COVID-19 Infections and Deaths Among Connecticut Nursing Home Residents: Facility Correlates

Yue Li, PhD; Helena Temkin-Greener, PhD; Gao Shan, MS; Xueya Cai, PhD


J Am Geriatr Soc. 2020;68(9):1899-1906. 

In This Article


By April 16, 2020, COVID-19 cases had occurred among residents in 50% and deaths in 40% of Connecticut nursing homes. The numbers of confirmed cases and deaths vary substantially over nursing homes, and higher RN staffing is strongly associated with fewer cases and deaths. Nursing homes with lower quality ratings and caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases in multivariable analyses. However, current data do not support the hypothesis that these nursing homes have excessively high numbers of confirmed deaths.

Connecticut is among the earliest states to publicly report COVID-19 cases and deaths in its nursing homes, and Connecticut's report is granular enough to allow for evaluation of variations over facilities. In an effort to fill the information gap for nursing home residents, their families, and policymakers, CMS released guidance on April 19, 2020, requiring nursing homes to report COVID-19 cases directly to the CDC and to notify residents and their representatives appropriately of conditions at the facilities.[30] Although the federally reported data are not yet available, a study by the Kaiser Family Foundation[10] documented that by April 23, 36 states were reporting some level of data about coronavirus cases and deaths in LTC facilities. The Kaiser study further reported that the LTC facility shares of total COVID-19 cases and deaths were 11% and 27%, respectively, but varied substantially over states. Our study found that in Connecticut, the nursing home shares of total confirmed cases and deaths are 11% and 39%, respectively, with large variations across counties. Such variations are likely due to multiple factors such as differences in population characteristics, case mix of nursing home residents, and the number of coronavirus tests being performed.

RNs lead almost all aspects of care delivery in nursing homes including the assessment, treatment, and management of resident conditions, and the supervision of other nursing staff (licensed practical nurses and certified nursing assistants). In most nursing homes, RNs are the linchpin for the assessment and provision of medical care including early identification of and response to emergencies and life-threatening situations. Previous literature on hospital care has demonstrated that increased RN staffing levels are key to the ability of hospitals to respond to outbreaks of emerging infections.[31] Our findings of the strong negative associations between RN staffing and counts of COVID-19 cases and deaths in nursing homes are consistent with these prior findings, and they highlight the critical role of RNs in dealing with COVID-19 outbreaks in nursing homes.

In addition to RN and other nurse staffing levels, the CMS five-star ratings incorporate two other components for nursing home quality of care: deficiency citations and risk-adjusted quality measures. Deficiency citations represent state surveyors' evaluations of quality and safety problems in nursing homes, covering a comprehensive list of federal and state standards in clinical and personal care; and quality measures include 15 risk-adjusted measures of care processes and health outcomes for both long-stay and short-stay residents. Our results suggest that nursing homes in better compliance with these multifaceted care standards and performing better in resident-oriented quality measures are more able to contain the spread of coronavirus among their residents, although their abilities to prevent COVID-19–related deaths were not found superior compared with other nursing homes.

Disparities in quality of care have long been documented in nursing homes, with consistent evidence showing that facilities caring for disproportionately higher numbers of Medicaid and racial/ethnic minority residents tend to be located in communities of lower socioeconomic status, be financially strained, and have worse resident outcomes.[18–20,32,33] Thus our finding of the higher cumulative incidences of COVID-19 infection in these facilities is likely a new manifestation of these long-standing disparities. In addition, early data suggested less social distancing in lower income neighborhoods,[34] possibly due to the lack of job security and other disadvantages, and a higher COVID-19 contraction rate among racial minorities.[35] These may also contribute to the disparities in COVID-19 contractions in nursing homes.

CMS recently released a series of guidelines, focusing on visitor restrictions, infection control policies, and plans on cohorting residents, to combat the surge of COVID-19 infections and deaths in LTC facilities. Starting in early March, CMS also refocused the on-site nursing home inspections on compliance with infection control standards.[36] Findings of this study may inform these current and future efforts to better control the epidemic in nursing homes and other LTC facilities. For example, although the CMS refocused inspections initially targeted nursing homes in areas hit earliest by the COVID-19 pandemic or with known infection control deficiencies, our results suggest that going forward, CMS and state nursing home inspectors may target more broadly those facilities with lower RN staffing levels and lower quality ratings, where transmission of the novel coronavirus is more rapid and deaths are more common. Also, current federal regulations require nursing homes to have an RN on duty at least 8 hours a day and 7 days a week. Although this staffing requirement may be hard to raise nationally, nursing homes able to increase their RN hours should consider doing so for more effective control of COVID-19 outbreaks.

Furthermore, in the face of the COVID-19 pandemic, nursing homes caring for more sociodemographically disadvantaged residents may be more likely than other facilities to experience severe shortages of staff, personal protective equipment (PPE), and medical equipment, as well as other issues such as poor testing capacity, delayed diagnosis, lack of access to medical treatment, and high risk of cross-infection among residents and staff. Thus national and local efforts to bolster healthcare capacity in nursing homes should target these facilities; other supports to mitigate coronavirus transmission in LTC facilities, such as staff training for proper use of PPE, may also target these highly strained facilities.

This study has several limitations. First, our analyses focused on Connecticut nursing homes, and results should be generalized to other states with caution. However, in the current absence of national COVID-19 data for nursing homes, findings in this study provide timely evidence to inform policies and practices. Second, the observational study design allows for estimation of associations only that may be biased by unmeasured confounders such as number of tests done in the nursing home (likely limited due to insufficient testing capacity in the state) and actual infection control and prevention practices in individual facilities. Finally, the lack of significance in the associations of nursing home star ratings and concentrations of disadvantaged residents with predicted COVID-19 deaths may reflect insufficient power in multivariable analyses.

In conclusion, nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths. Thus inspections of nursing home infection control practices may target facilities with lower RN staffing and star ratings. Compared with other nursing homes, nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more COVID-19 confirmed cases. Efforts to help nursing homes combat the COVID-19 pandemic should prioritize these facilities.