By the first and second weeks of April, when positive COVID-19 cases and deaths started to climb at Brighton Rehabilitation and Wellness Center, staff members began refusing to come to work. Or they started getting sick themselves.
Although Brighton owner Comprehensive Healthcare said at the time that there were no staff shortages, employees said dozens of staffers were getting sick and staying home or walking off the job.
Tayler Moore, a former temporary, or “agency,” nursing assistant who worked mostly full time at Brighton from January to July, was one of those who contracted COVID-19 — testing positive right before Easter, April 12.
She was cleared to return to work just over two weeks later, but for weeks afterward, she said, “The exhaustion just does not go away.”
She and Tristan Adams, another former temporary nursing assistant who worked at Brighton for two years till July, both said Brighton has long hired out-of-state agency workers. But after the outbreak began, Brighton had to go farther and farther to find agency workers — primarily from Southern states such as Louisiana, Texas, Alabama and Georgia.
For many of those agency nursing assistants, the pay was higher at Brighton — $15 an hour or more, plus travel stipends — than what they were making down South.
Yet, for many, the outbreak proved too much even for the higher pay.
“People who were up here before COVID started, they were amazing workers,” Ms. Moore said. “But they got scared and went home.”
With so many of the nursing staff either sick or refusing to come to work, at one point in early April Brighton’s managers put out their first request to the state to bring the National Guard in to help staff the building. The state, though, initially rejected the request, until May 11, when it sent 40 troops to Brighton for a week’s worth of work, primarily helping to clean the building.
But before the Guard came to help that week, left to care for the increasing number of sick residents was a staff already diminished years earlier by Comprehensive’s cuts to the full-time, in-house positions, according to annual cost reports filed with the federal government. Those reports detail the number of nursing staff employees and the hours they worked each year, including breaking out the difference between in-house and agency employees.
The company cut licensed practical nurses from 65 to 36 in the same time frame. Nursing assistants — who provide the bulk of care and comfort to residents — were cut from 233 in 2010, to 179 in 2013, to 136 in 2018, though it rose to 170 in 2019.
Even though the building’s population also fell 16% from 2010 to 2018, the overall nursing staff hours — between in-house and agency registered nurses, LPNs and nursing assistants — fell 25% during the same period, meaning fewer people were left to care for residents on a typical day.
Where Comprehensive cut hours the most, though, was among registered nurses. Those are the most highly trained — and expensive — on the nursing staff.
The company cut the number of full-time — or their equivalent — registered nurses in half, from 66 in 2013, the year before it bought the facility, to just 32 in 2018.
“They thought they could have [licensed practical nurses] replace registered nurses. But they don’t have the same training,” said a former Brighton full-time registered nurse. “That was a mistake.”
While Comprehensive worked to increase revenue by attracting more rehabilitation residents, the impact of the cuts on nursing staff helped to decrease expenses significantly — cutting nursing costs from $23.9 million in 2010 to $15.9 million in 2018.
A big part of that was cutting full-time, in-house employees who receive benefits such as insurance and pensions and replacing at least some of their hours with agency employees who don’t get benefits and cost less than full-time staff.
Brighton reversed course a bit in 2018 and 2019 by hiring more full-time and agency staff, pushing nursing expenses up by more than $2 million, to $18 million, in 2019. But total nursing hours in 2019 were still 10% below 2010.
Brighton hires so many people through out-of-town agencies that it began placing them in rooming houses in the area and providing a van service to take them to and from work.
The additional hiring of nursing staff in 2018 came after Brighton was named as a candidate for the federal government’s Special Focus Facilities list, the result of poor performance in state inspections beginning in 2017. The list, compiled annually by the Centers for Medicare and Medicaid Services through recommendations to state inspectors, points out the worst-performing nursing homes in the country.
Brighton declined to respond when asked whether it began hiring more nursing staff in 2018 as a result of being placed on the candidates’ list.
In 2018 and 2019, agency employees covered about 20% of nursing care hours at Brighton, according to cost report data.
Although statewide and national data was unavailable, using so much agency staffing appears to be unusual, at least in Pennsylvania.
Among 12 facilities in the state that have either the most beds or have had the most COVID-19 deaths, only two — Parkhouse Rehabilitation and Nursing Center in Montgomery County (with 16% agency staffing hours) and Spring Creek Rehabilitation and Nursing Center in Dauphin County (with 22%) — have anywhere near the percentage of agency work hours as Brighton. Five of the 12 facilities use no agency staff at all.
