How Wisconsin Nursing Homes Violated COVID-19 Safety Rules

The coronavirus pandemic has resulted in the deaths of more than 131,000 nursing home residents nationwide – approximately one-fourth of all U.S. deaths due to COVID-19. Many resident watchdog groups across the country are firmly in agreement that there is insufficient oversight and enforcement of U.S. nursing homes.

To learn more, the Milwaukee Journal Sentinel recently undertook what was reportedly one of the most comprehensive investigations into the safety of Wisconsin’s nursing homes during COVID-19 to date.

PKSD shares the highlights of the article below, along with some of the most glaring failures revealed by this investigation.

Investigation Details

According to the Journal Sentinel, their investigative review analyzed hundreds of both state and federal inspection reports of Wisconsin’s 360 nursing homes from as far back as March 2020 through January 2021. These reports revealed that citations for coronavirus-related violations were issued to 133 of these facilities in all. A number of these nursing homes were cited multiple times.

What Types of Violations Occurred?

The most consistent violation in more than 70 percent of Wisconsin long-term care facilities was for the improper use of personal protective equipment (PPE), including face masks, gowns and gloves. In almost 30 percent of the nursing homes that were issued citations, additional violations included:

• Failure to isolate or quarantine residents
• Failure to isolate or quarantine staff
• Failure to enforce social distancing guidelines

At a facility in Wisconsin’s Northwoods, staff relayed to inspectors how understaffing meant residents were often left to sit in their own urine. Yet despite not having enough staff to care for the existing residents, this facility continued to accept new admissions.

In Tomah, Wisconsin, at the Tomah Nursing and Rehabilitation facility, there were also multiple citations issued. The violations included failing to provide access to masks, gloves and gowns, despite having, according to facility director, Anthony Abela, “a substantial amount of available PPE.”

Several days following the Journal Sentinel’s inquiry, Tomah was again cited for multiple violations, including these:

• Tomah staff delayed sending a COVID-positive resident with low-oxygen levels to the hospital for eight hours – despite the orders of a visiting nurse practitioner. The resident continued to deteriorate and later died.
• A second COVID-positive resident at Tomah, who became dehydrated and developed a severe mouth infection, also died.

Did Facilities Improve Months into the Pandemic?

It seems that facilities did not improve their care management during the pandemic since many of the violations cited happened months after the pandemic began. In fact, two-thirds of the violations were from August 2020 or later. So even when nursing homes were given more access to testing and PPE, they still failed to adhere to even the most basic prevention measures.

Julie Willems Van Dijk – Deputy Secretary for the Wisconsin Department of Health Services – stated that these nursing homes faced “an incredibly difficult situation.”

To help many of the struggling facilities, the Wisconsin Department of Health Services:

• Distributed $105 million in federal relief funds
• Contracted for extra workers with two national staffing agencies
• Helped to expedite emergent training and certification for nursing assistants

Yet violations and other issues at many Wisconsin nursing homes continued, including:

• Inadequate testing and screening of staff and visitors
• Gross understaffing
• Knowingly permitting staff to work before their quarantine period was over – and in other cases allowing symptomatic staff to work as well

John Sauer, president of LeadingAge Wisconsin said, “I don’t want to offer apologies for bad care. I’d rather see a regulatory system that says we’re going to work with these problem facilities and figure out a way to improve quality as opposed to treating all providers as though we’re here to find fault.”

In all, both advocates and industry leaders agree that now, more than ever, is the time to consider how to reform the nursing home industry.

How Did Wisconsin Nursing Homes Compare to Those in Other States?

To compare the challenges of Wisconsin’s long-term care facilities to other nursing homes outside of the state, the Journal Sentinel reviewed facilities in Cook County, Illinois. An analysis of data from March through December 2020 revealed similar findings to those found at Wisconsin facilities: on average, one in three nursing homes had coronavirus-related violations.

At Oak Park Oasis in Chicago, employees not only failed to wear PPE in isolation rooms, but they also neglected to provide adequate monitoring of infected residents. Three patients, who were possibly exposed by these caregivers, later contracted – and died from – the virus. The inspector stated that the failures were so dire, that it qualified as an “immediate jeopardy” situation – meaning, residents were either seriously harmed – or likely to be harmed.

In Maryland, long-term care advocates reported in contrast how the Maryland Baptist Aged Home, which serves mostly low-income Black and Latino residents, reported no outbreak amongst either its residents or staff throughout the pandemic. How did this facility achieve this feat compared to other nursing homes?

According to its administrators, the Maryland Baptist Aged Home locked down early and performed both temperature and oxygen checks three times each day. Additionally, they made sure their staff had adequate supplies of PPE, paid them hazard pay, and tested both staff and residents.

Did Your Family Member Suffer Gross Negligence at a Nursing Home?

At PKSD, our Wisconsin nursing home abuse lawyers are dedicated to protecting our elderly from acts of gross negligence, willful misconduct and abuse. If your loved one suffered harm at his or her nursing home, we are prepared to help.

We have a long and proven track record, recovering millions in compensation for injured victims, including nursing home residents. Find out if you may have a case at no cost to you. While there is no obligation to hire our services, if we represent you, there is nothing to pay us up front or while we work on your case. We only collect payment for our services at the conclusion of the legal process.

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