On Whidbey Island, two dozen residents of a nursing home live in isolation with the novel coronavirus illness. Some breathe through oxygen masks, and are cared for by two nurses who volunteered to work and sleep in the quarantine ward to avoid exposing others.
It is an increasingly familiar ordeal at facilities across the state. But unlike many nursing homes, Careage of Whidbey knew it had a widespread outbreak -- at least 27 residents and 20 employees -- because it tested everyone who lives and works there, even though only two residents showed symptoms at the time.
Since a devastating outbreak was discovered last month at Life Care Center of Kirkland, COVID-19 continues to spread to more senior care facilities in the state, and residents' families and others are raising concerns about a lack of testing.
At least 90 facilities in the state had confirmed coronavirus outbreaks as of Tuesday, according to a Seattle Times analysis that identified at least 517 cases among residents and employees, 66 of whom have died. About half of those deaths are from Life Care. The Times analyzed information from county health departments and facilities and verified information from residents' families to reach its count because the state was unable to provide the data.
The numbers are an undercount, as The Times was not able to identify every facility with cases, and some senior care operators have not been transparent about their numbers. The actual number of infections is likely much higher, as across-the-board testing remains out of reach for most facilities and the state Department of Health (DOH) said Tuesday that about 100 other facilities have suspected cases or are awaiting more test results.
The lack of testing leaves the facilities unable to see the spread of the virus within their walls, as federal experts have found that infected people likely spread the disease even if they don't have symptoms. It's something the DOH acknowledges, though it continues to recommend that only those with symptoms get tested.
For families, the new pleas for testing of residents and staff echo those voiced just a month ago when the Seattle area became an early national epicenter of the coronavirus pandemic.
Nursing-home residents and health care workers are considered priority candidates for testing under federal and state guidelines, and the state has advised facilities to have a low threshold to test residents. But public health officials with the DOH, and King and Snohomish counties, say there still aren't enough resources available to test everyone -- even in facilities with confirmed cases.
That leaves administrators of nursing homes and assisted living facilities with a dilemma: follow the guidelines, and risk a widespread infection, or find an alternative that is not available to most of the 743 skilled nursing and assisted-living operations across the state.
Sean O'Neill, the administrator at Careage of Whidbey, managed to widely test his facility through help from a local hospital, which supplied testing kits. Staff then took turns driving three hours round-trip to hand-deliver the tests to the University of Washington Medicine virology lab.
"It should be a priority of state and federal governments," O'Neill said of the testing. "We become vectors for the whole community."
"Flying in the dark"
The families of residents in those facilities are fearful the limited testing leaves them vulnerable to a situation like the one at Life Care.
"Given that there are shared bathrooms between rooms, shared staff, a shared kitchen, how can you not test all the seniors that potentially have been exposed?" said Yang Liu, whose 86-year-old father is at Redmond Care and Rehabilitation Center. "Right now, they're just flying in the dark."
Last month, after an employee tested positive for COVID-19, Issaquah Nursing and Rehabilitation Center followed the public health playbook. It restricted visitors and began screening residents and employees for symptoms, precautions that are being followed by many facilities, without testing widely.
But a CDC team already in the area, responding to the outbreak at Life Care, visited the Issaquah facility with Public Health -- Seattle & King County to make sure it was following recommendations. The investigators were also interested in learning more about how the disease spreads in nursing homes.
When the residents were tested a week later, the results were surprising: 30% were infected. And among them, 13 of the 23 residents who tested positive did not show symptoms at the time they were tested.
Because the nursing home didn't know those residents were infected, it didn't isolate them until they later became sick or received positive test results, which likely contributed to the disease's spread, the CDC said in a report published Friday.
The CDC recommended that facilities with confirmed cases test residents to decide whom to quarantine, if testing becomes more available.
But screening based on symptoms is the primary option at most facilities.
The state's chief health officer, Dr. Kathy Lofy, said Tuesday she was concerned that it was "really easy" for the disease to spread in these facilities.
