'Tired, burned out, frustrated': Omicron surge hits nursing homes as vaccine mandate looms

Coronavirus cases in nursing homes have spiked far above last winter’s surge as the highly contagious omicron variant poses a renewed threat to vulnerable older Americans.

Data from the Centers for Disease Control and Prevention show 41,511 COVID-19 cases among nursing home residents through the week ending Jan. 16, far above any week during last winter’s surge. Cases among nurses and other staffers doubled the previous peak in December 2020, straining already depleted staffing levels.

And while deaths in nursing homes remain far below the surges that killed tens of thousands of residents in the spring and winter of 2020 before the COVID-19 vaccines were widely distributed, the numbers have started to climb again. The 988 nursing home residents with COVID-19 who died the week of Jan. 16 were more than double the weekly toll from a month ago, even as they were six times lower than last winter's deadliest peak, one week before Christmas 2020.

The alarming rise in cases highlights the need for sustained vigilance to immunize and boost nursing home residents and staff, experts say. Yet nursing home officials fear strict enforcement of the Biden administration's vaccine mandate for health facilities could exacerbate staffing problems at homes in communities with low vaccination rates.

Edward Williams, 62, a resident at the Hebrew Home at Riverdale, N.Y., receives a COVID-19 booster shot.

Health care facilities have struggled to keep workers and replace those who’ve left because of burnout or to pursue new careers. 

The resignations have created a staffing gap at nursing homes. The nursing home industry has lost 230,000 workers since the start of the pandemic, according to an American Health Care Association and National Center for Assisted Living analysis of Bureau of Labor Statistics data.

“We’re definitely pro-vaccine,” said Mark Parkinson, president and CEO of AHCA and NCAL. In “some parts of the country that are so hesitant to the vaccine, we're worried about staffing problems.”

The agency that oversees Medicare said nursing homes in 25 states must be fully vaccinated or have a qualifying medical or religious exemption by Feb. 28. Nursing homes in two dozen other states that unsuccessfully fought the mandate in a Supreme Court case have until March 15 to immunize workers.

For homes that don't comply, state inspectors who conduct surveys could assess penalties such as requiring a plan of correction, civil fines or denying Medicare or Medicaid payments. 

'A tough, tough situation'

Like the nation overall, efforts to vaccinate nursing home residents and staff have yielded mixed results. About 87% of nursing home residents are vaccinated, and 81% of home employees are vaccinated, according to the Centers for Medicare and Medicaid Services. Booster rates are lower.

More:'The public has not listened': Nursing home cases surge to all-time high as COVID-19 sweeps US

While breakthrough infections among the vaccinated are common with omicron, the vaccine protects people from severe illness, hospitalization and death. That’s why the surge has been less deadly than earlier surges that swept from room to room and bed to bed, sickening vulnerable nursing home residents, said Dr. David Nace, a University of Pittsburgh professor of medicine and nursing home expert. 

"There are clearly more cases (now), there are more outbreaks," said Nace. "Our data very clearly shows us that even with all these cases and everything going up, the vaccines are working because people are doing much better when vaccinated."

In states with higher rates of unvaccinated workers, nursing home operators are working frantically to close the immunization gap before the mandate for nursing homes and other health facilities that serve Medicare and Medicaid patients takes effect. The U.S. Supreme Court rejected the Biden administration’s vaccine requirement for private employers, but the high court upheld the mandate for millions of health care workers.

Jill Herron is the administrator for the 99-bed Welcome Nursing Home in Oberlin, Ohio, an independent facility started by her grandparents decades ago. 

Nearly all patients are fully vaccinated at the Northeast Ohio facility, but about one-third of her staff refuses the shot. That's true across many homes in the Buckeye State, where 67% of nursing home employees are vaccinated. Only Missouri has a lower rate of vaccinated nursing home workers, according to the Centers for Medicare and Medicaid Services.

Welcome Nursing Home has informed staffers about the vaccine's benefits and plans another immunization clinic next week. 

Herron said the vaccines proved effective during the omicron surge. Vaccinated patients had mild cases and recovered quickly. None required oxygen.

But those breakthrough infections among vaccinated residents feed skepticism among workers who are reluctant to get the shot.

Herron believes more staffers will agree to be immunized before the March 15 deadline, while others will qualify for medical and religious exemptions. But a handful of workers who don't qualify for exemptions may refuse the shot.  

"I wish that everybody would get it," Herron said. "But I also have to staff my building. It's a tough, tough situation."

Nursing homes across the state face similar challenges, said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents nursing homes, assisted living communities, home care and hospice providers.

" A lot of people in Ohio are very anti-vaccine," Van Runkle said. "It's really a cultural divide, mostly our rural areas."

The nursing home staff shortage that existed before the pandemic has only worsened now as lower-wage workers reassess careers or pursue contract jobs through staffing agencies that charge lucrative fees to place workers at nursing homes and other health facilities. A home that pays a nursing assistant employee $15 an hour must pay a staffing agency $40 or more an hour to hire a contract worker for the same position, Van Runkle said.

More:Stressed hospitals, weary nurses brace for another COVID-19 winter surge

The federal government has sent hundreds of billions of dollars to states in COVID-19 relief packages such as the American Rescue Plan Act. In Ohio, lawmakers authorized $300 million for nursing facilities to increase wages for workers and address staffing shortages, according to the Columbus Dispatch, part of the USA TODAY Network. 

Nursing home operators worry that if more staffers quit because of the vaccine mandate, they won't be able to care for as many patients. Some operators might decide the staffing and financial challenges are too steep to keep their facilities open, Van Runkle said.

'Emotional breaking point'

Even homes with fully vaccinated staffs can experience outbreaks.

That was the case at Webster at Rye, a small nonprofit home in New Hampshire that avoided an outbreak for more than 600 days since the beginning of the pandemic. But the virus swept through the home in November, infecting 32 residents and nearly 20 staffers. Six residents died.

Webster at Rye Administrator Todd Fernald said his staff was meticulous about protecting residents and themselves by wearing protective gear such as N95 masks, face shields, goggles, gloves and gowns. And all staffers and residents were vaccinated at the time of the outbreak but had not yet received boosters. The home had scheduled a booster clinic the day the outbreak began. Last week, the CDC released studies showing booster doses were 90% effective at keeping people infected with omicron out of the hospital. 

The fast-moving outbreak levied a heavy toll on his staff, Fernald said.

“I've never seen the staff at the emotional breaking point that they were during that outbreak,” Fernald said.

He does not know how the virus entered the building. But he said it arrived after the Centers for Medicare and Medicaid Services relaxed guidelines to allow visitors, who are required only to wear a mask.

He said homes are unable to restrict such visitors, but it creates risk for vulnerable residents, especially now as omicron spreads.

As in other nursing homes, Fernald said, his staff feels the sustained burden of the pandemic.

“They’re tired, burned out, frustrated with just having to deal with the constant battle of COVID,” Fernald said.

Ken Alltucker is on Twitter at @kalltucker, or can be emailed at alltuck@usatoday.com