After each shift at the Chicago nursing home where he cares for dozens of elderly residents, James Carter rides the train home worrying that he will bring the coronavirus home to his own family.
Carter, 23, a certified nursing aide, tries to take extra precautions: He puts all his work clothes in a special backpack that he frequently launders, and takes off his shoes before he sets foot in the house.
“I want to be able to go home safely and tell my mother, ‘You don’t have to worry about anything,’” said Carter, who lives with his mother and an aunt who has diabetes and high blood pressure that could make her especially vulnerable to the virus.
But Carter, who earns $13.70 an hour, believes that the nursing home, Alden Lakeland, has not done enough to protect and compensate the staff as they face life-threatening risks.
In early April, he and a few other colleagues presented the facility’s management with a demand letter asking for higher pay, more hires to relieve staffing shortages, and more personal protective equipment. The workers had support from the Service Employees International Union, which represents them.
In response, the nursing home management threatened to call the police, Carter said, and he was told he would be fired. The union pushed back, but Carter was ultimately suspended without pay for three days for the unauthorized use of a digital or cellular device during the confrontation with management, he said. (Carter denied recording the incident.)
“When you hold them accountable, they see you as a nuisance,” Carter said. “They’d rather have someone with less experience as long as you do what they say.”
Alden Lakeland now has five reported coronavirus infections and one death, according to the latest data from the Illinois Department of Health. But Carter says he wasn’t aware of any cases in the 300-bed facility until NBC News shared the information — even though certified nursing aides are in close physical contact with residents all day, lifting them in and out of bed, helping them use the toilet and brush their teeth, and feeding them meals.
Janine Schoen, a spokeswoman for The Alden Network, which owns the facility, said that “ensuring the safety of our staff and residents is our greatest concern,” and that all staff have the protective equipment they need. She did not respond to Carter’s allegation that he faced retaliation for demanding better working conditions or to the concern that staff members were not being notified about positive cases.
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Long before nursing homes became a breeding ground for the coronavirus, aides like Carter have faced low wages, strenuous conditions, communication breakdowns and staffing shortages, according to nursing home workers, advocates and industry experts.
But the virus has now turned these challenges into a full-blown crisis for these workers — the majority of whom are women and people of color — who have suddenly found themselves on the front lines of the pandemic, with limited protection and outside oversight.
Despite promises to protect these workers and the vulnerable residents they care for, the federal government does not require nursing homes to inform staff members about coronavirus infections or deaths, and the Department of Labor does not require any workplaces to follow coronavirus guidelines from the Centers for Disease Control and Prevention.
“It’s putting extraordinary responsibility on workers who are not trained or compensated to take the level of risk that they are taking,” said Kezia Scales, director of policy research for PHI, a national research and consulting organization for long-term care workers and personal aides. “Direct care workers are already living paycheck to paycheck. Now they are being asked to put their lives on the line for $13 an hour.”
Fired after complaining about working conditions
Nursing homes have struggled for months to provide enough personal protective equipment for employees and COVID-19 tests for both residents and staff members, often getting second priority to hospitals. The impact of the virus has been devastating: According to data collected by NBC News, at least one-third of the 90,000 known coronavirus deaths in the United States are linked to nursing homes and other long-term care facilities.
Some nursing home administrators have sounded the alarm about the lack of protections and have been candid about the outbreaks and shortages at their workplaces. But at other facilities, several workers who spoke to NBC News say their management has been unresponsive to their concerns — in some cases allegedly retaliating against staff members for speaking up, which would violate federal labor law — and has withheld the most basic information about coronavirus cases and deaths.
In late March, Tainika Somerville, a certified nursing aide at another Chicago nursing home, found out in a news article posted on social media that a resident whom she had cared for had died from COVID-19. She hadn’t even realized he was infected.
“You guys failed to tell me I came into contact with the resident, and that I should be tested,” she recalls telling the management of Bridgeview Health Care Center.
On March 31, Somerville, who was the SEIU union steward at the nursing home, and a group of co-workers delivered a petition to management, demanding better staffing, sick leave and hazard pay at the 146-bed facility.
“We are caring for the most vulnerable population while still living in poverty and struggling to take care of ourselves,” Somerville told the facility’s management, according to a video of the encounter. “While you’re sitting at home on your yacht, we’re at Bridgeview.”
