Health officials deflecting criticism for outbreak at Rowan County nursing home

An emergency room doctor at a local hospital is saying the facility and health officials “failed” to respond to the crisis appropriately, and families deserve to know the truth and deserve closure.

Rowan County Health Department officials fired back at those claims Tuesday, releasing a statement saying they've done their part to help control the outbreak.

“My hat's off to the doctor,” said Ronald Barber. “Stand up for what's right. God bless him.”

Barber’s great aunt, Dorothy Cleveland, died in the facility last week. He read the letter written by that ER doctor at Novant Rowan and published in the Salisbury Post.

That doctor, Dr. John Bream, criticized the Citadel and the Rowan County Health Department, saying residents with COVID-19 started coming to the hospital, but there was “no communication from the Rowan County Health Department or Citadel."

Bream claimed a team from the hospital had to engage them, "imploring a more aggressive response."

He also said family members of some patients were unaware of the outbreak and didn't know their loved ones were infected.

Barber told Channel 9 nobody told him about the outbreak either. No one at the Citadel even called him to tell him his great aunt had died.

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It's still unclear if she had COVID-19.

“Citadel needs to clean their act up,” he said.

But Rowan County's Health Department fired back on Tuesday, saying Bream’s frustration is misdirected.

They said the health department identified the Citadel's first case on April 7 and talked to the facility about infection control measures and containment.

On April 8, they said they got word of another case and reported the Citadel outbreak to the North Carolina Division of Public Health.

On April 9, they said Novant Health donated specimen collection kits to the Citadel to test residents. Two days later, on April 11, the health department delivered those specimens to the North Carolina state lab in Raleigh.

On April 13, they got the test results back and delivered them to Citadel staff. At that point, they said the Citadel promised to notify families.

Novant Health told Channel 9 doctors are entitled to have an opinion and that Bream has not resigned or been released from his position. Here is a statement from a Novant Health spokesperson:

This was an opinion editorial and team members and physicians are entitled to have one; however, the facts support that Novant Health took immediate and supportive action the moment a potential outbreak at the Citadel was discovered. This included daily communication with local health officials and sustained contact with local and national leaders of the Citadel. In addition to consultation and clinical guidance, necessary testing supplies were also offered. Novant Health will continue to work collaboratively and in lockstep with the Rowan County Health Department, the Citadel and other long-term care facilities in our COVID-19 response.

Channel 9 reached out to the CEO of the Citadel’s parent company about the claims.

Below is the statement sent to Eyewitness News from Accordius Health CEO Kim Morrow.

Is this a time for criticism or support? Or have we (nursing homes) been forgotten as stated by Mark Parkinson in his statement on April 10th in McKnights Long Term Care news. Weeks before guidance was mandated we put measures into place; but once this dreadful disease made its way into the doors it was too late. The heroic staff that are still brave enough to come to work; do that and they are the super humans. We appreciate and honor our staff who stand up and deliver good care because they care.

Accordius Health stands committed to our core values; two of them being integrity and honesty. We will always be truthful with those we serve; residents, families, employees and community.

Of course there is a lot of fear and anxiety out there; how could there not be when we are dealing with the unprecedented threat from the novel coronavirus. We care deeply for what we do. Our staff of caregivers are scared by what they read about the place they love and believe strongly in. Our staff are committed and are working tirelessly to meet all resident care needs.

In early April, two residents had transferred to the hospital with what were exacerbations of underlying medical conditions. Their family members were notified of their transfer. It is typical that the hospital will be the one reporting findings and updates to the family. Our role was to inform all families that there was a positive and then to notify all families of the status of their loved one.

The center actually found out those residents were tested and were positive when checking on the condition of our residents in preparation for readmission. Additionally, it was around this time that we were informed that a contract healthcare worker had tested positive.

Since the first week of March we were monitoring our residents for COVID 19 symptoms (fever, cough and shortness of breath) based on CDC guidelines and our local healthcare provider guidance.

In retrospect the virus had already started to spread within the center. By now, there is an ever broadening range of symptoms and new symptoms as scientific, anecdotal and community standards have evolved and continue to evolve.

Early in April, the center reached out to the Health Department and its hospital partners continued to have regular discussion with the hospital.

