The first inkling Joseph Notarino’s family had that something was wrong came only a few days after nurses at the Whispering Pines nursing home posted a photo of him eating ice cream. It was March 26 and Notarino had only been there a few weeks, rehabbing from surgery.
Five days later his wife made her daily call to the East Haven facility and was told Joe wasn’t feeling well. The plan was to give him Tylenol. At 9:15 that same night, they called to say he had died.
The 85-year-old war veteran was one of the first to die of COVID-19 at Whispering Pines, but within weeks a total of 24 residents would die as the virus spread rapidly through the 65-bed facility.
“I don’t understand how he went from talking to my mom on Monday and Tuesday to dying on Wednesday,” said Cynthia Pullman, Notarino’s daughter. “We had no idea that the virus was sweeping through the place.
“I don’t think that they were prepared.”
A lack of preparation for the devastating sweep of a pandemic that would claim more than 2,500 elderly men and women at Connecticut nursing homes was evident on multiple fronts — from equipment to care protocols to communication, a Courant analysis of emails, documents, interviews and reports has found.
The state Department of Public Health — ostensibly in charge of the state’s pandemic response — found itself playing catch-up from the beginning. The agency was hamstrung by a lack of long-term planning, inadequate staffing in key areas and an archaic reporting system that didn’t fully capture the spread of the virus. Compounding the problems, an internal fight between high-ranking administrators exploded into public view just as the epidemic was gaining traction in Connecticut.
There were numerous consequences. A lack of emergency preparedness meant critical equipment that might have better protected staff and reduced the spread of the coronavirus was in short supply or defective. An industry plan to segregate infected patients and avert community spread was slow in coming together.
For their part, the nursing homes would eventually see a correlation between staffing levels and death rates, according to the report by Mathematica, a private firm hired by the state to analyze what happened inside the nursing homes. In its investigation of an outbreak at the Three Rivers nursing home in Norwich — where at least three died — the state found there were not enough staff to properly separate the treatment of potentially infected patients.
The report also points to the high level of risk in the nursing homes posed by patients heading off site for chemotherapy or dialysis and then bringing infections back with them.
Many of the issues that allowed the virus to spread so quickly through long-term care facilities were ultimately the result of federal inaction. There was a severe shortage of testing kits that hamstrung any chance to determine how fast the virus was spreading. Constantly changing guidelines from the CDC and the Center for Medicare and Medicaid Services (CMS) “had them switching policies from shift to shift,” one provider said.
As COVID started spreading through nursing homes in late March and early April, several facilities were swiftly overrun. The state’s first two major outbreaks were an assisted living facility in Ridgefield, where 16 died, and a nursing home in Stafford Springs, where Patrick Reil became the first nursing home patient to die, on March 20. Within two weeks, 12 more were dead at Evergreen.
Bill White, owner of the Beechwood Long Term Care Center in New London, which has had three COVID-19 deaths, said the virus has challenged everyone — “feds, state, ourselves, everyone” and the response to it changed multiple times — weekly and even daily at times.
“Not everyone keeps up with change at the same pace. Take the state. For all their best intentions, they are not built to move fast on anything,” White said.
Several months after her father’s death, Pullman still thinks about that ice cream social — with a nurse wearing no gloves or mask handing her maskless father a fudge bar, a look of excitement on his face as he grabbed for it.
“It was all about being prepared, and whose fault is it that we were not?” Pullman said. “Isn’t it the state’s responsibility to make sure the nursing homes were ready? Clearly no one was prepared, and people like my dad lost their lives.”
On March 24, on the grounds of St. Francis Hospital in Hartford, Gov. Ned Lamont toured one of the first mobile field hospitals going up around the state to help with an expected surge of critically ill patients.
In the early days of the pandemic, as businesses shut down and residents retreated to the safety of their homes, Lamont was giving daily counts on how many ventilators were available and intensive care capacity as officials worried hospitals would be overrun as they had been in Italy and parts of New York. But none of the field hospitals was ever used as the feared surge did not materialize.
At the same time, there were signs that nursing homes could be a serious problem. Deaths mounted quickly at a long-term care facility in Washington state — one of the first outbreaks on U.S. soil. Medical experts had made clear that age was a major risk factor in determining mortality.
But a report by Mathematica, the New Jersey company hired by the state, concluded that experts from the long-term care facilities were “somewhat neglected” as the state made its plans for the virus, focusing more on the availability of hospital beds and procuring ventilators for hospitals. At his March 23 press conference, Lamont even said the state was getting thousands of nursing home beds ready to help alleviate the pressure on hospitals.
“We have to look at it in terms of how can we get beds, how can we get more space (in hospitals), and we have now prioritized about 2,000 nursing home beds that we think over the next month or so would be made available for COVID related infections as needed,” Lamont said.
