89°F
weather icon Clear

COVID-19 nursing home patients not isolated — 7 dead, 38 infected

The nursing home resident’s first recorded signs of COVID-19 were subtle: a low-grade fever, accompanied by coughing.

By then it was late March, and staffers at Horizon Health and Rehabilitation Center in Las Vegas should have been on high alert. At least two of their residents had already been hospitalized and tested positive for the respiratory disease caused by the novel coronavirus, emails between public health officials show.

But medical records contained no evidence that the resident’s temperature was taken for five of the six following days. On April 1, a nurse noted that the resident had purple lips and struggled to breathe.

The resident, whose gender and other identifying information have not been made public, died at a local hospital on April 5. A test revealed that the resident had been infected with COVID-19.

Despite having symptoms in line with the disease, Horizon did not isolate the patient from their roommate. The roommate later tested positive too, according to a newly released, 29-page investigative report from the Nevada Department of Health and Human Services.

As COVID-19 ravages nursing homes across the nation, state investigators determined that infection-control deficiencies at Horizon placed the home’s residents in “immediate jeopardy” of serious injury, harm or death from the pandemic.

The 138-bed facility has seen one of the worst outbreaks in Nevada, where coronavirus-related deaths at nursing homes account for about 20 percent of the state’s more than 390 virus-related deaths. The Heights of Summerlin in Las Vegas has reported the most deaths, 26, in the state.

As of Friday, the disease had infected 38 residents at Horizon, killing seven. An additional 37 staff members have contracted the disease, leading health officials to designate Horizon as one of four “high-risk” nursing homes in Nevada.

The most alarming deficiencies include that the nursing home did not follow federal guidelines to isolate patients known or suspected to have COVID-19 in a quarantine wing with designated staffers. Investigators also substantiated a complaint that residents who had been exposed to the disease were moved into rooms with people who hadn’t been exposed, the report states.

“It wouldn’t take long for that disease to spread,” said Christopher Cochran, a UNLV professor who chairs the department of health care administration and policy. “All it takes is one person not to adhere to the guidelines who has interaction with these patients.”

Horizon interim administrator Brett Passon and director of nursing Mark Dinardo did not respond to multiple emails requesting comment for this story.

But according to the state’s investigative report, Horizon officials did not admit to the accuracy of investigators’ findings and claimed that the alleged deficiencies “do not individually and collectively, jeopardize the health and safety of the patients.”

Horizon leadership told investigators that federal guidelines were changing so often that it was unclear what the facility should be doing, according to the report.

Those explanations fell short for Marilyn Clark, whose parents reside at Horizon. Both tested positive for COVID-19 in mid-April, but Clark’s family didn’t find out that the disease had infiltrated the nursing home until her sister read about the outbreak in a news article.

“Management, where are they in this facility?” Clark asked. “What are they doing?”

Clark said both her parents were asymptomatic throughout the disease, but they were placed in separate rooms after state investigators came into the facility. They’ve since been reunited.

Investigation started in April

State investigators arrived at Horizon in early April and immediately began identifying problems, the report shows.

They pieced together their investigation through on-site inspections, residents’ medical records and interviews with 13 staff members, including the facility’s administrator, nursing director and infection control nurse.

They found five cases in which a resident’s roommate had tested positive for COVID-19 but the resident was not moved into another room or unit to be quarantined.

“That’s a pretty serious allegation right there,” Cochran said.

In another violation of infection control protocols, medical records indicated that a resident showing COVID-19 symptoms was “wheeling” around the nursing home, the report states.

Horizon officials said they did not create a quarantine area because moving patients would create “a greater risk of spreading the virus,” the report states. They also said there were too many employees out sick to designate part of the remaining staff to only treating patients in a quarantine wing.

Investigators found that Horizon’s staffers also struggled to obtain the personal protective equipment necessary to perform their duties.

On April 5, a staff member examined a suspected COVID-19 patient from the doorway of their room “because no personal protective equipment was available,” according to Horizon records reviewed by investigators.

Investigators later found that some of Horizon’s medical staffers weren’t trained to properly wear close-fitting N95 masks while treating COVID-19 patients.

Many workers told investigators they were not aware that they had violated infection control protocols, the report states.

Those violations included a staff member’s failure to disinfect a vital sign machine between treating patients.

On another occasion, a worker cleaning a room for “contact isolation” touched her face mask with contaminated gloves and came out four times to get supplies from a cleaning cart without washing her hands.

Investigators also spotted a biohazard bag attached to the railing of a bed occupied by a patient.

Corrective actions

State health officials have directed Horizon to take a number of corrective actions.

The nursing home established a quarantine wing on April 10. Staffers are receiving new training on using protective gear properly, cleaning medical equipment and washing their hands. Infection control practices are also being reviewed.

Horizon will have to monitor its staffers to make sure they’re compliant and report any shortcomings to a state quality assurance committee every month for the next three months.

During its last regular health inspection in December 2019, Horizon received 17 health citations; the state average was about 13. Its health inspection rating is “average,” according to Medicare.gov’s Nursing Home Compare tool.

Clark, whose parents caught COVID-19 at Horizon, said the state’s demands on the facility will make things better only if the watchdogs continue to put pressure on nursing homes.