DOH spokeswoman Amy Reynolds said health officials didn't know until recently that people without symptoms could test positive for the disease, and more is being learned about their role in its spread. The scientific evidence has been "shifting," she said. DOH does not have current plans to change its guidance, Reynolds said, but will continue to align with the CDC.
King County public health will arrange testing if a senior care facility has its first suspected case, but won't widely test everyone. Testing requires resources, like time, swabs and protective equipment for health care workers, that remain in short supply, said Keith Seinfeld, a spokesman for the health department. And testing also can't guarantee to identify every person who will become sick, he said.
"If we had unlimited supplies and unlimited staff, the situation would be different," Seinfeld said.
Facilities can arrange tests for residents without their local health departments. Tests can be ordered by physicians at skilled-nursing facilities or, at independent or assisted living facilities, by residents' primary care providers. Employees are eligible to be tested at drive-thru centers with a provider's reference. But those providers are also being asked by DOH to restrict testing to those with symptoms.
On a video call, Elizabeth Lightfoot grew alarmed when she saw her mother, who is 90 and has dementia, wander out of her room at the Sunrise of Mercer Island assisted living facility. The facility had just had a resident test positive for COVID-19, and Lightfoot, a professor of social work at the University of Minnesota, wanted to know what was being done to protect her mother.
She learned from a regional manager that residents were told to say in their rooms, and that employees' temperatures were being taken daily. But Sunrise repeated the public health guidance: testing is only for residents with symptoms. They would be tested at the hospital.
Those guidelines seem outrageous, Lightfoot said.
"After they had that tragedy at Life Care Center, if I were them I would be thinking, 'Whatever we do, let's make sure this doesn't happen again,'" she said.
"Going on for weeks"
Like Careage, the few other facilities that were able to test all residents and staff also found people carrying the virus who didn't show symptoms. Some of the companies have since called on officials to provide the same to other facilities. Era Living said in a written plea that the the benefits became clear after all residents at one of its facilities were tested.
The facility, the Ida Culver House in Seattle's Ravenna neighborhood, partnered with the UW Medicine after one resident died and another tested positive. The UW found additional cases: three of the 79 residents tested and two of the 67 employees tested were positive, despite the facility not noticing symptoms. Residents who were negative were later tested again, and one was positive.
In Bellingham, Shuksan Healthcare Center tested nearly all of its 38 residents with the local health department after receiving several positive results. Ultimately, 33 residents and 20 employees tested positive. Four of those residents have died, as well as a former resident who died soon after moving out of the facility.
Robin Dale, chief executive officer for the Washington Health Care Association, said unclear guidelines add to facilities' frustrations in coping with the coronavirus crisis. His association, which advocates for long-term care and skilled nursing facilities, has refrained from handing down directives to members but has referred them to state DOH guidelines.
"That's part of the frustration," Dale said. "This has been going on for several weeks now."
Just as families of residents want testing, so do those who care for the residents in the state, said Adam Glickman, secretary-treasurer for SEIU 775, which represents long-term care workers in Washington and Montana. His members who face a heightened risk from coronavirus because of their age or underlying health conditions are especially concerned.
"There is just a tremendous lack of testing," he said.
Getting out of town
For Tom Paulson, a former journalist who wrote about health care, the testing didn't go far enough at Hearthstone of Greenlake. His 93-year-old mother had lived in the Seattle retirement community before he learned two employees there tested positive for COVID-19.
Staff tested residents with symptoms and those who may have come into contact with the virus, according to Carol Gordon, the facility's administrative manager. Paulson was told staff wanted to test all residents but couldn't.
So he picked up his mother, packed three months of medication for her and drove her seven hours to their family cabin near Priest Lake on the Idaho Panhandle.
Eight more people tied to Hearthstone have since tested positive for COVID-19, including a resident who lived next door to Paulson's mother. She feels fine, he said, but he still worries she may have been exposed to the virus.
"I don't know how hard [Hearthstone] tried, but they said they couldn't get tested unless the residents were showing symptoms," Paulson said.
"That's a good way to find out who needs care. But it means you're not going to be able to contain outbreaks because you're not staying ahead of it."
