President Trump declared a national state of emergency March 13. The death and infected counts rose rapidly, into the hundreds and tens of thousands, respectively. A nationwide prohibition on group interaction was ordered, while federal officials took the historic step — one of many — of banning all visitors from nursing homes, except for “essential” workers.

Statistics from China, where COVID-19 first raged, showed a mortality rate of about 1% in younger people but 15% or higher in seniors.

“The grim reality is that, for the elderly, COVID-19 is almost a perfect killing machine,” American Health Care Association President and CEO Mark Parkinson told CNN on March 11.

State “shelter in place” decrees led to an estimated 100 million Americans staying at home. 

As of mid-March, the number of positive COVID-19 cases in the U.S. was rising so fast that the World Health Organization said the U.S. had the potential of becoming the virus epicenter. 

Life Care Center of Kirkland was the epicenter of initial U.S. COVID-19 outbreaks, garnering widespread criticism and finger-pointing that became somewhat less harsh as hundreds of other locations around the country also discovered victims in their midst. At least 37 deaths were attributed to COVID-19 at LCC Kirkland as of late March. More than 80 of its residents, 34 staff members and 14 visitors had tested positive for COVID-19 as of press time. 

The investigation concluded that the facility didn’t act quickly enough to identify and manage ill residents or notify the state’s health department about the increasing rate of respiratory infections among residents. It also didn’t have a “sufficient backup plan” after its primary doctor became ill.

“We have learned valuable lessons,” said Washington Department of Social & Health Services Secretary Cheryl Strange about the Kirkland situation. “We are applying these lessons daily in our efforts to prepare long-term care facilities throughout the state for the potential of COVID-19.”

A Centers for Disease Control and Prevention report also noted that staff members working in multiple facilities contributed to the spread of the coronavirus.

Among them: The agency suspended standard facility surveys for a three-week period starting near the end of March. Officials said they would conduct just three types of surveys until at least early April: complaint/facility-reported incident surveys involving Immediate Jeopardy; targeted infection control surveys; and self-assessments. All were to include heightened infection control scrutiny. 

CMS also removed the three-day stay requirement for Medicare skilled nursing coverage during the outbreak. This allows the agency to provide temporary emergency coverage of SNF services — without a qualifying hospital stay — for people who need to be transferred as a result of COVID-19. It also authorizes the renewed SNF coverage without first having to start a new benefit period. 

“This is a perfect storm. I hate to use that terminology, but that’s exactly what we’re seeing here,” said David Gifford, M.D., chief medical officer for the American Health Care Association/National Center for Assisted Living.

The CDC recommended that providers restrict mask usage to only healthcare workers and prioritize them for selected activities. The agency also encouraged shifting to cloth isolation gowns and considering using coveralls. 

In addition, it called for implementing extended use or re-use procedures and prioritization for both gowns and masks. 

Officials urged providers to re-examine their infection control procedures and emergency preparedness plans, while also calling on groups with PPE stockpiles for non-emergency uses to share with frontline healthcare providers.

The guidance expanded on a less stringent yet unprecedented recommendation to limit visits earlier that week. The tougher measure received instant support from providers, even though it meant further stressing already stretched staffs.

The Centers for Medicare & Medicaid Services declared that providers should restrict visits to only essential healthcare personnel, with the only exceptions being for compassionate care situations such as end-of-life. Healthcare workers and surveyors were exceptions to the restrictions, provided they pass a health screening each time they entered a facility.

The MDS changes, which were first announced in late December, had been set to start Oct. 1. The move is especially striking as the proposed Minimum Data Set (MDS) 3.0 v1.18.1 will be the first major issuance since the Patient Driven Payment Model took effect Oct. 1, 2019. 

The agency did not provide a timeline for implementation. 

Among the ideas: FaceTime book clubs between residents and their families; serenades through windows, including a performance from a bagpiper; hallway bingo games and a variety of contests.

Meanwhile, individual facilities, chains and associations began campaigns encouraging the public to send handwritten cards, letters and videos to residents. More stories of creativity can be found at carenotcovid.com.

The regulations require that all nursing home applicants and residents of Medicaid-certified facilities be screened for mental illness and intellectual disability, and, if needed, those services will be provided. Proposed changes include updating the definitions of mental illness and intellectual disability; streaming the screening process; allowing the use of telehealth technology; and placing a greater emphasis on individual preference regarding where they would like to receive long-term services. 

“The new definitions and requirements of screening will be very important for the nurse leader and the nurse assessment coordinator to understand,” Alexis Roam, MSN, RN-BC, DNS-CT, QCP, curriculum development specialist with the American Association of Post-Acute Care Nursing, told McKnight’s. It will help nursing coordinate with admissions and others, she added.

Other proposed changes include implementing statutory modifications to the Resident Review requirements that aren’t reflected in the current regulations, and simplifying what information must be collected during resident evaluations.

Treatment should start with low-risk, noninvasive strategies and then slowly introduce pain medications, including opioids as needed, according to physicians Brandon Verdoorn, M.D., and Christina Y. Chen, M.D., in Mayo Clinic Proceedings. They recommend that providers use the following framework to help manage care:

• Begin with a thorough pain assessment, focusing on pain-related function.

• Address associated conditions, such as depression and insomnia, at the same time.

• Start with low-risk pain management strategies, including nondrug interventions that get the patient actively involved in her or his own improvement.

• Use higher-risk — often pharmacologic — strategies cautiously, when needed.

• Frequently reassess and discontinue ineffective treatments.

Pain medications “are important tools for addressing chronic pain, which ultimately affects one’s function and independence,” Chen said.

There are several things you can attempt. First of all, change it when the resident has not recently had anything to eat or drink. Eat foods that thicken the stool, such as rice, pasta, cheese, bananas, potatoes, applesauce, smooth peanut butter, pretzels, yogurt and marshmallows. 

If lots of fluids are filling the colostomy bag during the day, offer the resident two or three glasses of fluid like sports drinks, fruit or vegetable juice, and broth, that will replace electrolytes. But limit these, especially if the resident has a cardiac problem.

Drinks like soda, artificial chocolate drinks, Kool-Aid and fruit juices do contain lots of sugar and will cause an increase in output. Make a list that hangs in the room so that everyone, including the resident, family and all staff, know what you have tried and what may have been successful or not so successful with slowing the output!

Foods high in sugar content, such as carrots, grapes and oranges, will come through fast as well,  especially if the resident has an ileostomy or short bowel syndrome. Trial and error also will be the thing that works best as, like I mentioned, everyone is different. Make a list of the fast-traveling foods and give a copy to the family so they, too, know what they should not bring in as a snack, or limit the amount or number of times they offer it to their loved one!

Some colostomy wearers swear by eating marshmallows before changing the appliance, and/or sprinkling some sugar directly on the stoma to cause it to shrink a bit. It’s all about trial and error, and everyone is different! Try a few things to see  what works. Be sure it’s on the care plan so everyone can benefit from the trials and success.