But the state’s preparedness problems started even before it became clear in March that the coronavirus was spreading quickly in Connecticut. The last time the state Department of Public Health updated it’s emergency preparedness plan was 2011 — a 32-page document that doesn’t even mention long-term care facilities.
“All the state has is a mutual aid plan, which deals with evacuations in case there is a hurricane or a massive power outage or some event,” said Patricia Rowan, the lead investigator for Mathematica. “It was designed thinking that only a handful of nursing homes would be impacted by an event and not all of them all at once. But because COVID impacted everyone at some point the whole notion that facilities would help each other went out the window.”
Reil and Notarino, who had been rehabbing at Whispering Pines for only three weeks before his death, were considered “short-term stays.” In its report, Mathematica determined that 36 percent of the residents who died in long-term care facilities had been at the facility for less than 100 days — many coming from hospitals under pressure from state officials to open up beds to ensure they could handle a surge of COVID-19 patients.
State officials have pushed back against the idea that they focused too much on hospitals in early and mid-March. Gov. Lamont has repeatedly pointed out that the state shut down nursing homes for visitors in early March, though he didn’t make masks mandatory in long-term care facilities until April 4, after a national mandate on masks was issued.
Interim Department of Public Health Commissioner Deidre Gifford took exception to Mathematica’s conclusions that the state “neglected” nursing home experts during the early stages of the pandemic and instead focused on hospitals.
“We were very concerned about not having enough hospital beds and people dying, so there was a lot of attention on that, but I don’t think it was at the expense of the nursing homes,” the commissioner said.
Gifford said the state immediately provided funding for nursing homes, has paid for all of the COVID testing and doled out millions of pieces of personal protective equipment (PPE) wherever it was needed.
She recently issued an order to all long-term care facilities that they must have a 30-day supply of PPE in their buildings as of Oct. 16. They will need to submit records to DPH of what they have stockpiled, and teams will be checking when they do inspections.
More than 2,800 long-term care residents have died of the virus — about 72 percent of the state’s total deaths. Nearly 12,000 more have been infected. Most of those cases occurred in April and May. It wasn’t until late May, when DPH with the assistance of the National Guard increased testing and inspected every nursing home for infection control violations, that the state got control of the virus and the deaths slowed.
Lack of PPE, data
The early response to the coronavirus crisis inside nursing homes was marked by two key factors: a lack of good information about what was happening inside the facilities and a lack of protective equipment to ensure staff would stay safe and not carry the virus from one patient to another.
The earliest signs of serious trouble came in the from of massive outbreaks. State officials got a much closer look at what the virus could do when some of the first cases in Connecticut hit a nursing home in Stafford Springs in late March.
The progression of the disease through the Evergreen Health Care Center played out in numerous nursing homes across the state just weeks later. Within weeks of Reil’s dying of COVID-19, there were 11 more deaths at Evergreen as the virus spread from the first floor to the second floor and among staff and residents.
Staff complained of a lack of PPE and guidance on infection control — describing entering rooms without masks, and sick residents in the same wings as those without the virus. About a dozen staff members eventually tested positive.
The lack of adequate PPE was the result of a sequence of problems.
“Though DPH expected to only provide PPE “where truly needed,” stakeholders on all sides recognize the critical importance of adequate PPE to protect staff and residents,” the Mathematica report says.
Emails from DPH’s emergency response coordinator at the time, Susan Roman, show that DPH officials were seeking information from long-term care providers on what PPE they had stored and that they were checking on their own stockpile that was supposed to be kept at Camp Hartell. There is even a discussion about alerting providers of likely N95 mask shortages.
But sources said some of the equipment stored at Camp Hartell was unusable and had to be thrown out because it was so old, while other items such as masks were distributed with the caveat that they weren’t medical grade masks and providers had to sign a release indicating they wouldn’t use them as such.
With little to no stockpile, DPH relied on getting the necessary PPE from the National Stockpile, which didn’t come through. The state ended up searching the globe for masks and surgical gowns, in many cases paying top dollar or fighting with the federal government or other states for the equipment.
Officials at the unions representing health care workers have complained the lack of PPE was a major factor in the spread of the virus in long-term care facilities, particularly among the staff using old equipment or none at all. Mathematica was unable to determine how many nursing home staff were sickened or how many died, but union officials have said at least 18 of their members died and more than 3,000 contracted COVID-19.
“The state’s plan for PPE was to rely on the National Stockpile to provide everything from N-95 masks to ventilators, but when that didn’t occur, the state was handicapped,” Rowan said.
Information was also in short supply. The department was using archaic reporting systems that they tried to upgrade in the middle of the pandemic.
Before the COVID-19 outbreak, DPH relied on data collection systems in which facilities reported information to the department via either paper copies or fax. The reportable disease data DPH received did not specifically identify cases among residents in nursing homes and assisted living facilities separate from those reported by hospitals, or among people who lived in the community.