Per the CDC guidelines we had implemented mandatory masking on 4/2/20. We have always provided the PPE necessary to keep our staff and residents safe and well, often ahead of CDC recommendations.

What is happening at The Citadel Salisbury is heart-wrenching for any of us who work in long term care. We are grateful for the Health Department and our partners at Novant. That is the collaborative, community, population health, “for the greater good” plan that we worked on so hard for 6 weeks before this pandemic started.

Accordius has received text messages from many of our partners at the hospital who tell us “we all don’t feel the way Dr. Bream does.” I have welcomed all communications from our community health partners and would have appreciated hearing from Dr. Bream before just now.

We are not asking to be treated like heroes like hospital staff across the nation just for the right to exist without being vilified.

Rowan County Public Health Response To Outbreak at The Citadel:

Admittedly, COVID-19 has brought many challenges to everyone throughout the United States. Here in Rowan County, NC we have the good fortune of having excellent leadership in the Medical Community. Gary Blabon, President of Novant Hospital Administration has been with us every step of the way during this crisis. Novant Health Rowan has been especially supportive and has offered supplies, resources and physician expertise to the County, and specifically regarding the Citadel. Under Gary’s leadership, the community has two amazing experts, Dr. Tom Trahey, Chief Medical Officer of Novant Rowan and Dr. Yomi Agbebi, Lead Infectious Disease Physician of Novant Rowan. They have worked tirelessly to provide assistance to Rowan County Health Department (RCHD) in developing treatment plans and care protocols for the skilled nursing facility. We will continue to collaborate with the professional expert advice provided by Drs. Trahey and Agbebi. While we appreciate Dr. John Bream’s passion and concern, the frustration expressed in his letter is misdirected.

Rowan County Health Department and Novant Rowan responded quickly to positive case information received from the official North Carolina State reporting system. We then worked with the facility and Novant Health Rowan to perform testing within 24 hours and implement on-site plans for containment. Our personnel then hand-delivered the tests to the state testing facility in Raleigh and received results according the highest priority timeframe.

As with any outbreak, The Health Department conducts extensive case investigation. According to the Centers for Disease Prevention and Control (CDC), given their congregate nature and pre-existing risk population (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at the highest risk of being affected by COVID-19. RCHD responded urgently to test and set on-site standards for containment.

The Rowan County Health Department’s primary authority includes investigating and tracing potential community spread and assisting the facility with implementation of plans to limit on-site spread. RCHD is not permitted to contact family members of those who test positive for COVID-19 if there is no risk of exposure. Patients at long term care facilities are not patients of RCHD, and our response is to notify the patient or facility where the patient resides.

In this case, RCHD relies upon the long term care facility to communicate patient status to those family members who are entitled to receive status updates. Immediately upon notifying the Citadel of the risk of an outbreak, The Citadel agreed to follow CDC and NC Department of Health and Human Service guidance as it was issued.

Rowan County organized multiple daily calls with the Citadel Administration and Novant that included extensive guidance on appropriate disinfection, appropriate need for and use of Personal Protective Equipment (PPE), accessing PPE, accessing testing supplies, testing for residents and staff, infection control measures, and investigation information.

Below is a recent timeline of factual events:

4/7/20: First Citadel case identified by the Rowan County Health Department (RCHD). RCHD had a preliminary discussion with Citadel Administration regarding infection control measures, containment, and prevention.

4/8/20: Received confirmation of additional positive cases at the Citadel. RCHD identified and reported the Citadel outbreak to the NC Division of Public Health as required by law.

4/8/20: RCHD had a conference call with Dr. John Bream to discuss Citadel situation per Dr. Bream’s request.

4/9/20: Conference call between Novant Health Rowan, Citadel, and RCHD. A RCHD Communicable Disease Nurse conducted a site visit at the Citadel. Novant donated specimen collection kits to Citadel to complete resident testing.

4/10/20: Conference call between Novant Health Rowan, Citadel, and RCHD to discuss situation progression. The RCHD received Citadel resident specimens at approximately 8:45 pm.

4/11/20: RCHD packaged resident specimens and Emergency Management delivered specimens to NC State Lab in Raleigh. We received testing supplies from State to facilitate testing Citadel staff.