“We don’t use agency,” said Katie Roof, vice president of clinical care and quality for Masonic Villages, which includes a nursing home in Elizabethtown, Lancaster County, that is one of the state’s largest, with 453 beds, but which has had no positive COVID-19 cases among residents.
Having a totally in-house staff has helped during the outbreak, she said.
“We can train our own staff. We know our staff care about their jobs, care about the residents,” she said. “And we can keep track of our own staff better instead of with the wildcard of agency staffing” where you might have new temporary workers coming in every day in a large facility.
Having so many agency employees at Brighton caused problems during the pandemic, full-time and agency workers say.
Every week at least some of the dozens of agency workers were new to the building and were not being trained on all of the detailed policies put in place to try to control the spread of COVID-19.
“Oh, no. Nothing. You just get thrown onto the floor and told, ‘Good luck,’” said one agency nursing assistant who asked to remain anonymous.
That problem continued well into the pandemic.
Kenna Witt, an agency nursing assistant from Wisconsin, said she was told by her agency to show up to work at 2 p.m. May 4 to be trained along with other new agency staffers.
“But when I did, [Brighton’s staff] didn’t know what we were doing there,” said Ms. Witt, “and they sent me, instead, to the fourth floor to start working immediately.”
At first, for her 12-hour shift she was sent to work for eight hours in 4E — the dementia unit where the outbreak began — and then spent four more hours working in The Grove, where COVID-19 was later arriving than in other parts of the building. Many residents in The Grove eventually were infected.
“To have quality care, you want to have staff who are trained there by managers who develop a relationship with them,” said Pam Walz, an attorney with Community Legal Services of Philadelphia and an advocate for elder care. “If they are there for short periods of time and only there briefly and don’t know the state requirements, I think it’s going to make it harder for them to work as a team.”
Ms. Witt had originally signed up to work at Brighton for six weeks. But after just one day of “horrific conditions,” she called her agency and said she feared her license would be revoked if she were blamed for obvious violations of regulations. She did not go back.
In her first 18 months of working as a temporary nursing assistant, Ms. Witt said she had worked in 20 different nursing homes.
“I’ve seen a lot of different types of facilities, some of them bad. This was horrible,” she said of Brighton.
Ms. Witt described residents, their rooms and even nonresident areas as filthy and unkempt, with residents wandering around aimlessly and a staff that was exhausted or uninterested, or both.
The floors were so understaffed, she said, that one registered nurse was responsible for three floors during the overnight, 11 p.m. to 7 a.m. shift.
“I saw [staff members] on the floor taking off their masks and gowns while they were on the floor,” a violation of protocols in place at the time, she said. “One of them said, ‘I already had [COVID-19] so why do I need to wear [protective equipment]?’”
When she asked a full-timer why COVID-19 spread so quickly through the facility, she said she was told: “Because the workers floated around the floors.”
“And other aides told me they’re on different floors every shift and won’t work in the same place for a week.”
She said that on the one day she worked at Brighton, at least four state investigators were in the building for what would become a five-day inspection. Those investigators would later report that they found violations so numerous that residents were in “immediate jeopardy.”
She said employees ran around the building that day, May 4, warning staff, “The state is on the way up!” so they could straighten up rooms or hallways and make sure everyone was wearing masks and gowns.
“Because [most of the staff] did not have on their gowns,” she said. “And as soon as the state walked off the floor, they tore them off.”
Department of Health and Human Services Inspection Report
The state’s report from the May 1-5 inspection details some of the same findings that Ms. Witt described to the Post-Gazette before the report was released in late June. Those findings led to a requirement that Brighton re-educate the entire staff on infection prevention protocols, just as it had about two weeks earlier after an April 17 state inspection found similar violations.
For the staff’s part during that May inspection, Ms. Witt said: “They were just upset the state was still there after four days.”
The staff “kept saying the worst is over” with the outbreak, she said. “But there’s just no way, because that place is not going to get any better.”
The pace of deaths would slow after that week. But at least 22 more residents would die over the next five weeks before the 82nd and last known Brighton victim of the outbreak was reported by the state June 10.
Next: State sanctions
Sean D. Hamill
Laura Malt Schneiderman