State: Nursing home with 33 deaths violated infection protocol

GRAND RAPIDS, Mich. (WOOD) — Samaritas Lodge nursing home in Grand Rapids, which has lost 33 residents to COVID-19, made infection control mistakes that had the potential to spread the disease, a state report says.

State inspectors spent nearly a week at the home earlier this month in response to the deaths. They cited the home for two infection control violations.

Perhaps the most glaring mistake uncovered: The home in late April moved an 89-year-old woman who was at high risk for getting COVID because she left four days a week for dialysis into a room with another 89-year-old woman.

The other woman had “no potential for community exposure” because she was confined to her room, the report stated.

About two weeks later, the woman on dialysis, who had been in a private room, tested positive for COVID-19.

Nine days later, the other woman tested positive.

The report doesn’t say whether they survived.

Records show confidential informants had warned nursing home administrators against moving them together.

“My concern was that (the dialysis patient) was already at risk if she was going back (to dialysis) four times a week and exposing (the other woman) potentially,” the report quoted one of the informants as saying. “But that was the way they (administrative staff) wanted it.”

Another informant said the woman on dialysis wore a mask during her appointments but the “administrative team ‘could have done more’ to protect residents in the facility,” according to the report.

Kaye Scholle, a state long-term care ombudsman assigned to represent residents at Samaritas Lodge, said moving the women in together was a mistake.

“That didn’t meet best practices, nor do I think it was the guidelines that were set forth at that time,” she said.

Inspectors also found staff in the kitchen not washing their hands properly — or at all.

They saw a worker using a mechanical lift on a resident without sanitizing it before or after, violating infection control standards.

They also found the plastic seal on the door leading to the home’s  COVID-19 unit unzipped and saw two workers assigned to that unit with their personal protection goggles on top of their heads.

“Certainly those infection control measures should have been mandated to be in place, which I’m sure they were, but weren’t being followed at the moment,” the ombudsman said.

Samaritas Lodge’s 33 COVID-19 deaths are the most of any nursing home in West Michigan and rank fifth in the state. The top four are from the Detroit area. At Samaritas Lodge, 78 residents have tested positive, along with 24 workers, state records show.

“I’m just glad that there was a citation and that there is going to be a plan of correction to meet the care needs of the residents that they serve,” the ombudsman said.

In a Friday statement to News 8, Samaritas said it had made “significant progress” in fighting the virus and that only one patient had tested positive in the last month.

While it disagreed with some of the state’s findings, Samaritas added it had “already implemented a number of measures that should address concerns raised by the inspectors.” That includes hiring an infection control consultant, who started last week.

The full statement from Samaritas:

“At Samaritas, we have no greater responsibility than the health and safety of those in our care. In fact, we have made significant progress in recent weeks when it comes to combatting COVID-19. We are grateful to report that we have no current positive cases of the virus in our community, and we will begin receiving new residents from the hospital next week. Over the past four weeks, we have only had one new positive case of COVID-19 and that resident has fully recovered. Above all, we are committed to continuing to work closely with local and state health regulators as we continue to provide appropriate care to our residents.

“As such, we welcome the input of the department of health surveyors and take very seriously the report issued recently. We have already implemented a number of measures that should address concerns raised by the inspectors. This includes hiring an external infection control consultant who began working with us last week, and ending the no-shower policy that was adopted for a short period of time as an emergency measure to help end the spread of COVID-19. We do, however, disagree with some of the findings in the report related to our infection control practices, and we are in the process of drafting a response to dispute and appeal those allegations.”