By nearly any measure, the COVID-19 outbreak at Brighton Rehabilitation and Wellness Center has been one of the most pervasive and deadly in any nursing home in the country.
Whether it’s the total number of positive cases among residents (332 during the outbreak that ended in June) or staff (115), the number of residents’ deaths (82), the percentage of the population that tested positive (72%) or the fatality rate of those who tested positive (25%), Brighton is in rare company.
The number of cases and deaths “certainly puts them up with among the worst in the country,” said Brian Lee, executive director of Families for Better Care, a national nonprofit based in Austin, Texas, that advocates for nursing home residents and their families and researches trends in nursing home care.
He and four nursing home experts contacted by the Pittsburgh Post-Gazette all said that what happened at Brighton was one of the worst outbreaks they’d come across in their nationwide research.
“It’s up there, clearly,” said Nicholas Castle, chairman of West Virginia University’s Department of Health Policy, Management and Leadership, and a former professor at the University of Pittsburgh. “And unfortunately there are one or two facilities like this in every state where something like this occurred.”
Getting a true list of the worst nursing home outbreaks is currently not possible. The Centers for Medicare & Medicaid Services (CMS), which oversees the nation’s nursing homes, did not order them to report cases and deaths until mid-May. By that time, Brighton’s and other nursing homes’ outbreaks were already ebbing. And the list of cases and deaths CMS now has is riddled with errors in reporting, including some nursing homes reporting more deaths than beds in the building, among other errors.
But outbreaks nationwide have received scrutiny from state authorities, the media and researchers, and Brighton’s is among the worst.
Early in the pandemic, Brighton quickly surpassed the bellwether nursing home, Life Care Center in Kirkland, Wash., which had an outbreak in February and early March that stunned the nation — 43 people died there.
And Brighton’s outbreak has been as deadly as those that drew the scrutiny of health authorities in New Jersey: Paramus Veterans Memorial Home, in Paramus, where 81 veterans died, and Andover Subacute and Rehabilitation Center, in Andover, where 83 residents died
Brighton currently has the second-most COVID-19-related deaths of any nursing home in Pennsylvania. The only one with more — Fair Acres Geriatric Center in Delaware County — has recorded 94 deaths. With 745 beds, it is the state’s largest nursing home; Brighton has 589 beds.
Experts on nursing homes say the findings of a Pittsburgh Post-Gazette investigation of what led to Brighton’s outbreak not only seem to be similar to what occurred in other large COVID-19 outbreaks, but they also follow well-known patterns found in pre-pandemic research about nursing homes.
That is true whether it was Brighton’s reliance on a high number of part-time agency staff, or its practice of having staff members work on multiple floors or units, or its ongoing use of quad rooms, or its lack of early steps to prepare for a possible outbreak.
The most consistent point by those researchers is that Brighton’s problems with staffing — cutting registered nurses from the full-time staff, relying on agency staff, having staff move between different floors and units — probably played the largest role.
“More staffing, better educated staffing and more reliable staffing would do better during a pandemic,” said Dr. Rachel Werner, a health care management professor and executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “Staffing is a key component to this.”
Mr. Castle, who has done research on the use of agency staff — temporary employees who work for agencies hired by nursing homes — agrees.
“We do know from our research that if you have a higher percentage of agency staff, quality will decline,” he said. “Part of the reason for that is the agency staff don’t know the residents, they don’t know the policies, they don’t know the procedures, and they aren’t as efficient as a full-time staff member that’s been at the facility for a decent amount of time.”
“And once you eliminate RNs you have problems,” he said. “They’re an important part of a facility. They’re not just pushing paper or filling out forms. They’re often an integral part of what’s going on in a facility.”
Suzanne Meeks, editor-in-chief of The Gerontologist, a journal that explores issues of aging including nursing homes, said that even before the outbreak, “We knew that staffing was a big issue with respect to quality” in nursing homes. “And we know that the virus has wreaked havoc with staffing. The stability of the staffing at a facility may be one of the contributors.”