4/13/20: RCHD received test results and sent to Citadel Administration (approximately 12:00pm EST) and coordinated investigation process with Citadel Administration. Conference call between Novant, Citadel, and Health Department took place, Citadel Administration conveyed that they started the process of notifying families, continued the discussion regarding infection control measures, containment, and prevention and 21 specimen collection kits given to the Citadel for testing of staff.

4/14/20: Emergency Management worked with Citadel Administration to order necessary supplies. Citadel Administration conveyed that they continued the process of notifying families, RCHD Communicable Disease nurse and Environmental Health Specialist conducted a second site visit.

4/15/20: Conference call between Novant Health Rowan, Citadel, and RCHD took place. Citadel conducting staff testing - 21 additional specimen collection kits given for testing of staff. Continued the discussion regarding infection control measures, containment, and prevention.

4/16/20: RCHD had a conference call with the State Outbreak Coordination Team.

4/17/20: Began to receive staff test results from State Lab; RCHD began staff investigations and interviews.

4/18/20: Received additional staff test results; continued staff investigation and interviews.

4/19/20: Discussion with Citadel Administration regarding status of residents and staff management.

4/20/20: Conference call between Novant Health Rowan, Citadel, and RCHD. Continued the discussion regarding infection control measures, containment, and prevention.

Rowan County Health Department will continue to work in collaboration with Novant Hospital in compliance with all State and Federal rules, regulations and laws.

Nina Oliver, Public Health Director

Nursing home with more than 100 cases says it’s doing everything it can to protect residents

Local nursing homes and assisted living facilities are dealing with outbreaks of COVID-19 and this includes the Citadel in Salisbury.

There are at least 102 confirmed cases at the facility.

Over the last few weeks, families have told Channel 9 they have concerns because the nursing facility never alerted them to the outbreak. Now, the Citadel has responded to these complaints and we have obtained a letter sent to residents.

The parent company of the Citadel, Accordius Health, sent a letter to families asking for help keeping residents as safe as possible.

“It was like a freight train,” CEO Kim Morrow said. "We literally went from one case to 50 in 72 hours. No one did anything wrong to create this."

Morrow told Channel 9 they learned about the first case at the Citadel April 1.

She, at that time, employees began wearing full PPE, notified families and worked out a plan with the health department to test everyone.

Employees said they complained for weeks the facility started using the gear too late.

Some families have told Channel 9 they had no idea there was an outbreak at the facility until they saw it on the news.

In the letter from the parent company, leaders said “In certain centers, the virus attacked so fast and so aggressively that we didn’t have time to speak with you before you heard it through the media.”

The CEO said cases didn’t increase because people were newly exposed to the virus but because testing became available to nursing homes late.

Last week, a local man told Channel 9 his great aunt died inside the Citadel and no one ever told him that she died.

Ronald Barber said instead, he found out 24 hours later when a funeral home director called him.

“Mr. Alexander said, ‘Ron are you going to come make this appointment?’ I said, ‘Make an appointment?’ He said, ‘Did they not tell you Ms. Cleveland passed away?’ I said, ‘No, sir. Nobody called or anything,’" said Barber.

His aunt had recently moved to hospice care within the facility. Now, he wonders if she was one of the 102 patients who tested positive for COVID-19. He said the facility never let him know about the outbreak but he found out by watching the news.

“I had no idea it was gonna mushroom like that,” said Barber.

He said he wishes the facility had done more to let him know his aunt was nearing death and he wishes she could have said goodbye, even just by phone.

"It’s bad enough she had to pass on her own, by herself,” Barber said. “I just wanted to tell her that I’ll see her again in heaven one of these old days.”