The Mathematica report concluded that it wasn’t until May 8 that DPH started receiving daily electronic reporting from long-term care facilities. It was only then that health officials quickly got such vital information as number of positive and pending COVID tests, deaths, transfers of nursing home residents to the hospital, and nursing home bed availability.
Without up-to-the minute data, it was a challenge to determine exactly how hard the virus was hitting long-term care facilities in early April, frustrating town officials dealing with the rising death totals.
For example, at Whispering Pines, within a week of Notarino’s death DPH officials insisted there had only been six deaths at the facility when town officials knew there had been at least 14. At Kimberly Hall North in Windsor, state officials believed there had been only nine deaths when there had been 35.
“It’s no secret there’s been data issues with the state,” East Haven Fire Chief Matthew Marcarelli said at the time. “I was surprised that people didn’t seem to be as prepared for this as I would have thought they would be.”
Questions of care
The outbreak at the Evergreen nursing home in Stafford Springs raised issues about the readiness of the long-term care providers themselves.
Staff complained of a lack of PPE and of being short-staffed as some got sick and others refused to work in a COVID home. In its report, Mathematica said the biggest indicator of why more people died in some facilities than others was staffing. The facilities with more staff had fewer deaths.
“It’s pretty clear staffing matters,” White said. “If I have one aide taking care of 16 patients and they get sick, I now have 16 people who could be infected. If I have an aide taking care of eight patients at a time less can be infected.”
The two associations representing nursing home providers are doing their own independent study. Matthew Barrett, who heads the for-profit Connecticut Association of Health Care Providers, has said fighting “the pernicious character of such highly contagious virus” has been difficult on many levels. The associations have worked with DPH on everything from procuring PPE to expansion of families access to their loved ones that have been isolated for months, he said.
The Mathematica report is critical of DPH for not enlisting the help of long-term care providers in developing plans at the beginning of the pandemic. A few of its long-term recommendations revolved around getting better input from them.
One of the critical questions was how to separate the infected residents from others. Early on, the providers were critical of the state for not moving quickly enough to open COVID-only facilities where hospital patients could be sent to recover. Providers said they discussed the plan with state officials for at least a month before the state decided to act.
Lamont’s executive order establishing the COVID-only facilities came 11 days after he unveiled the first version of the plan. At that point, there had been 13 deaths in nursing homes. Within 11 days there were 195, and the worst was yet to come.
Eventually Athena Health Care Systems was appointed to use two of its existing facilities, in Bridgeport and Sharon, as COVID-only homes ,as well as run two empty facilities in Meriden and Torrington that the state would open up.
“The buildings clearly were late coming on line,” Athena’s marketing director, Tim Brown, said. “There were issues with the equipment that the state initially delivered. Some of it was broken and had to be replaced.”
DPH eventually called in about 30 National Guardsmen, and in a matter of hours they had the Meriden facility outfitted and ready to go, Brown said.
But the reopened facilities never caught on.
Meriden, which could have handled as many as 90 patients at once, handled 31 total and at times had as few as four patients in it.
“It took awhile for the state to allow nursing homes and assisted living facilities to transfer residents directly to the COVID-only units, and we would recommend that be done from the beginning if there is another surge,” Brown said.
“The emphasis was on freeing up hospital beds, but if you transfer a few residents from a nursing home, perhaps you stop the spread of the virus quicker in that facility.”
There is evidence the COVID-only homes made a difference. Athena found that there was a 10-1 ratio of survivors to deaths in the COVID facilities compared to a 3-1 ratio in regular long-term care facilities.
Gifford said that criticism that it took the state too long to open the COVID-only facilities doesn’t take into account the massive effort involved in doing something that had never been done before.
“I would say the state acted quickly. There’s always people who Monday morning quarterback, but in the grand scheme of things, we stood up a program in a few weeks,” Gifford said. “We conceived of these new facilities that had never been done before, developed a payment scheduled, identified partners who could run the facilities, helped them get staffed up and physically moved people.”
The state has maintained the leases on the vacant facilities in Meriden and Torrington, and Gifford said both of them could be opened quickly if the need arises.
At arguably the most important moment in the last century for experts in public health, Connecticut’s department was in free fall.
The very day that Gov. Lamont announced the state’s first COVID case, an internal struggle involving then-Commissioner Renee Coleman Mitchell and one of her deputy commissioners, Susan Roman, came to an ugly head when Roman resigned.
Roman’s resignation letter to Lamont could not have been more clear of what she thought of her boss.
“Working for Commissioner Coleman-Mitchell has been an incredible disappointment for me,” Roman said, without elaborating further.
