(Reuters) – One night in April, as coronavirus swept through the Hammonton Center for Rehabilitation and Healthcare, Robyn Esaw, a double amputee, signaled for help with her bedpan. She said she hit the bedside button that turns on a red hallway light. None of the few remaining staff showed up – and one of them turned the light off. Esaw only got help, eventually, by wheeling herself to the nursing station and yelling.

On another night in another room of the New Jersey home, Barbara Grimes noticed her roommate sitting in a puddle of urine, which seeped into a wound on her tailbone. No one checked on the roommate for three hours. The woman, Grimes said, had given up on calling for help.

That same month, Hammonton staffers moved David Paul and another man into a room last occupied by two residents infected with the coronavirus, one of whom later died of COVID-19. The floors were still dirty, the bathroom littered with trash, Paul said. Paul and the other man, he said, soon tested positive themselves, and his roommate died. In all, the Hammonton outbreak resulted in 238 infections and 39 deaths, state data shows.

“You cannot live here and really believe that these people care about you,” said Esaw, 70, who has lived in the home for nine years and knows Grimes and Paul well.

Nursing homes worldwide, filled with elderly residents who are particularly vulnerable to COVID-19, have suffered a harrowing toll in the pandemic. 

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In the United States, longstanding problems with staffing shortages and chronic turnover have left nursing homes especially exposed. An estimated 40% of the country’s more than 100,000 COVID-19 deaths are connected to long-term care facilities such as nursing homes or assisted-living centers, according to a Kaiser Family Foundation tally.

About a quarter of nursing homes responding to a recent federal survey reported shortages of direct-care staff during at least one of the last two weeks in May, according to a Reuters analysis of survey data from the Centers for Medicare and Medicaid Services.

A separate Reuters analysis of federal nursing home data shows that, before the virus hit, about four in 10 homes nationwide would not have met the minimum staffing regulations in California, which has among the highest standards in a nation where some states have few or no requirements for nursing staff levels. About 70% of U.S. nursing homes would fail to meet a stricter staffing standard advocated by some experts, the analysis showed.

The coronavirus pandemic has laid bare and deepened these historical staffing problems, according to interviews with nearly two dozen nursing home workers and residents nationwide. Nursing home staffers are quitting in large numbers, these workers said, because of illness fears and what they described as a slipshod emergency response by management.

As outbreaks hit homes nationwide, administrators often sought to downplay the danger, 17 workers at eight homes run by eight different companies told Reuters. Managers hid the severity of outbreaks, the workers said, in part because they were desperate to retain staff who were scared and disillusioned with poor working conditions and pay as low as $11 per hour. Some managers pressured sick or infected workers to show up, said five workers at four facilities.

At Hammonton Center, overworked nursing assistants have regularly had to bathe, clean and feed as many as 30 residents by themselves, far more than usual. Staffing on two occasions was so thin that nursing assistants found residents who had been dead for several hours in rooms no one had time to check, two Hammonton employees said.

Centers Health Care, which runs the facility, declined to comment on most accounts of residents and workers cited in this report. It denied any lapse of care at the home. The company disputed the contention that residents were not discovered for hours after they died.

Reports of overwhelmed staff extend far beyond Hammonton. At Life Care Center of Nashoba Valley in Littleton, Massachusetts, so many staff had quit or called in sick that managers left a teenage nursing-assistant trainee on a shift caring for nearly 30 dementia patients, said a current worker and a former worker. Part way through the shift, one more nursing assistant was assigned to help her in response to staff complaints, the workers said.

The vast majority of more than 40 nurses and nursing assistants at the Life Care home have quit since April, six current and former workers told Reuters. Twenty-six people died, according to federal data, including a nursing assistant. The outbreak caused 87 confirmed infections, the data show.

The rapid staff exodus left residents without the most basic care, the workers said. “These are people who all need to be changed. They’re incontinent. A lot of them need help eating,” said Lisa Harmon, a nurse who supervises weekend shifts. “There’s only so much one person can do.”

Tim Killian, a spokesman for the home’s owner, Life Care Centers of America Inc – one of the nation’s largest operators – acknowledged that a large portion of the Massachusetts home’s staff quit under “extremely challenging” conditions. He said facility leaders could not recall a teenager being assigned to care for dementia patients alone.

Echoing other industry advocates, Killian said nursing homes have generally reacted well to an unprecedented challenge, despite little government help. The U.S. government has taken heavy criticism for being slow to react to nationwide shortages of protective gear and testing kits.

“It’s just ridiculous to think that nursing homes, absent direct and substantial government support, could manage a global pandemic,” Killian said.

‘HIDING IT FROM US’

Staffing had long been a problem at the Massachusetts Life Care home, with nursing assistants often caring for too many residents, workers said. The shortages became a crisis in the outbreak, they said, as management failed to provide protective gear or to communicate how the virus was spreading.

