients at Fountain Valley Regional Hospital in Orange County, part of for-profit Tenet Health. There, the complaint said, patients were not routinely tested for COVID-19 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 had just been found to be COVID-positive.
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 COVID test or quarantined before her next two shifts, the complaint said.
The public health department said it could not comment on a pending inspection.
Barbara Lewis, Southern California hospital division director with the union, said COVID patients were on the same floor as cancer patients and post-surgical patients who were walking the halls to speed their recovery.
She said 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 said the hospital "quickly implemented" changes directed by state health authorities and does place some COVID patients on the same nursing unit as non-COVID patients during surges. She said they are placed in single rooms with closed doors. COVID tests are given by physician order, she added, and employees can access them at other places in the community.
It's in contrast, Lewis said, to high-profile examples of the precautions that might be taken.
"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 said. "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've died of COVID-19 lived in nursing homes or assisted living facilities, researchers have found.
Patient mixing has been a scattered concern at nursing homes, which Medicare officials discovered when they reviewed infection control practices at more than 15,000 facilities.
News reports have highlighted the problem at an Ohio nursing home and at a Maryland home where the state levied a $70,000 fine for failing to keep infected patients away from those who weren't sick — yet.
Another facing penalties was Fair Havens Center, a Miami Springs, Florida, nursing home where inspectors discovered that 11 roommates of patients who tested positive for COVID-19 were put in rooms with other residents — putting them at heightened risk.
Florida regulators cut off admissions to the home and Medicare authorities levied a $235,000 civil monetary penalty, records show.
The vice president of operations at the facility 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 a request for comment.
In Iowa, Medicare officials declared a state of "immediate jeopardy" at Pearl Valley Rehabilitation and Care Center in Muscatine. There, they discovered that staffers were in denial over an outbreak in their midst, with a nursing director overriding a community doctor's orders to isolate or send residents to the emergency room. Instead, officials found, in late April, the assistant nursing director kept COVID patients in the facility, citing a general order by their 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 outbreak, with 61 residents infected and nine dead, according to the report.
Medicare officials are investigating Menlo Park Veterans Memorial Home in New Jersey, state Sen. Joseph Vitale said during a recent legislative hearing. Resident council president Glenn Osborne testified during the hearing that the home's residents were returned to the same shared rooms after hospitalizations.
Osborne, an honorably discharged Marine, said he saw more residents of the home die than fellow service members during his military service. The Menlo Park and Paramus veterans homes — where inspectors saw dementia patients with and without the virus commingling in a day room — both reported more than 180 COVID cases among residents, 90 among staff and at least 60 deaths.
A spokesperson for the homes said he could not comment due to pending litigation.
"These deaths should not have happened," Osborne said. "Many of these deaths were absolutely avoidable, in my humble opinion."
KFF Health News © 2020