Days later, Somerville says she was fired. She said the management told her the reasons included that she had violated the terms of the SEIU’s collective bargaining agreement with the facility, which she denied.
The facility declined to comment on Somerville’s employment, but denied that management had retaliated against employees for raising concerns. “Bridgeview Health Care Center has not disciplined or terminated the employment of any person due to PPE use or COVID-19 concerns in the community,” Martha Peck, the facility’s administrator, said in a statement, adding that the nursing home had adequate PPE for the staff. The nursing home had begun implementing hazard pay the day before Somerville and her colleagues had presented their petition, but did not specify the amount.
Peck acknowledged, however, that the nursing home had been unable to promptly inform staff and families about COVID-19 cases in March. “We were not receiving notification from the hospitals to confirm positive test results to us on our residents. Those early communication issues led to significant confusion and made notification of families and staff of positive cases impossible,” Peck said. “Now we have better access to testing and improved communication with hospitals regarding positive COVID-19 cases.”
Bridgeview has now reported 32 cases and 14 deaths due to the virus, according to the state health department.
'Nobody has these workers’ back’
Federal oversight of these hazardous workplaces is limited. After months of public pressure and mounting deaths, the federal government recently began requiring greater transparency from nursing homes about outbreaks: On May 8, the Centers for Medicare and Medicaid Services implemented new rules requiring facilities to notify federal officials, residents and families about coronavirus infections and deaths.
But the new federal rules do not require nursing homes to inform their own staff members about cases — even though employees have the most direct and potentially dangerous contact with infected residents. And the data reported to the federal government won’t be posted publicly until late May, according to the agency.
CMS said in an email that all nursing homes are required to have infection control plans and "would inherently need to inform staff about cases of COVID-19 in the facility" to implement them effectively. The agency's inspectors are currently focused on infection control and problems that place residents in "immediate jeopardy."
Nursing homes across the country — including Alden Lakeland, where Carter works — say they are following CDC recommendations, as well as that of state and local health departments, regarding proper infection control and PPE inside long-term care facilities.
The American Health Care Association, an industry group representing nursing homes, said that it’s “common practice” for long-term care facilities to notify staff about COVID-19 cases, and the group has issued recommendations for them to do so. But not all facilities are following suit.
And some health and safety experts say the current workplace guidelines aren’t enough, as the CDC does not enforce them: The federal agency that directly oversees the country’s workplaces — the Labor Department’s Occupational Safety and Health Administration — has not made it mandatory for employers to follow the CDC’s recommendations; instead, they only have to meet OSHA’s existing requirement to maintain “a workplace free of recognized hazards likely to cause death or serious physical harm.”
“OSHA has disappeared — nobody has these workers’ back,” said Debbie Berkowitz, a former OSHA official under the Obama administration. “They are not enforcing the CDC guidelines. Employers can follow them or ignore them, and there are no consequences.”
OSHA had received more than 310 complaints about staff exposure to COVID-19 in nursing homes as of April 28, according to a recent NBC News investigation. Only hospitals received more OSHA complaints from employees. The agency also received reports of 47 staff deaths from the coronavirus in nursing homes, as well as 120 whistleblower complaints from nursing home employees since mid-February, the Labor Department said.
Federal worksite enforcement, however, has been limited. OSHA said it is prioritizing inspections of health care facilities where staff members have died, or where they otherwise face “imminent danger exposures related to COVID-19.” Since the beginning of March, OSHA has conducted workplace inspections of 95 nursing homes nationwide due to deaths, hospitalizations, complaints, or referrals from other federal agencies, according to federal records — a tiny fraction of the 7,000 facilities that have reported coronavirus outbreaks, according to data collected by NBC News.
The Labor Department said that additional federal requirements to protect employees were unnecessary. “Under existing OSHA rules and requirements, employers have a duty to protect employees who are exposed to coronavirus at work,” the department said in a statement. “Because of the enforcement authorities already available to it and the fluid nature of this health crisis, OSHA does not believe that a new regulation, or standard, is appropriate at this time.”
There are separate federal inspections focusing on resident health and safety in nursing homes, required and overseen by the Centers for Medicare and Medicaid Services, but their primary focus is on the risks facing residents, not staff. And the number of facilities overwhelmed by COVID-19 is far greater than the agency’s inspection capacity.
