What Cuomo’s nursing home report does not say

A new New York state Department of Health report posits that unwitting nursing home staff, and possibly visitors, caused thousands of COVID-19 deaths at facilities across the state. While that could be true, that does not mean that Gov. Andrew Cuomo is as blameless as the report concludes. 

There are a few broad reasons to ascribe some responsibility to Cuomo, who has said he has no regrets about his handling of nursing homes during the coronavirus outbreak. The first is that he is a three-term governor who could have done more early on in the pandemic to safeguard nursing homes, especially when it came to ensuring facilities had adequate staff and personal protective equipment. Such issues are outside the direct purview of the report, yet still relevant to its conclusions that nursing home quality and admission policies had little effect on the nursing home death toll, which stands at 6,432 as of the report’s July 6 release. That accounts for about a quarter of New York’s 24,914 from confirmed or likely cases of COVID-19 as of that same date.

The report cites data suggesting the coronavirus had spread through the facilities weeks before anyone even knew it was in the state. Therefore, it argues, Cuomo’s subsequent actions can’t be to blame. 

Nearly all the deaths in nursing homes came after the Cuomo administration ordered facilities to accept COVID-19 patients from hospitals, but there are reasons to believe the coronavirus was already surging before then and there is a lag between infection and death. So the report asserts that admission policies were “not a significant” factor in nursing home deaths. 

This is all complicated stuff – you can read the report here – so it makes sense to go through a few important issues about nursing home deaths, which shows things are much more complicated than the report lets on.

A few dates are key to the report

More than 6,000 COVID-19 patients were moved from hospitals to nursing homes between March 25 and May 10 in order to free up hospital beds during the worst of the pandemic. Nursing home deaths from COVID-19 reached their peak on April 8, whereas nursing home admissions of patients with COVID-19 reached their peak on April 14. 

The intervals between these various dates are important to the report’s key claims. This includes the idea that the 14 days in between the March 25 order and April 8 apex in deaths is too short of a time for the skyrocketing death toll to be caused by patients with COVID-19 returning to nursing homes after the March 25 order and subsequently spreading it throughout the facility, considering federal guidance that suggests it takes about 18 to 25 days for the coronavirus to kill someone. 

If admitting COVID-19 patients to nursing homes was driving the deaths, the report asks, then why did they peak six days before admissions? This suggests that admissions were not the overriding cause for deaths in nursing homes, but that is very different than saying they were not a factor at all – and absolving the governor of responsibility for the March 25 decision in the process. A number of possible factors could also explain why deaths peaked earlier than admissions, such as increasingly better treatments for COVID-19, more awareness of its dangers, and a wider availability of PPE as time went by.

The report also makes a claim, based on the length of time between the peak of deaths and the day when the most facilities reported COVID-like symptoms among staff, which was nine days before the March 25 order. That shows that the virus was already in dozens of nursing homes before COVID-19 patients began coming in from hospitals. CDC guidance at the time allowed asymptomatic people to work in nursing homes, which added to the spread of the coronavirus.

“It all paints a picture that this came earlier,” said Jim Malatras, president of SUNY Empire State College, who has taken a leading role in analyzing COVID-19 data on behalf of the Cuomo administration. “Many of those staff members worked in the most impacted communities of color … (the pandemic) was already infecting those regions.”

The timeline can be interpreted in other ways

The March 25 order remained in effect for 46 days, the deadliest period of time during the pandemic. Even if it took 25 days for a COVID-19 case to go from infection to death, that still leaves three weeks when the order arguably caused fatalities before the order was rescinded on May 10. This is a period of time when more than 2,000 people died of the disease in nursing homes. 

A graph in the report with these key dates does not include data from nursing home deaths that happened in the 25-day period after May 10, but it is entirely plausible that some deaths could have happened after that date due to admissions from hospitals. Yet, the report cites claims that such patients could not have been contagious by the time they reached the nursing homes because of federal guidance that suggests people are not very contagious nine days after the onset of symptoms.

Some big scientific assumptions make the DOH timeline work

The Cuomo administration has blasted the CDC throughout the pandemic. Cuomo has even noted at various junctures just how much the coronavirus has surprised scientists and policy makers alike in recent months. This is especially true when it comes to how much asymptomatic people spread the virus.

Yet, the administration still believes that the CDC has it right with its claims about how long someone is infectious and how long it takes for COVID-19 to kill. Like so many other things with the pandemic, these are just informed guesses rather than bulletproof scientific conclusions. 

“You can be critical at times,” Malatras said of the disconnect between the administration’s criticism of the CDC and reliance on its data.”It's not all black and white.” 

Even so, these lengths of time are based on COVID-19 patients at-large. The situation could be different with older, more vulnerable, nursing home residents though they are disproportionately killed by the virus. There is some evidence for example that it could take as few as 10 days for an older person to die from COVID-19. If that were proven true, it would challenge the whole premise of the DOH report. There just are no definitive answers on this point about how long it takes, considering the lack of peer-reviewed scientific studies on the pandemic. “All you can do is measure things, and then point out the strongest factors,” said Malatras, while considering that future research could change the scientific understanding of just how long it takes COVID-19 to kill people or how long they are contagious. “If you put a gun to my head and say: You know, with 1 million percent certainty?’ Of course not,” he added about the reliance on the CDC guidelines. “That's why you have academic journals.”