In March, veteran nursing assistant Patti Galvan noticed residents getting fevers and coughing. She brought her own mask, but a manager told her not to wear it, saying it wouldn’t prevent infection. Other workers said management told them to remove masks they brought from home because they would cause other workers to ask for protective equipment the facility could not provide.

Killian acknowledged protective-gear shortages, which created “tension” between management and workers, but said administrators were powerless to solve nationwide supply problems.

Staffers started getting sick and staying home, but managers “weren’t taking it seriously,” said Galvan.

“They were just hiding it from us,” said Galvan, who left more than two months ago after getting flu-like symptoms and has no plans to return. “If they were honest with us, and were more caring and more responsible, they wouldn’t have lost us all.”

Galvan had worked at the facility for three decades.

Amy Lamontagne, the facility’s executive director, said management never withheld information. “There was no secret-keeping,” she said.

Killian said management couldn’t inform staff about coronavirus infections until it had confirmed test results or, when testing wasn’t available, a formal diagnosis from a nearby hospital.

Colleen Lelievre, a nurse who still works at the facility, said testing wasn’t needed to recognize the unusual number of residents with COVID-19 symptoms in March. But management, she said, never leveled with the staff about why so many residents were being hospitalized.

As more workers quit or called in sick, those who remained regularly worked 80- to 90-hour weeks, said Harmon, the weekend nursing supervisor. Physical- and occupational-therapy assistants filled in for nursing assistants.

The depleted staff couldn’t bathe and feed every resident, workers said. In a dementia unit, workers were unable to keep residents from wandering into hallways and other patients’ rooms, potentially spreading infection. Staff had no time to sit with dying residents, said Harmon, who sometimes left her phone with them so they could call relatives in their final hours.

Despite these conditions, the facility reported no staff shortages in response to the government’s nursing-home survey. Killian said the facility had no shortages in late May because the number of residents had declined to the point where the home was “fully staffed” with many fewer workers. Lamontagne said the 120-bed facility now has 65 residents.

Overall, 192 of Life Care’s more than 200 nursing homes responded to the federal survey, and about 29% of those reported staff shortages, according to the Reuters analysis.

Harmon and Lelievre said the Massachusetts home still has far fewer staff than it needs. The facility has very few nursing assistants, Lelievre said on Saturday, making it nearly impossible for staff to safely move some residents out of their beds, which often requires two people.

Lamontagne, the executive director, had a different take: “We’re doing fine with our staffing,” she said.

Several workers questioned why the facility wasn’t more prepared, since its owner had, weeks before, managed the site of one of the first major U.S. outbreaks, at the Life Care facility in Kirkland, Washington – with 45 deaths linked to the home, according to local public health authorities.

“They didn’t have any plan,” said John De Mesa, a nursing assistant who said he contracted the virus in March.

Killian said the gap between the Washington and Massachusetts outbreaks gave the company little time to act on lessons learned.

In late March and early April – as many Life Care residents were hospitalized – the Massachusetts National Guard came to the home to administer tests. Administrators brought in corporate staff and workers from a nearby Life Care facility to give the appearance of a fully staffed home around the time of the Guard visit, Harmon and Lelievre said. Most of the added staff left within a week, they said.

Killian dismissed the contention that the extra staff were deployed for appearances, saying all staffing decisions aim to improve care.

The home told workers they could not get tested along with residents, staffers said. The state at the time, in early April, was restricting testing in nursing homes to residents only.

After workers complained about the lack of testing, management sent a text message to the staff on April 5.

“We encourage you to direct any questions or concerns about your health to your personal physician,” read the message, which was reviewed by Reuters.

Some workers sought out their own testing. Life Care did not test workers until mid-May, Harmon and Lelievre said. Staff had to bill their insurers for the tests, they said. Those with no insurance had to pay upfront and seek reimbursement from Life Care.

Thirty-four workers at the facility had tested positive by the end of May, according to federal data. Those who became ill with COVID-19 were not paid for their time away, Harmon and Lelievre said. Killian said sick workers could use accrued paid time off.

HISTORY OF STAFFING PROBLEMS

Insufficient staffing and frequent turnover have caused quality-of-care problems at nursing homes for decades, studies and government inquiries have shown.

Most nursing-home revenue comes from Medicaid and Medicare, the federal health programs for the poor and elderly. The fixed payments, some researchers say, incentivize companies operating on thin margins to cut staffing to the bone. Industry lobbyists have long sought higher reimbursements, which they argue haven’t kept pace with costs.

The American Health Care Association, an industry trade group, testified before Congress twice last year and requested help in attracting workers. Since the pandemic hit, the group has asked state officials for help recruiting nurses from less-impacted regions, as New York City hospitals did. “Just like hospitals, we called for help,” the group said in a statement.

“In our case, nobody listened for months.”

The federal government conducted its nursing home survey last month to seek data on staff and equipment shortages during the pandemic. At least 3,200 nursing homes – 23% of the 13,600 facilities that submitted data – reported staffing shortages in late May, according to the Reuters analysis. About 2,000 facilities did not respond to the survey.

