No Gowns, No Masks, No Gloves: Nursing and At-Home Aides Fall Through Regulatory Cracks

The following article was originally published April 8, 2020, and republished through a collaboration with KPCC and LAist.

Story by Jackie Fortiér

Every day she works in a Los Angeles nursing home, Wesley Chen goes from room to room providing occupational therapy to weak and elderly patients.

She doesn't have a gown or a mask or gloves — all things that would help protect her and her patients from getting and spreading the coronavirus.

"A gown would be nice, because what if somebody coughs? I get their germs on my scrub top, and I go to another patient's room to do a chair transfer," Chen said. "I bring them really close to my body, their shirt is touching my shirt. [Then] I sit them down in a chair. What if they touch their shirt and then they grab a french fry and they put that in their mouth?"

The facility where Chen works has a stockpile of what's known as personal protective equipment, or PPE. But she can't use it, even though she's considered an essential health care worker. That's because the gear is being saved for the expected onslaught of COVID-19 patients that Gov. Gavin Newsom toldCalifornia nursing homes they must take in when those patients are discharged from hospitals.

The scarcity of personal protective equipment and fluctuating regulations have created a maze for home health aides and nursing home workers and administrators to navigate. Chen says it's psychologically difficult to deal with.

"Yesterday I went into work, it was strictly no face masks — the day prior to that was 'face masks are optional.' It's very confusing," she said. "If I could wear personal protective equipment every single day with every single patient, that would be ideal. But that is just a dream."

Without the protection provided by gowns, masks and gloves, Chen is scared she may unknowingly transmit COVID-19 from resident to resident while working.

"Every time we send someone into a patient's room, we're putting that patient at risk and we're also putting that other individual at risk," she said.

REGULATORY BLIND SPOT

After a coronavirus outbreak at a nursing home in Washington state infected more than 80 residents and left 23 people dead, a federal health investigation found that the virus spread rapidly through the facility partially due to underprotected health care workers.

Researchers are also finding that it can take 13 days for someone who is exposed to the coronavirus to develop symptoms, meaning health care workers could be spreading the virus even if they feel healthy.

"Practitioners want to treat patients, but they also want to keep their patients safe. And right now, those are conflicting ideas," said Jennifer Bogenrief, assistant director of regulatory affairs for the American Occupational Therapy Association.

Many therapists like Chen are unable to get highly sought-after personal protective gear. Even if they can get it, Bogenrief said, some are barred from wearing equipment like masks, to keep from frightening patients.

"Some occupational therapy practitioners report being threatened with write-ups or job loss or reduction in hours, even if they provide their own," Bogenrief said. "Some are required to wear the same masks all day with all patients, some aren't given any personal protective equipment at all."

Currently, both California and federal guidelines say if you're a health care worker treating COVID-19 patients or suspected patients, you need PPE, including goggles, face masks, gowns and gloves.

But health workers like Chen fall into a regulatory blind spot, Bogenrief said, because there aren't any known coronavirus cases in the nursing home where she works.

"There are no clear guidelines for providers in areas with no known community spread, even though we now know the virus can spread undetected for weeks," Bogenrief said.

Current regulations from the state health department only mandate personal protective gear when a case has been found, but not as a preventative measure. When reached for comment, California health regulators said that they are following Centers for Disease Control and Prevention guidelines and that nursing home workers are required to follow infection control guidelines irrespective of the ongoing pandemic.

SHOULD THERAPISTS KEEP WORKING?

Teresa Teng, an occupational therapist who visits patients in their homes in L.A., felt an ethical dilemma when the coronavirus outbreak hit.

"I'm required to buy my own masks, gloves, and gowns if they are needed," Teng, who's an independent contractor, said. "If I did want to wear personal protective gear, I didn't have the resources to sustain my client caseload, and there weren't any places to buy them."

Teng decided it wasn't worth the risk. She stopped providing therapy to her elderly clients in March.

"It's been a relief for me not to have the fear that I'm transmitting the disease communally. And for a lot of my clients, when I did call them to let them know, they all sounded relieved at the moment."

Not working isn't an option for many health workers, including Chen, the nursing home therapist. She can't afford it. And she's afraid her patients' health would decline without her care, potentially making them even more vulnerable to COVID-19.

"With this lack of interaction, a lot of these individuals are not getting out of bed anymore, they're not sitting up as they would normally. That's going to take a toll on their body, on their muscles on their lungs, on their breathing," Chen said.

Even without the personal protective gear she wishes she had, Chen said she'll keep working — and just wash her hands as often as possible.

"My idea is to keep their body in tip-top shape, so that whatever comes, they can try to fight it as best as they can," she said.

Correction: A previous version of this story misspelled Teresa Teng's last name. LAist regrets the error.