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Quality in Nursing Center Care

A blog for and about The Joint Commission’s Nursing Care Center Accreditation Program.

Winning Practices as COVID-19 Evolves in Nursing Homes


A nurse and an old man who sits in a wheelchair strolling in the park at sunset

By Sandra Carey, RN, BSN, MBA, CPHQ

In the early days of the COVID-19 pandemic, nursing homes were hit hard. The patient population was among the most vulnerable and staff found themselves scrambling to keep residents safe, despite isolation measures.

In April, Joint Commission Nursing Care Center Executive Director Gina Zimmermann blogged about her concerns that COVID-19 precautions “go against everything we’ve been taught about avoiding loneliness in nursing home settings.” Since then, the months have worn on and family visits have been phased back in with precautions, easing some residents’ isolation. 

I’ve been so impressed with the creativity of many of our accredited nursing homes during this difficult time. In a matter of weeks, so many organizations changed their entire practice models. The Nursing Care Center organizations I’ve surveyed have inspired me and some of their innovative ideas could easily be replicated in other nursing homes. Below are some highlights on the ingenious ways staff are finding workarounds during this difficult time.

Family Visitations
As I mentioned earlier, family members are now starting to be allowed to visit nursing homes residents again, per guidance from the Centers for Medicare and Medicaid Services (CMS). It’s been a great joy to see residents reunite with their loved ones after many long weeks apart.

There are certainly still risks involved with family visits. One organization I recently surveyed is using its now-shuttered dining room for family visits. The visiting relative can make an appointment to visit their loved one after presenting a negative COVID-19 test. They must still complete a written screen and have their temperature taken before entrance is allowed. They must also be socially distanced Also, visitation is usually limited to one or two family members.

Another best practice is to educate the family members on proper hand washing (the organizations can use their hand washing competency form for this). This way, the organization can be assured the family members wash their hands correctly before entering the organization and coming in contact with their loved ones. 

Limiting food sharing between families remains a good idea at this point. One accredited nursing care center organization is allowing food prepared and packaged by a restaurant to be brought to residents by family members, but nothing from a home kitchen. Similarly, many nursing homes have moved laundry services in-house to avoid bringing anything contaminated from private homes into the facility.

Another organization posts room numbers on the resident’s windows facing outward. This way, families can visit their loved ones who are outside by simply speaking with them on their cell phones through the windows.

Contact Tracing
CMS has largely left contact tracing responsibilities to  health care organizations or local authorities. It can be an overwhelming undertaking, especially when dealing with such a vulnerable resident population.

One of the simplest solutions I’ve seen streamlines the contact tracing process  – a nursing home placed a sheet of paper inside a plastic wrap and secured it to each patient’s door. Staff members and any visitors sign the sheet before entering the room each time. Administration stores the sheets for 14 days and can easily coact trace who has been in the room, if a patient should test positive. Simple yet brilliant!

Two-Week Holding Units
Positive cases of COVID-19 have been associated with new admissions and/or transfers from hospitals. It would be a lot easier if there were a COVID-19 Care Pathway through the INTERACT System, (Interventions to Reduce Acute Care Transfers) )  a quality improvement program that focuses on the management of acute change in resident condition. that’s used by most nursing homes and is designed to decrease the number of patients returning to hospitals. This tool outlines symptoms and prompts nurses to ask doctors about specific in-house interventions before entering orders to return to the hospital.

Right now, this doesn’t exist and the majority of patients who test positive for COVID-19 are sent to a hospital, although they don’t need to be. This back-and-forth between hospitals and nursing homes only increases the spread of infection.

One organization developed a specialized isolation unit for those higher risk patients moving between facilities. Within the nursing home, they receive the same care as other residents, just from a different location. Since there are no group activities or dining at this time, the two-week holding unit reduces co-mingling without removing any further social interaction. The dedicated staff from this unit receive specialized COVID-19ovid training before reporting to work in the unit.

COVID-19 Monitors
Safety precautions are as important as contact tracing. Staff members have really stepped up to learn the necessary protocols for hand washing, personal protective equipment (PPE), etc. However, it takes practice to implement them perfectly, especially when it’s busy on the floor.

One nursing home I surveyed hired a “COVID-19 monitor.” This individual is specially trained to spend the entire shift on the floor, making sure staff, visitors and family are following PPE protocols and are signing their name when entering patient rooms. 

This role was a new hire, however many organizations don’t have the resources to take on extra staff right now. The results were positive so it’s a great option if financial resources allow. Existing staff have really been flexible about learning from the COVID-19 monitor to keep residents as safe as possible.

COVID-19 monitors can also be used to educate and practice good hand hygiene in one to one activities with all the the residents in the organization using the organization’s hand hygiene competency audit tools. Most organizations post hand hygiene signs for all to read, but these one to one competencies are an active way to teach the residents about proper hand hygiene.

Disaster Drills
The absolute last thing any health care organization needs is a disaster in 2020, but we must always be prepared. I’m based in Florida and it’s already been an active hurricane year. Nursing Care Center organizations are required to perform one internal and one external disaster drill yearly.

There’s a lot of discussion on how the drills need to be modified for COVID-19. For instance, residents are often evacuated to a separate building in a hurricane. Because of the pandemic risk, organizations are struggling with the need to secure two buses—one for COVID-19 positive residents and the other for non-infected residents.

All of these are valid questions and the best piece of advice I can offer is conducting disaster drills for residents with COVID-19 only. We already know how to evacuate residents from years of drills. Having an isolated specialty unit is a new concept and should be one of the focuses of your drills for 2020.

As we complete more after-action reports, I’m confident there will be more creative and successful practices that have protected residents during COVID-19 and in other types of disasters. While these tips aren’t all encompassing, I hope they provide a starting point.

I’d love to hear about any winning practices you developed for your nursing care center during this time. Please share in the comments!

Sandra G. Carey MBA, BSN, RN, CPHQ, surveys the standards in the
Comprehensive Accreditation Manual/Accreditation Manual for long term care. Prior to joining the Joint Commission, Carey was a regional director of Clinical Services in Florida. Her last three positions were chief nursing officer, director of quality and risk management, director of quality review, education and quality improvement, and director of nursing. She was also a state surveyor and quality of care monitor in Florida (AHCA) surveying a variety of health care organizations.