U.S. regulators set few standards for nursing-home staffing, requiring only the presence of a registered nurse for one eight-hour shift and a licensed nurse, with a lower-level credential, in the building at all times.

At least two-thirds of states, including California, set minimum-staffing standards for nursing care, though the requirements vary widely and often contain loopholes. Some, including Indiana and Virginia, have no minimum standards for direct-care nursing staff.

California requires its 1,200 nursing homes to provide 3.5 hours of daily direct care, part of a 2017 law setting some of the highest standards nationally. If applied nationwide, about 37% of nursing homes would fail to meet that requirement, according to the Reuters analysis, which examined federal data on staffing during the last quarter of 2019 for nearly 15,000 nursing homes.

About a third of California homes don’t meet the state’s own staffing standards because regulators last year granted them exemptions from requirements for overall staffing or for certain positions. The state said it granted some waivers because of workforce shortages.

Annual turnover of nursing staff at homes in California – among the few states that track that data – has increased from 44% in 2014 to 53% in 2018.

Some researchers believe California’s requirements don’t go far enough. Charlene Harrington – a nursing professor emerita at University of California, San Francisco, who has studied nursing-home staffing shortages – advocates for 4.1 hours of per-patient direct care. She cites a 2001 federal study that concluded quality of care can decline below that level. At least 70% of nursing homes nationwide would fail to meet that higher bar, the Reuters analysis shows.

Some scholars and industry advocates blame staffing problems on systemic weaknesses in U.S. nursing-home funding.

“No one wants to pay the taxes for them, even though they’re all of our grannies, or mothers,” said Vincent Mor, a professor at Brown University’s school of public health, who has studied nursing home quality and staffing.

Some experts blame nursing home owners, mostly for-profit companies, for skimping on staff to make more money. Harrington, the UCSF nursing professor, called industry complaints about government funding “nonsense,” arguing that major companies would leave the business if it were unprofitable.

IN THE DARK

When outbreaks hit, some nursing home managers pressured sick workers to show up unless they had a positive coronavirus test, or to return to work before the recommended self-quarantine period, five workers at four facilities said.

Nursing assistant Gabby Niziolek, 20, said she started feeling sick in late March during a shift at Plaza Healthcare and Rehabilitation Center in Elizabeth, New Jersey. Some co-workers had started feeling ill, she said, and she noticed residents losing their appetite and turning a pallid color.

When she asked to leave, her manager told her to finish her shift, Niziolek said. The next day, after she got tested, she said she was told to return to work while awaiting results. When the results came back positive, Niziolek’s boss asked if she was showing symptoms. She said she was, and stayed home.

“If you’re positive and you don’t have symptoms, they still want you to work,” Niziolek said.

Plaza Healthcare and Rehabilitation Center did not respond to requests for comment.

Residents and staff at New Jersey’s Hammonton Center were kept in the dark for weeks about the extent of the facility’s outbreak, said three residents and six staffers.

As illness spread in late March, managers told workers that the sudden jump in residents with fevers, appetite loss and shortness of breath stemmed from cases of “aspiration pneumonia,” a condition that usually isn’t caused by an infectious disease. Weeks later, managers said that residents who had been hospitalized tested positive for the coronavirus.

Workers weren’t informed at the start of shifts that they would be working on hallways filled with residents believed to be infected, staffers said.

Home operator Centers Health Care said it couldn’t be sure that symptomatic residents had the virus until testing became more widely available in April.

A nursing assistant who was among the first to test positive for the virus said she reported the diagnosis to her supervisor and told several co-workers, as her doctor had advised. Five days later, when she was at home sick, a manager called to chastise her for telling co-workers, she said.

Centers Health Care said in a statement that its staff are “working tirelessly around the clock.” The company said staffing shortages are an industry-wide issue, but that it has ensured it meets state minimum staffing requirements during the pandemic by redeploying staff as needed within its network of facilities. The company declined to detail its staffing levels.

Hammonton nurses and aides said that about half of the facility’s direct-care staff have left, and that the facility replaced some with workers from temporary staffing agencies.

Hammonton Center reported some staff shortages to the government, as did about half of the 38 Centers Health Care homes that responded to the survey, according to the Reuters analysis of the data.

Grimes, who has lived at Hammonton for six years, said she started noticing that her roommate had a “horrible cough” that kept getting worse. She told nurses about the condition, and her roommate was hospitalized in April. The woman later died, but Grimes said staff never told her the cause.

Grimes said she got moved to a separate wing for those who had not contracted the virus – but staff never explained, she said, whether her roommate had tested positive. Last month, after getting a second test, Grimes learned she was positive, though she said she only had a slight fever.

“We don’t know when somebody gets sick; we have to sniff it out like a bloodhound,” she said. “You can only guess what happened when that person is getting carried out on a gurney.”