‘Something needs to be done’
Months before the coronavirus arrived, Lori F., a registered nurse, had health and safety concerns about the nursing home where she worked as a unit manager. Villa at Bradley Estates, a 198-bed facility in Milwaukee, had been cited in its most recent CMS inspection for failing to implement an infection control program; staff did not properly sanitize glucose meters or handle medications in a sanitary manner, according to the December 2018 report, though many of the violations were characterized as posing “minimal harm or potential for actual harm.” The facility currently has a health inspection score of 1 out of 5 stars — the lowest rating.
The facility was also short-staffed, inspectors found — a longstanding problem in a financially strapped industry with high turnover and work that is both physically and mentally taxing. Then the pandemic made things even worse, as staff became infected or quit because of the risks, according to Lori, who declined to be identified by her full name for fear of retaliation.
By late March, Lori says she became increasingly alarmed as employees were still not given enough gloves and masks, and other infection-control procedures were not followed; some staff members left masks improperly hanging off one ear or around their necks, she said.
“We currently don’t have ANY masks for our new residents or for therapists to use to treat residents in their rooms,” she wrote to her supervisor March 19, according to an email she shared with NBC News.
“Why do we need them?” her supervisor replied. “Are residents infected?”
Three days later, Lori began to feel unwell and stayed home from work for the next two weeks on her doctor’s recommendation, she said. The nursing home’s human resources department wanted her to obtain a doctor’s note, but Lori said her doctor didn’t believe it was necessary to examine her in person. On April 3, Lori got a call telling her that she was fired, she said.
“They wanted to bring somebody else in there who was not going to be blowing the whistle,” Lori said. “I was saying, ‘Something needs to be done.’ I don’t think they liked that I had that voice.”
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Villa Healthcare, which owns the nursing home, denied that the facility had inadequate protective equipment. The federal government recommended on April 2 that all nursing home staff in states with coronavirus emergencies wear masks while in the facilities.
"We welcome the opportunity to investigate any concerns and determine their validity,” the company said in a statement. “Villa at Bradley Estates has at all times had sufficient levels [of] PPE, including those necessary for infection control and personal protection, to ensure that we meet the needs within the center.” The facility did not comment on Lori’s employment or its previous health inspections and score.
Lori doesn’t believe she was infected with COVID-19. But the virus has since spread to a growing number of her former colleagues and patients: As of last Friday, 23 residents living at the facility were diagnosed with the virus or are presumed to be infected, according to data posted by the nursing home, and Lori says she has talked to current staff members who are at home recovering from the virus.
‘Who would take care of the residents?’
Back in Chicago, nursing home staff members have organized to press their employers for better working conditions amid the pandemic: Carter was among the 6,000 members of SEIU who were prepared to strike May 8 for higher pay and safer working conditions.
The Illinois Association of Health Care Facilities reached a tentative deal with the union May 7, averting a strike by workers at 64 nursing homes. The agreement will increase minimum pay to $15 an hour, plus $2 hourly hazard pay because of the coronavirus, and workers will receive additional sick days. Employers will also be banned from forcing employees to work without adequate PPE.
Not all nursing home workers in the state will benefit: In Illinois, only about half are unionized, according to the SEIU. But industry groups are pushing for changes that could help workers as well: They have recently asked the Trump administration for $10 billion to provide nursing homes with additional staffing, PPE and other resources. "Long-term care facilities are facing extreme financial strain in responding to this crisis," AHCA said in a statement. "We need additional help from federal and state officials to support these heroes on the front line."
Even before the union deal was struck, Carter says, he saw some improvements at Alden Lakeland: Employees finally have better gowns, face shields and N95 masks, though they have to wear each mask — meant to be disposable — for two weeks.
And the nursing home is still seriously short-staffed, according to Carter — often there are only two certified nursing aides to handle a floor of 75 to 80 residents, when there should be at least four, he said. “If somebody dies, god forbid, the CNA should be the first one to notice.” Carter continues to challenge his unpaid suspension through the union.
Despite the ongoing risks, Carter says, he is committed to the work.
“I am lucky enough to have a job — there are a lot of people who don’t have a job,” said Carter, who commutes an hour each way by train since his car broke down weeks ago.
And his mind always turns to the residents whom he cares for every day — hearing their stories, putting them to bed, combing their hair — and the family members who have expressed deep gratitude for his work.
“People are scared of nursing homes,” Carter said. “If I had to stop working because of the risks, then who would take care of the residents?”