“When are they going to go back in and make sure the findings are really taken care of?” she asked. “These places house all our seniors, our grandmothers, our grandfathers. Someone needs to do the follow-up and make sure the facilities keep up, even after COVID.”

Contact Michael Scott Davidson at sdavidson@reviewjournal.com or 702-477-3861. Follow @DavidsonLVRJ on Twitter. Contact Briana Erickson at berickson@reviewjournal.com or 702-387-5244. Follow @ByBrianaE on Twitter.

Don't miss the big stories. Like us on Facebook.
Politics Videos
COVID-19 case reported at Legislature's special session - Video
A person who was inside the Nevada Legislature Building has tested positive for the COVID-19 virus, Legislative Counsel Bureau Director Brenda Erdoes said Friday, July 10. (Las Vegas Review-Journal)
Trump Pushing for Reopening Schools and In-Person Learning - Video
Donald Trump launched an effort on Wednesday to reopen schools across the United States with in-person learning.
Special session to tackle $1.2B budget deficit in special session Wednesday - VIDEO
Closing the state’s $1.2 billion budget hole will be the prime focus of the upcoming special legislative session that will convene at 9 a.m. Wednesday in Carson City, according to a proclamation issued by Gov. Steve Sisolak. (James Schaeffer / Las Vegas Review-Journal)
Lawmakers to tackle $1.2B budget deficit in special session Wednesday - VIDEO
Closing the state’s $1.2 billion budget hole will be the prime focus of the upcoming special legislative session that will convene at 9 a.m. Wednesday in Carson City, according to a proclamation issued by Gov. Steve Sisolak. (James Schaeffer / Las Vegas Review-Journal)
Clark County Democratic leaders resign
Several key Clark County Democratic Party leaders have resigned as progressive leadership has swelled in recent months.
Dream Big Nevada celebrates DACA ruling - VIDEO
The U.S. Supreme Court on Thursday rejected President Donald Trump’s effort to end legal protections under DACA for 650,000 young immigrants. Astrid Silva, founder of Dream Big Nevada, discusses the temporary victory and the next step for Dreamers.
Councilwoman Michele Fiore walks out of city council meeting - Video
Las Vegas Councilwoman Michele Fiore walks out of a City Council meeting during public comments.
Mitt Romney marches in Washington, D.C., protest - Video
On Sunday, Republican Sen. Mitt Romney of Utah joined a group of protesters marching through Washington, D.C. (Las Vegas Review-Journal)
Nevada gyms, bars that do not serve food can reopen Friday - VIDEO
Nevada Gov. Steve Sisolak on Tuesday evening said Phase 2 of the state’s Nevada United: Roadmap to Recovery will begin on Friday. (James Schaeffer / Las Vegas Review-Journal)
Nevada Rep. Horsford admits to having affair - VIDEO
Nevada Congressman Steven Horsford admitted to having an affair with Gabriela Linder, a former intern for Sen. Harry Reid. Linder detailed her account of the affair in a podcast she called, "Mistress for Congress." (Heidi Fang/Las Vegas Review-Journal)
Sisolak says businesses will begin reopening under phase 1 - VIDEO
The first phase of reopening Nevada’s businesses will begin Saturday, May 9, Gov. Steve Sisolak said Thursday. (James Schaeffer / Las Vegas Review-Journal)
Joe Biden denies Tara Reade's sexual assault allegation - VIDEO
The former senate aide claims Biden assaulted her in 1993 when he was a senator. Biden first denied the accusations via a public post on Medium. (Las Vegas Review-Journal)
RJ interview with Sisolak on the reopening plan for Nevada - VIDEO
The Las Vegas Review-Journal interviewed Nevada Governor Steve Sisolak on the plan for reopening Nevada during the coronavirus pandemic. (James Schaeffer / Las Vegas Review-Journal)
Sisolak reacts to Goodman CNN interview- VIDEO
Las Vegas Mayor Carolyn Goodman repeated her call to immediately reopen businesses during an interview with CNN’s Anderson Cooper on Wednesday, leading to a reaction from Nevada Governor Steve Sisolak. (James Schaeffer / Las Vegas Review-Journal)
Sisolak praises Nevadans for staying at home, saving lives - VIDEO
Gov. Steve Sisolak said Thursday it’s still too early to know when the state’s COVID-19 shutdown orders could be lifted or when businesses could start to reopen their doors. (James Schaeffer / Las Vegas Review-Journal)
Trump gives governors 3-phase approach to open US - VIDEO
President Donald Trump declared victory in America’s war against the “invisible enemy” as the president’s Coronavirus Task Force released “Opening up America Again” guidelines. (James Schaeffer / Las Vegas Review-Journal)
Trump names Jacky Rosen to task force on reopening economy - VIDEO
President Donald Trump named Sen. Jacky Rosen, D-Nev., to be a member of his Opening Up America Again Congressional Group Thursday to advise him on coronavirus policy. (James Schaeffer / Las Vegas Review-Journal)
Bernie Sanders endorses Joe Biden for president - VIDEO
On April 13, former presidential hopeful Bernie Sanders announced his official endorsement of former Vice President Joe Biden. (Las Vegas Review-Journal)
THE LATEST