Four Minnesota nursing homes with COVID-19 outbreaks cited for serious infection-control violations

A troubled nursing home in Moorhead transported a coronavirus patient to a dialysis center without notifying staff at the center or the driver of the patient's infection, potentially exposing at least nine people to the deadly virus.

At a nursing home in west-central Minnesota, a resident with symptoms of the virus was allowed to attend communal meals and group bingo games, endangering 17 other residents of the facility.

And in Winona, a nursing home with a major coronavirus outbreak moved a patient who appeared sickened with the COVID-19 respiratory illness to a room with someone who was healthy. Staff also wandered about the facility without removing contaminated protective gear.

Those are among the findings of state inspection reports last month of four Minnesota nursing homes with coronavirus cases. The reports, released Wednesday by the state Department of Health, offer a glimpse into how the virus has spread in more than 200 long-term care facilities across the state, killing 759 people and infecting more than 2,600 residents. All told, 81% of the deaths from the virus have been in long-term care — among the highest rates in the nation.

"These violations are the result of long-standing infection-control problems that are becoming glaringly visible in this pandemic," said Kristine Sundberg, executive director of Elder Voice Family Advocates.

All four nursing homes cited were found to have placed their residents in "immediate jeopardy," which means they were put at risk of serious harm or death by the violations. The facilities include the Moorhead Rehabilitation and Healthcare Center, Parkview Home in Belview, Sauer Health Care in Winona, and the Villa at Bryn Mawr in Minneapolis.

The reports illustrate a broader pattern: Nursing homes with a poor track record at controlling infections appear to be particularly vulnerable to the virus' spread. So far, about 75% of Minnesota's nursing homes with outbreaks of COVID-19 have been cited for infection-control violations over the past three years, according to a recent Star Tribune analysis of federal health data. That's higher than the industry average: Nationally, 63% of the nearly 10,000 nursing homes have been cited over the same period, according to Kaiser Health News.

Inspectors found that social distancing guidelines were sometimes poorly enforced and efforts to isolate infected residents often failed. At the Villa at Bryn Mawr, for instance, unsupervised residents shared cigarettes from the same ashtray and sat right next to each other on a patio, putting multiple residents at risk of infection. The nursing home has since removed open ashtrays from its outdoor smoking area, the report said.

The longest and most detailed of the inspection reports focuses on multiple breakdowns in infection-control protocols at the Moorhead Rehabilitation and Healthcare Center. The facility is on a federal list of the most troubled nursing homes in the nation.

Inspectors found the nursing home failed to monitor patients for symptoms of the coronavirus, then failed to implement infection-control practices to contain the virus' spread — imperiling all 43 residents in the facility. Several residents who tested positive for COVID-19 remained on wings with uninfected residents. Other healthy residents were exposed to roommates with the virus, according to the 64-page report.

At least three residents at the Moorhead nursing home have died from the virus and seven have been hospitalized, the report said.

In one incident, a patient who had tested positive for COVID-19 was sent to a dialysis center without notifying the center or the driver of the patient's status. The failure potentially exposed all nine residents at the facility who received dialysis services, as well as staff at the dialysis center and transportation personnel, the report said.

According to the report, the patient was receiving dialysis treatment for about an hour before a nurse called to inform the center that the patient was infected with COVID-19. The infected patient was also transported in the same van as someone who was not infected. And the driver of the van was never told that one of the passengers had the virus, the report said.

Inspectors also observed multiple incidents in which residents were not wearing masks. In one case, a patient with COVID-19 was seen in a common area without a mask. Staff walked by infected residents in their wheelchairs without attempting to assist them with their masks, the report said.

"Basic principles of preventive medicine were violated across the board," said Eilon Caspi, a gerontologist and adjunct faculty member at the University of Minnesota's School of Nursing, who reviewed the report.