The level of infection and death arising from Covid-19 in nursing homes should lead to tighter regulation of the sector.
Since the virus first reached our shores in late February 2020, there have been thousands of outbreaks of Covid-19 and hundreds of deaths among nursing home residents.
Given their age profile, nursing home residents are already vulnerable and many have underlying conditions making them at high risk of acquiring a transmissible illness before Covid-19 was ever a concern. It goes without saying, many of the staff in these nursing homes have worked tirelessly during the pandemic, some putting their own lives at risk to care for the residents.
It appears from the outset of the pandemic, the primary focus was on policies designed by NPHET (National Public Health Emergency Team) and other state agencies to prevent hospitals and other acute services from being overwhelmed and, as a consequence, that put additional pressure on care homes who were effectively put to the back of the queue.
However, we have known since the beginning of this year that the virus was spreading from China and, in those circumstances, nursing homes should have been seen as an ‘at risk’ sector for Covid-19. Yet there was very limited testing and PPE provided initially for residents and staff when the pandemic became a threat here.
Some issues identified as potentially leading to risk of transmission of the coronavirus in nursing homes include:
- The wisdom of transferring patients from acute hospital settings to residential care homes when there were beds lying empty in private hospitals. Why put an already vulnerable population and their carers at increased risk when there was capacity elsewhere?
- The practice in the sector of agency staff moving between nursing homes between shifts contributing to the infection spreading.
- Not closing nursing homes to visitors early enough. It remains to be seen if those nursing homes who were criticised for taking ‘unilateral action’ by restricting visitors in early March had better outcomes in terms of infection rates than those who remained open until the public health advice was for them to implement visitor restrictions in mid-March 2020.
- Inadequate access to PPE and testing.
The Health Information and Quality Authority (HIQA) is the regulator for nursing homes. The above issues took place under HIQA’s watch.
HIQA’s remit is set out under Section 7 of the Health Acts 2007 which states the object of the regulator is to promote safety and quality in the provision of health and personal social services for the benefit of the health and welfare of the public. Section 8 (II) of the same act stipulates that HIQA is to set standards on safety and quality in relation to services provided in a nursing home and to monitor compliance with those standards.
Regulation 27 of the Care and Welfare of Residents in Designated Centres for Older People Regulations 2013 states a nursing home shall ensure that procedures consistent with the standards for the prevention and control of healthcare associated infections published by HIQA are implemented by nursing home staff. In May 2016, HIQA published National Standards for Residential Settings for Older People including standards on infection prevention and control practices.
In an effort to see if infection rates and deaths from Covid-19 in the nursing home sector could have been managed better, it is instructive to look at the standards and monitoring of infection control in nursing homes prior to the outbreak of Covid-19. If nursing homes had in place robust infection control measures prior to the Covid-19 crisis, then it would have been likely that the impact of the pandemic would have been minimised in these settings.
According to the regulator’s website as of December 2018, there were 581 registered nursing homes in Ireland and 76.4% were inspected by HIQA officials in 2018.
When one peruses the published inspection of nursing home reports on HIQA’s website prior to March 2020, there is very little specific reference in some of those reports to nursing homes being compliant with infection control or otherwise.
As a result of an inspection where a nursing home is found to be providing an unsafe service to residents, the Chief Inspector at HIQA can cancel the registration of the nursing home. When one looks at the register, there is only one nursing home listed as of June 2020.
HIQA’s Overview Report on the regulation of nursing homes in 2018 states 18% of nursing homes inspected where infection control was assessed were not compliant in this area. However, that statistic doesn’t give the full picture on the level of compliance of nursing homes in infection control in 2018 because infection control is not assessed by HIQA at every inspection and not all nursing homes are inspected each year.
On March 10, 2020, HIQA published a response to the Covid-19 crisis. It stated in the context of requesting nursing homes to inform it of deaths related to Covid-19 that nursing homes were not required to notify HIQA about their measures to prevent or to manage incidents or outbreaks.
This is a peculiar stance to take given the regulator was declining to inspect nursing homes during the pandemic where there was a suspected or notified case of the virus. The notice stated HIQA will be cancelling any routine inspections in centres and services where they have been notified of any suspected or confirmed incidence of Covid-19.
Where HIQA identifies risk in a service where Covid-19 has been confirmed and it believes an inspection is required, HIQA will follow public health advice in relation to any required precautions.
This appears to suggest HIQA didn’t deem it necessary to inspect all nursing homes where there was an outbreak of the virus. Surely any nursing home where there was an outbreak of Covid-19, that constituted a risk to residents and warranted an inspection by the regulator?
On April 21, 2020, the regulator sent a framework of self-assessment to nursing homes in the event of a Covid-19 outbreak. It is unclear how many inspections HIQA have carried out to monitor compliance especially among those nursing homes with known Covid-19 cases following the distribution of this publication.
The Nursing Home’s Expert Panel report requested by the Minister for Health is to address, among other things, the national response to this issue and it is hoped that lessons will be learnt on foot of that publication.
Depending on its findings, an inquiry may be warranted to ensure full accountability occurs.
Notwithstanding the significant challenges faced by those working in the health care sector during the pandemic, it is important that the standards afforded to care residents remain in accordance with reasonable clinical standards and judgements on care and infection prevention.
Stakeholders should be seeking more stringent regulation and enforcement of the sector which would result in standards being enforced and improvements in the provision of care to some of the most vulnerable in our society.
In the absence of a stronger regulatory watchdog, nursing home residents remain at risk.
- Marian Fogarty, Associate Solicitor with Cantillons Solicitors. Cantillons Solicitors are based at 38/39 South Mall, Cork.