Expired surgical masks. Isolation gowns that resemble oversize trash bags. Extra-small gloves that are all but useless for the typical health worker’s hands.
Nursing home employees across the country have been dismayed by what they’ve found when they’ve opened boxes of protective medical gear sent by the federal government, part of a $134 million effort to provide facilities a 14-day supply of equipment considered critical for shielding their vulnerable residents from the coronavirus.
The shipments have included loose gloves of unknown provenance stuffed into unmarked Ziploc bags, surgical masks crafted from underwear fabric and plastic isolation gowns without openings for hands that require users to punch their fists through the closed sleeves. Adhesive tape must be used to secure them.
Health regulators in California have advised nursing homes not to use the gowns, saying they present an infection-control risk, especially when doffing contaminated gowns that must be torn off.
Some nursing homes have received masks with brittle elastic bands that snap when stretched. None of the shipments have included functional N95 respirators, the virus-filtering face masks that are the single most important bulwark against infection.
“People hate to complain about personal protective equipment they’re getting for free but many of these items are just useless,” said Brendan Williams, president of the New Hampshire Health Care Association, which has been fielding a flurry of calls about the defective gear from nursing homes it represents. “It’s mystifying that the government would think this is acceptable.”
The Federal Emergency Management Agency began shipping the masks, gowns and gloves this spring to 15,000 nonprofit nursing care facilities whose limited finances have made it difficult to buy protective equipment on the open market. The first cache of shipments was completed in mid-June, and the second round will wrap up by early August.
In a statement, FEMA said it had addressed the complaints about the first shipment of goods and had asked the private contractor that is providing the supplies to replace the tarp-like gowns with models more familiar to medical personnel. The agency said, however, that the original gowns sent out meet federal and industry standards.
“We have received complaints on less than 1 percent of the total PPE shipments to nursing homes,” the statement said. “We continue to engage with nursing homes to keep lines of communication and feedback open at all times.”
FEMA subsequently acknowledged in an email that the contractor has been sending out a small number of the older gown models.
The controversy over inadequate and low-quality protective equipment has come to embody what public health experts and nursing home executives describe as a halting and haphazard federal effort to protect the 1.5 million Americans who live in nursing homes and long-term care facilities.
More than 40 percent of all coronavirus deaths in the United States have been tied to nursing homes, according to a New York Times analysis, which found that the virus had infected 316,000 people at 14,000 facilities as of July 15. The virus has been particularly lethal to those in their 60s and older, more so for those in poor health, and it can rapidly spread through buildings where residents live in close quarters and workers move from room to room.
“The federal response to protect one of the most vulnerable populations in the country has been a dismal failure,” said Tamara Konetzka, a health economist at the University of Chicago who has been studying the pandemic’s outsize impact on nursing home residents.
The Trump administration’s largely hands-off approach to personal protective equipment, or P.P.E., has forced states, cities and big hospital chains to compete for limited supplies, leaving nursing homes at a disadvantage as prices have soared.
The recent spike in caseloads across the South and the West has reinvigorated calls for President Trump to use his authority and compel domestic manufacturers to produce desperately needed gear.
“We’re extremely disappointed with the government’s response,” said Katie Smith Sloan, the president of LeadingAge, an industry group that represents nonprofit senior service providers. “Folks on the ground are desperately trying to save lives and protect their staff, but we’re leaving them in the dust.”
The crisis is likely to intensify as the virus gains a foothold in nursing homes across the Sun Belt. Infections at long-term care centers in hot-spot states have jumped by 18 percent since late June, according to an analysis by Kaiser Family Foundation. Florida recorded a 51 percent rise, and Texas saw its cases climb by 47 percent.
The federal government has not said whether it plans to provide nursing homes with additional personal protective equipment in the months ahead.
The Centers for Medicaid and Medicare, which oversees nursing homes, earlier this month said it would supply every adult care facility in the country with rapid, point-of-care test kits but the rollout is expected to take months. In the meantime, the vast majority of nursing homes in the United States are unequipped to regularly screen their employees and residents for the coronavirus.
Without widespread testing, health experts say medical-grade gowns, single-use gloves and respirator masks are among the few tools that can protect nursing home residents from devastating outbreaks that often begin with asymptomatic staff members who unknowingly introduce the virus from the surrounding community.
“It’s really mind-boggling and frustrating that five months into this pandemic we still can’t get facilities the P.P.E. they need,” said David C. Grabowski, a professor of health care policy at Harvard Medical School. “I don’t know whether it’s a matter of incompetence or just indifference about older adults and the people who care for them.”