More PPE from the state surely would have helped

The state has insisted that it has provided nursing homes with adequate personal protective equipment, such as masks, since the onset of its COVID-19 outbreak, despite reports that have suggested otherwise. “From the beginning (of the pandemic), New York state took aggressive steps to prepare healthcare facilities, including nursing homes,” State Health Commissioner Howard Zucker said during a press conference on Monday. “New York sent over 8.5 million pieces of PPE, took staff temperatures, suspended nursing home visitation statewide. The purpose of all these actions was to limit the opportunities for nursing home residents to be exposed to COVID-19.”

While Zucker is citing the total amount of PPE sent to healthcare facilities, it’s unclear what portion of those supplies were distributed to nursing homes, as opposed to, say, hospitals. 

In April, the Cobble Hill Health Center in Brooklyn told The Wall Street Journal that the nursing home spent weeks asking state officials for more PPE.

Other nursing homes throughout the state have reported similar issues. Assemblyman Ron Kim told the New York Post in April that, “Zucker’s assertion that ‘necessary precautions’ were being taken to prevent the spread of infections in nursing homes was ‘clearly not the case.’

“It’s either he’s lying or they have absolutely no idea what’s going on on the ground,” Kim said. “The staff, the families, everyone is telling me there’s completely a lack of support and they don’t have the necessary PPE to be safe.”

Staffing shortages had already made nursing homes vulnerable

New York doesn’t have minimum employment requirements when it comes to nursing homes and other long-term care facilities, which has often resulted in understaffed nursing homes. “You cut the staff because you can,” Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, told City Limits in 2019. “You cut it to the bone, and then what we end up seeing is terrible, terrible understaffing.”

Nursing home employees are also underpaid and, because of the often grueling nature of the work that they do, it’s difficult to attract more staff. Low–paid employees are often forced to work at multiple facilities to make ends meet, which could have contributed to wider spreading the virus. A smaller staff also means that employees have to take on more work, which can put elderly and immunocompromised individuals at increased risk due to employees’ prolonged exposure to individuals who may be infected.

Lack of Medicaid funding

State Sen. Rachel May, Chair of the Committee on Aging, told City & State in early May, that she believes a large reason why the state's nursing homes were hit so hard by COVID-19 was due to a lack of Medicaid funding. “(The state’s nursing homes) have gone 12 years without a cost-of-living rate increase for Medicaid recipients,” May said. “That means, in skilled nursing homes, they're spending a lot more money per day on care for their residents than they are receiving back from Medicaid. And that has led to a financial crisis and cuts to funding numerous times. The state has also cut some capital funding to nursing homes so they weren't able to expand or create safer spaces (for their residents during the onset of the outbreak).” 

However, the state has rebuffed the notion that the lack of funding, PPE or staff are to blame for the unprecedented outbreak. 

“There seems to be new theories every day, but let’s stick to the actual facts: as this pandemic tested every facet of our healthcare system,” top Cuomo aide Rich Azzopardi said in a statement sent to City & State. “Nursing home infections became a nationwide issue and New York responded by providing a database of more than 96,000 healthcare workers – which more than 400 of 600 nursing homes used – and provided more than 14 million pieces of PPE to these mostly private businesses. We have also put into place safety protocols to try to keep the virus at bay which included barring visitors, required temperature checks and later testing of both workers and residents. As we’ve seen in the DOH analysis released this week, the virus was in facilities and in our communities way before New York received its first confirmed positive from the federal government and through no fault of their own, were likely brought in (by) asymptomatic employees.”

It’s true that – as one might expect in light of their vulnerable populations and close quarters – nursing homes and other long-term care facilities have accounted for a remarkably large share of deaths in some other states as well. In New Jersey, the proportion of COVID-19 deaths in nursing homes has been even higher than in New York. 

The report even cites one statistic that finds New York was in the bottom tier when it comes to nursing home deaths as a share of a state’s total COVID-19 death toll. Yet, if correlations do matter – and the report uses several of them to make its various claim – then it should be noted that while New Jersey and Pennsylvania adopted policies similar to the March 25 order in New York, a Pro Publica analysis found nursing home deaths went down in California after it stopped sending COVID-19 patients to nursing homes early on in the pandemic. 

Conclusion

The report revealed a lot of new information about how nursing home staff, and maybe visitors, spread the coronavirus through nursing homes in February and March. A more effective federal response to the pandemic obviously made it harder for the state and nursing homes to react to the danger once they knew it was there. Maybe nursing home staff were the biggest vector for the coronavirus, and the biggest overall factor driving the deaths. But even if that is true, that does not mean that COVID-19 patients from hospitals had no effect at all.

There are a lot of outstanding questions about how easily the coronavirus spreads, how fast it kills and how long people remain infectious once they recover, so it is too early to really know how one factor or another contributed to COVID-19 deaths in nursing homes. Yet, there are still reasons to believe that the March 25 order at least played some role, as well as Cuomo’s handling of PPE, staffing and other issues. With so much up in the air, the one thing we do know is the DOH report raises as many questions as it sought to answer about the governor’s role in the tragic affair.