On a June 10 call, Oklahoma health officials told the state's nursing homes that they would take a slow, measured approach toward allowing visitors to return to the facilities whose elderly, vulnerable residents account for more than half of Oklahoma's coronavirus deaths.
Two days later, some leaders of long-term care facilities say they were startled to receive an email from the State Health Department announcing that nursing homes that met certain benchmarks could begin reopening to visitors on Monday, June 15, allowing them to end a monthslong lockdown that has separated many ailing residents from their families.
The decision has raised alarms among some nursing home leaders and advocates, as the state has experienced a record surge in new COVID-19 infections this week and is preparing for President Donald Trump's indoor campaign rally in Tulsa on Saturday, which city officials expect to draw more than 100,000 people and which will not require masks or social distancing.
Anything that could accelerate the virus's spread in the state worries those tasked with protecting nursing home residents — especially as some facilities are still reporting shortages of personal protective equipment, or PPE, and lack of access to COVID-19 testing.
"At a time when our cases are breaking records, we are going to open long-term care. Why would we risk everything we have done over the last three months?" asked Mary Brinkley, executive director of LeadingAge Oklahoma, which represents nonprofit nursing homes. Brinkley was on last week's call with state health officials.
"It's happening much quicker than is prudent — there are thousands of older lives at stake," said Don Blose, CEO of Spanish Cove Retirement Village outside of Oklahoma City. "I wish they hadn't rushed this thing."
Do you have a story to share about how the coronavirus is affecting nursing homes? Contact us
State officials say that they have taken appropriate measures to ensure the health and safety of Oklahomans and that it is up to each facility to tailor its own visitation policy in accordance with state guidelines. The State Health Department did not respond to multiple requests for comment.
Nationwide, the virus is responsible for more than 50,000 deaths linked to nursing homes and other long-term care facilities, according to an NBC News survey of state health departments, a figure that represents more than 40 percent of all U.S. deaths from the virus. While COVID-19 deaths have been relatively low in Oklahoma compared to other states, they have been largely concentrated in long-term care facilities, which have already seen a marked increase in deaths.
As of Monday, 194 long-term care residents in Oklahoma had died from the virus — a 55 percent increase since May 11, according to data from the health department. By comparison, in New York state — which was hit hard earlier in the pandemic, and where the virus has caused more than 6,100 long-term care deaths — there was a 15 percent increase in nursing home deaths during the same period.
Oklahoma has joined a handful of states that have reopened nursing homes to visitors, but its rules are significantly more lax than most others. Earlier this month, Indiana, Connecticut and Massachusetts began allowing only socially distanced outdoor visits, with masks required. In Tennessee, all staff and residents must be tested at least once, and facilities have to be free of new COVID-19 cases for 28 days.
Under Oklahoma's new phased-in reopening guidelines, nursing homes are encouraged but not required to have visits take place outdoors. A facility can allow all residents to have limited in-person visits if 14 days have passed since its last symptomatic COVID-19 case and the surrounding county has seen a declining number of cases or a declining positivity rate during the same period, among other benchmarks for Phase 3; masks should be available to visitors, but they are not required, either. Most nursing homes already qualify for Phase 3 opening to visitors, the state said.
"This guidance will allow us to continue to protect the health and lives of Oklahomans while allowing them to safely resume valuable interactions with their loved ones," Oklahoma Gov. Kevin Stitt, a Republican, announced June 12. The new guidance also allows qualified nursing homes to resume communal dining, group activities and in-house beauty salons as long as certain health protocols are followed.
Across the country, the nursing home lockdowns have taken a serious toll on nursing home residents and their families. While some facilities have encouraged video calls and window visits, not all residents have been physically or mentally capable of staying in touch with their loved ones remotely. Research has shown that social isolation among the elderly is associated with premature death, chronic health conditions and dementia, among other conditions.
"Restrictions on visitation directly impact quality-of-life for our residents and their loved ones," Steven Buck, president and CEO of Care Providers Oklahoma, which represents nursing homes, said in a statement. "At the same time, we expect this process to unfold cautiously and with an emphasis on safety."
The new policy in Oklahoma has prompted families to flood nursing homes with questions about when they can visit their loved ones, said Blose, whose facility is still closed to visitors. LeadingAge Oklahoma said nursing homes are working on individual plans to reopen in light of state guidance.
Melinda Reid fears for her 85-year-old mother, who has congestive heart failure and lives in an assisted living community outside Tulsa. Reid said her mother's facility has been careful to protect its residents, but she worries what will happen if there is an outbreak in the broader community.
"If cases start rising in the community, how long can they fight this off?" asked Reid, who does not plan to visit her mother until she feels far more progress has been made in curtailing the virus. "We are coming into a very dangerous time."
Oklahoma is significantly further along than other states in reopening businesses as a whole: On June 1, the state kicked off Phase 3 of its reopening plan by allowing businesses to have unrestricted numbers of staff members, summer camps to open and hospitals to resume limited family visits. The state's marked progress in reopening contributed to the Trump campaign's decision to hold the president's return to the campaign trail in the state, officials said.
"It's taken us three months to get to where we are, and now that they opened things up we are in a much worse position than where we first started," said Blose, who said he is competing with restaurants to purchase increasingly expensive personal protective equipment. "I am really scared when school starts it's going to be even worse."
The American Health Care Association, which represents for-profit nursing homes, said long-term care facilities need significantly more support, including personal protective equipment, if they are to reopen safely.
"Providers are eager but cautious to welcome visitors and volunteers back into their buildings,” the group said in a statement. "We must ensure that they have the resources they need, like testing, PPE, funding and staff support, so we can keep our residents safe and engaged."
Download the NBC News app for full coverage and alerts about the coronavirus outbreak
In Oklahoma, for instance, 31 of 238 nursing homes said they did not have a week's supply of N-95 masks, according to NBC News' analysis of recent federal data. Eleven of the state's nursing homes said they had no access to COVID-19 tests for residents.
The federal government is shipping two weeks' worth of protective equipment to every nursing home in the country, but some of the equipment has been shoddy and defective, according to multiple reports and industry groups. Officials of the Federal Emergency Management Agency said Thursday that they plan to send out another two-week shipment to nursing homes in August.
Elaine Ryan, vice president of state advocacy for AARP, said testing is still lagging far behind what nursing homes need to protect their residents and staff members.
"We've made some progress, but it's not nearly enough," Ryan said. "I don't think any state has this under control at this point."