And other pre-COVID research has shown “pretty clearly that the proportion of staff that are RNs clearly affects the quality of care,” said Ms. Meeks, who is also a professor and director of the Aging and Mental Health Lab at the University of Louisville.
“I can’t imagine that [hiring so many agency staff] didn’t play a role” at Brighton, she said. “Some of them are going to work at more than one facility, so you have cross-contamination there potentially, which is really problematic.”
In addition, Brighton routinely had staffers work different units and floors in the building, not only between different shifts but within shifts, something that “is going to make a big difference” in the quality of care, Ms. Meeks said.
“Even before COVID, crossing units was not seen as a good thing to begin with,” Mr. Castle said. “The preferred practice is called ‘consistent resident assignments,’ where you stay with the same group of residents on all your shifts.”
Not only does letting staff regularly move from unit to unit potentially help spread disease, he said, “If you’re family with the residents, you can detect problems, detect illnesses earlier. It’s something that’s been promoted in nursing homes for some time. The reason some don’t [use consistent resident assignments] is because of critical staffing problems.”
Tamara Konetzka, professor of health services research in the Department of Public Health Sciences at the University of Chicago, said research she and others have done on how COVID-19 affected nursing homes found that staffing played a crucial role.
“Homes with more nurses’ aides had fewer deaths,” she said. “And those with best practices like cohorting and good infection prevention protocols did well, too.”
After Comprehensive Healthcare bought Brighton in 2014, it significantly cut overall nursing staff hours, including among nursing assistants, also known as nursing aides.
Data for 2020 is not yet available, but after continually cutting nursing aides’ hours of work, Brighton did increase their hours in 2018 and 2019, including hiring more in-house, full-time assistants.
Nevertheless, 16% of those nursing aides’ work hours in 2019 were still being provided by agency staffers in a year when 20% of all nursing staff hours — including licensed practical nurse and registered nurse hours — were provided by agency staff.
“When you get to rely on agency staff and the percentage of agency staffing is high — and I’d say 20% agency staff is fairly high — then you are going to have quality issues,” Mr. Castle said.
In addition to problems with staffing, Brighton also had a history of infection prevention violations before the outbreak. And then, three inspections during the outbreak this year found more.
Brighton early on did try to cohort residents, creating a unit to isolate COVID-19-positive residents from those who were not infected. But as the virus spread, Brighton did not continue to cohort residents, families and staff have said, and early in the outbreak declared that it would treat everyone in the building as if they were all infected.
“My guess would be that when it got into all the units, it got away from them,” Mr. Castle said.
There is one factor, researchers say, that early data shows played a large role in which homes had worse outbreaks than others.
“All [the other issues are] dwarfed by the prevalence of positive cases in the area around the nursing home,” Ms. Konetzka said.
Multiple researchers have found that the nursing homes with the highest numbers of cases and deaths tend to be in counties with high numbers of cases and deaths outside the homes.
That’s what makes Brighton’s outbreak somewhat unique.
Early on in the outbreak, the Beaver County area had one of the lowest case counts in the southwestern part of the state if Brighton were removed from the count.
For the first three months of Brighton’s outbreak, the nursing home’s case count represented more than 50% of all cases in Beaver County, and it did not drop below 50% of the county’s cases until the end of June.
It now represents just 13% of the county’s 2,509 positive cases. But Brighton, which at one point represented 91% of Beaver County’s 82 COVID-19-related deaths that had occurred by mid-May, still represented 58% of the county’s 142 deaths as of Nov. 9.
Brighton does “seem to be different [than other nursing homes with large outbreaks] because it wasn’t in such a hot spot,” Ms. Konetzka said, “but it got in there anyway.”
At least 82 residents of Brighton Rehabilitation and Wellness Center died after contracting COVID-19 at the nursing home between March 30 and June 10.
The Post-Gazette has attempted to create as complete a list of those residents as possible, finding and confirming 44 of those people who died during the outbreak.
If you know someone who died of COVID-19 and would like them to be added to this list, please email reporter Sean D. Hamill at firstname.lastname@example.org.
Sean D. Hamill
Laura Malt Schneiderman