The CEO sent a statement Monday saying in part: “We have spoken with the family member that you have previously interviewed. We grieve with this family, and we are carefully reviewing our procedures in light of this situation”

Full Statement:

Dear Residents, Families, Friends:

We all remain committed to keeping our residents as safe as possible and we need your continued help. That may be difficult to ask of you or even believe for some of you because in certain centers the virus attacked so fast and so aggressively that we didn’t have time to speak with you before you heard it through the media. I am sorry. I am sorry that this is happening. I am sorry that nursing homes are being vilified by the media when our one and only purpose is to serve, love and care for those who can no longer care for themselves. This is not a job that we choose; yet it is our answer to a calling so unique, personal and rewarding that those not in our space just cannot understand “why we do that kind of work.” We become the second family to many residents and form a bond that is special for both of us. We minister to the lonely, abandoned, infirm and too often spend the last days, hours or minutes with people before they die; an experience that every time leaves lasting marks on our hearts, reaffirms our commitment to our purpose to serve with human kindness and eases the guilt of family who just couldn’t be there. Stories of our people, their lifetime commitments to long term care is not being praised or even recognized by the public during this pandemic; meanwhile they continue to come to the nursing home and care for our nation’s greatest generation and most vulnerable population.

The virus causing Coronavirus Disease 2019 (abbreviated COVID-19) causes outbreaks in nursing homes mainly because of the proximity of resident living and the close contact required during resident care. Many of our residents are elderly and most have medical conditions putting them at high risk of becoming sick, severely ill, or even die with COVID-19. Visitors and healthcare personnel are the most likely sources of introduction of the virus that causes COVID-19 into a facility. No one really knows how long this virus has been on its attack in the US. No one really knows how it is transmitted – droplets or airborne. No one really knows why 60% of persons who test positive don’t know they even have it.

Family members, residents, friends, all skilled nursing companies across the country, including Accordius, share the bewilderment of hearing there are no cases in the center to 5, 10, 20, 50 all within 24 to 48 to 72 hours. Cases are not popping up because residents are newly exposed to the virus; cases are just now being identified and confirmed by testing; which is finally available to nursing homes. Numbers are not increasing because we are not cleaning, or because we are not wearing PPE, or because “one-time last year a staff member didn’t change their gloves” as reported by a local news story found in a state survey done prior to Accordius ownership. Pressure at the state and national level has Departments of

Health taking a more proactive approach to identifying if and where the virus exists in our communities and nursing homes. In early March there were simply no test kits available and if there was, results from labs were taking anywhere from 11-14 days to come back. Hospitals and nursing homes had to partner on screening tools for patients to determine the risk of “having it” or “not having it” before they could be transferred. We will continue to see numbers and statistics released based on these new testing strategies throughout the summer. There is no date or projected timeframe to tell when this pandemic will end. Along with diligent work every day, I pray. I pray for our people; your people and everyone impacted by this global health event. The magnitude of impact on unemployment, healthcare, the economy all our lives is beyond profound.

Some of our resident’s exhibit symptoms, many do not. Our approach to resident care has mirrored the community standard for care and that is symptom management. There is no cure for COVID-19. Our teams including our medical directors and attending physicians have stayed up to date on the guidance from the World Health Organization, CMS, AMDA, AHCA and other resources. Approaches have and continue to change day to day and hour by hour.

What did we do to plan? Early on I began meeting with our community hospital systems and many medical directors to scenario plan the projected healthcare needs in our major and smaller communities. Hospitals could exceed their capacity by 150% so they secured partnerships with nursing homes where they could discharge patients that needed a place to recover or be in quarantine leaving space in the hospital for those who were really sick. We developed an Accordius task force. COVID19taskforce@accordiushealth.com. Our group would go on to review policy and procedures and pandemic plans; pathways for care and infection control measures based on the CDC, CMS, SPICE guidance. We had to review our processes for everything; enhanced isolation; staff screening tools; medical equipment and the list goes on.

To continue to protect our vulnerable residents, we are following these actions to reduce the risk of COVID-19 in our residents and staff:

We are restricting all visitation.

All visitation has been restricted except for certain compassionate care situations, such as end of life situations. These visitors will first be screened for fever and respiratory symptoms.We know that your presence is important for your loved one but, per guidance from the Centers for Disease Control and Prevention (CDC), this is a necessary action to protect their health. We have introduced alternative methods of visitation (such as Skype and FaceTime) so that you can continue to communicate with your loved ones. I would anticipate you not being able to visit the nursing home for at least another 45-60 days. I hear your concerns over the timeliness of calls back or availability for you to speak to your loved one. We are working on center specific plans to make this better. I am sorry.