COVID-19 is ravaging nursing homes throughout the nation, with staggering impact in New Jersey. As of May 4, 508 long term care facilities in New Jersey reported 22,061 confirmed cases, with 4,010 COVID-related deaths, accounting for over half of deaths from coronavirus in the state. The residents, their families and loved ones, and the providers who care for them are all victims of this sweeping pandemic.

The stress and fear of contracting the virus, the 24/7 demands of providing medical and nursing care to very sick nursing facility residents, and adjusting to day-to-day challenges like shortages of personal protective equipment (PPE), testing kits, staff, and inadequate training and monitoring of infection control practices make the jobs of health care providers and support staff more difficult than ever.

To address this problem, public health officials, health care professionals and the public need to understand the complexity of how the coronavirus spreads in nursing homes, where residents are isolated and do not leave the facility. The virus was brought to them—by those who provide their care, family members, or other visitors who were asymptomatic. The current nursing home wave of COVID-19 mortality predominantly stems from the domino effect of not having adequate testing kits and PPE available back in mid-March, as state and local governments directed attention and resources to the hospitals, where they were expecting a surge of COVID-19 patients. Even as everyone acknowledged early on the high risk COVID posed to health-compromised older people, nursing homes were simply not prioritized in response preparation.

For example, the Centers for Disease Control (CDC) criteria early on for testing for COVID-19 included symptoms such as fever, cough and shortness of breath. Yet older patients often have different symptoms, such as low-grade fever, poor appetite, and in some instances, diarrhea or vomiting. Cough and shortness of breath are uncommon, even though their chest X-rays may show evidence of pneumonia.

Nursing home residents who develop undetected COVID-19 infections are more liable to infect each other and nursing home staff. They cannot “socially distance” because they need assistance with daily activities. Some residents with dementia are unable to understand the importance of hand-washing and social distancing and wander, touching everything and further spreading the virus.

And once the members of nursing home support staff become sick, facilities become further understaffed. There are not enough employees to feed residents in each of their own isolated rooms. With staff members delivering individual services, fewer are available to remind residents to drink water. Residents become dehydrated and more compromised, and therefore more vulnerable to the devastating effects of COVID-19.

Physicians and nurse practitioners from New Jersey Institute for Successful Aging at Rowan University School of Osteopathic Medicine have been on the front lines since the beginning of the pandemic, providing care to the most vulnerable elderly in nursing homes, assisted living facilities and their homes throughout Camden, Burlington and Gloucester counties. They work physically and remotely with staff every day, caring for very sick residents, allaying fears, and communicating with families and loved ones.

Our providers try to treat nursing home residents in place at a nursing home rather than in the hospital. If there is a lack of supplies and staff, plus inadequate training and enforcement of infectious disease precautions, residents will decline in health and either need hospitalization or comfort care in the nursing home. The choices are not easy for families. If families choose hospice and comfort care, nursing home residents will die in the facility. If families choose hospitalization, hospitals will become overwhelmed with nursing home patients and start consulting palliative care/hospice services.

Even though the statistics reveal a grim picture, we must acknowledge the tireless efforts of physicians, nurses, nursing assistants, housekeeping, dining services, and other staff in nursing homes who still come in to work double shifts, carrying double the workload. Politicians and other leaders directing our pandemic response should recognize and protect these workers as the front line responders they are, and give them the tools to better care for nursing home residents.

Anita Chopra, MD, FACP, is Professor and William G. Rohrer Endowed Chair in Geriatrics and Director of the New Jersey Institute for Successful Aging.