In a call with nursing home providers last month, Col. Brian Kuhn, director of operations at the Defense Logistics Agency, blamed Federal Resources Supply Company, the private contractor that is providing the goods.
The Coronavirus Outbreak ›
Frequently Asked Questions
Updated July 23, 2020
What is school going to look like in September?
- It is unlikely that many schools will return to a normal schedule this fall, requiring the grind of online learning, makeshift child care and stunted workdays to continue. California’s two largest public school districts — Los Angeles and San Diego — said on July 13, that instruction will be remote-only in the fall, citing concerns that surging coronavirus infections in their areas pose too dire a risk for students and teachers. Together, the two districts enroll some 825,000 students. They are the largest in the country so far to abandon plans for even a partial physical return to classrooms when they reopen in August. For other districts, the solution won’t be an all-or-nothing approach. Many systems, including the nation’s largest, New York City, are devising hybrid plans that involve spending some days in classrooms and other days online. There’s no national policy on this yet, so check with your municipal school system regularly to see what is happening in your community.
Is the coronavirus airborne?
- The coronavirus can stay aloft for hours in tiny droplets in stagnant air, infecting people as they inhale, mounting scientific evidence suggests. This risk is highest in crowded indoor spaces with poor ventilation, and may help explain super-spreading events reported in meatpacking plants, churches and restaurants. It’s unclear how often the virus is spread via these tiny droplets, or aerosols, compared with larger droplets that are expelled when a sick person coughs or sneezes, or transmitted through contact with contaminated surfaces, said Linsey Marr, an aerosol expert at Virginia Tech. Aerosols are released even when a person without symptoms exhales, talks or sings, according to Dr. Marr and more than 200 other experts, who have outlined the evidence in an open letter to the World Health Organization.
What are the symptoms of coronavirus?
What’s the best material for a mask?
Does asymptomatic transmission of Covid-19 happen?
- So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
The contract calls for the provision of 1.2 million pairs of protective eyewear, 13 million medical gowns and 66 million pairs of nitrile gloves.
“They just kind of carte blanche shipped them all out,” Col. Kuhn said, according to a recording of the call posted online. He said that the masks made from underwear fabric were not intended to be used by staff members — only by nursing home visitors — and that the expired respirator masks should never been distributed. “It was one of those things, I’ll be honest, that just slipped through the cracks,” he said.
In response to the complaints, FEMA directed the Federal Resources Supply Company to produce an instructional video explaining how the gowns should be donned and doffed. The contents of each shipment are determined by the number of employees at each care center.
Federal Resources, which is based in Stevensville, Md., did not respond to questions sent by email.
In interviews, nursing home executives and employees that have received their second shipments say the contents are an improvement over the first batch but that many problems remain.
Nursing homes in New Hampshire have received face masks with flimsy paper ear loops instead of elastic bands. In Arizona, some facilities have been sent gloves that are either all large sizes or all extra small.
At the Los Angeles Jewish Home, workers were heartened two weeks ago to receive about 1,000 disposable gowns, 187 pairs of eye goggles and 12,000 gloves in a range of sizes. But they were dismayed to also find 2,000 of what employees dismissively referred to as “trash bag gowns.”
“It’s outrageous that they are still sending these gowns,” said Dr. Noah Marco, the chief medical officer of Los Angeles Jewish Home, which has 1,200 beds and 50 employees. “And it’s insulting and inappropriate for the federal government to say we just don’t know how to use them.”
Even nursing homes expressing gratitude for the supplies say they are often mismatched to their needs, while others say the amounts are paltry given how quickly nursing home employees churn through single-use protective gear as they tend to dozens of patients a day.
“If I’m being totally honest, I’d describe these as a token offering,” said Sondra Norden, the chief executive of St. Paul’s Elder Services in Wisconsin. “If we had a major outbreak, we’d burn through these supplies in a few days.”
Virginia Mennonite Retirement Community, a 120-bed nursing home in Harrisonburg, received its second shipment two weeks ago. It contained a mix of gowns — several hundred of the standard and highly coveted isolation gowns and a similar amount of the problematic gowns.
“I’m not sure how we would even use those,” said Jan Emswiler, a nurse educator who trains employees on the proper use of protective gear. She was especially confounded by a packing slip claiming the boxes contained 3,500 pairs of gloves. There were only 1,000 pairs, she said.
“Oh god, even before Covid, we were going through 3,000 pairs in a day,” Ms. Emswiler said. “We appreciate what we’ve gotten but we could really use a lot more.”
As for the gowns without arm holes, Ms. Emswiler said they had been placed in a storage closet.
“I hope we never have to use them,” she said.