Roman’s emails in the week before she resigned show how central she was to the department’s response. She was involved in getting extra testing kits, setting a budget, attending all emergency operations center meetings and coordinating DPH’s staff responses from submitting an application for PPE to the National Stockpile to establishing a 211 line for residents to call with COVID questions.
The problems in the department did not end with Roman’s resignation. In the weeks that followed, Coleman-Mitchell was almost completely silent, rarely appearing at Lamont’s daily press conference. She was eventually fired May 12. Even the state’s top epidemiologist, Matthew Cartter, appeared to have been sidelined as Lamont turned to experts from Yale University and the private sector to oversee contact tracing, testing and the state’s reopening.
The Mathematica report also details the impact of staff openings in critical units needed to fight the pandemic.
For example, six of the nine positions in the department’s emergency preparedness unit were vacant and some weren’t filled until July. In the Facilities and Licensing Unit (FLIS), the key department in dealing with long-term care facilities, there were nine vacancies out of 37 positions in the enforcement unit and six vacancies of 62 spots in the survey unit.
The infectious disease unit, another key department, was down six of 66 positions.
Even more telling, a small infection control unit that had been funded through federal grants disappeared in 2019. The federal funding through the Infection Control Assessment and Response program was prompted by the 2015 Ebola outbreak and supported state agency staff and training activities on infection control.
But Gifford downplayed the vacancies, saying, “It’s not unusual for there to be vacancies in agencies that don’t get filled quickly.”
“It’s hard to know what the impact was on any department without knowing the specific job that wasn’t filled,” Gifford said. “All agencies, whether it was state’s or the CDC or the federal government, had done a degree of planning, and it was clear that all of them needed to hire outside help or consultants because of the nature of this virus and what we were dealing with.”
A consultant from Boston was hired to oversee the implementation of the state’s tracing and testing programs with DPH employees in effect reporting to them. Lamont turned to Yale University’s Dr. Albert Ko to co-chair his reopening task force and for advice on how to fight the pandemic, particularly in nursing homes.
When asked about it, Lamont made it clear at a press conference in mid-May, as the virus was still wreaking havoc in long-term care facilities, that he didn’t have enough confidence in the department. Lamont said he hired the Boston Consulting Group because he felt their expertise “was greater than what his own state agencies could provide” as he prepared to reopen the state.
“You know, to tell you the truth, I don’t think we could. I’m still getting to know state government; there are amazing people here with a great deal of expertise, but, look, there weren’t a lot of Dr. Ko’s and all the people we brought in on the scientific side to help advise us when it came to a brand new pandemic like COVID,” Lamont said.
A second wave
Now, with coronavirus numbers across the state climbing again, the state is bracing for a second wave of COVID infections and taking steps to avoid widespread infection and death at nursing homes.
In early May, the state announced its plan to test all 20,000 or so nursing home residents for the virus as well forming teams of DPH officials and National Guard personnel to conduct point prevalance surveys of each nursing home to check on their PPE supply and infection control measures.
The testing allowed providers to discover which residents were asymptomatic but could still spread the virus and to separate them accordingly. The deaths and cases in nursing homes immediately started slowing down.
DPH also started having weekly phone calls with providers. “The weekly phone calls were very helpful in understanding the guidelines which were always changing,” said David Hunter, executive director of the Mary Wade House in New Haven.
“There’s definitely more of a partnership now with the state government and long-term care facilities,” Hunter said. “They may come in for an infection control review and recommend how some other facility is doing it. It seems the state is with us rather than against us.”
The Mathematica report does say the state missed a golden opportunity to test all of the staff at the nursing homes at the same time they did the residents. Eventually the state also tested all of them.
The state was expected to end the free testing at the end of this month, but with recent outbreaks at nursing homes in Colchester and Norwich and a general spike in COVID-19 cases, particularly in Eastern Connecticut, DPH recently announced it will continue testing through the end of the year.
Gifford has said many of the short-term recommendations made by Mathematica have already been implemented and that staff is reviewing the long-term ones. Among the recommendations already in place: streamlined reporting for facilities, increased infection control inspections, testing of all DPH and National Guard personnel that enter buildings and better stockpiling of PPE.
“It’s helpful for all of us, and I am glad that we have this tool in our tool box to help nursing homes as we move forward,” Gifford said.
But for the thousands who lost loved ones, like Larisa Zagorski, whose father Edward Balskus died at Kimberly Hall North, it’s too little too late.
“The nursing homes were following DPH and the CDC, and they weren’t getting very clear guidance,” Zagorski said Friday as she stood outside of the window of her mother’s room at Kimberly Hall North.
CarylAnn Balskus survived the deadly onslaught at Kimberly Hall North, where 45 people died, even though she also tested positive.
“They had protocols in place at hospitals for how to handle COVID patients, so why weren’t there any protocols for nursing homes,” Zagorski said. “I feel like they turned a blind eye to the nursing homes.”
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