You can tell a lot from a person’s hands. Every time Joan Dawson of Birmingham has a video call with her mother, she asks to see them.

“You look for marks or scratches,” Dawson said. “Are they clean? Is there dirt under the fingernails?”

Dawson’s mother lives in a nursing home, and these calls have provided the only contact between the two women since early March, when nursing homes in Alabama closed to all visitors. The calls have replaced daily visits by Dawson and her sister.

“For mother and for us, FaceTime has been a lifesaver,” Dawson said. “It has saved my sanity.”

Not every family is so lucky. Not all nursing homes have made video visits available to families, and some residents are too ill to participate. Even the best video call can’t replace an in-person visit, Dawson said.

She and other family members have come together as part of a national group called Caregivers for Compromise to ask Alabama officials to reopen nursing homes to essential caregivers, a designated person for each resident allowed at least one weekly visit. Training, protective equipment and negative COVID-19 tests would be required for all essential caregivers.

Officials in Minnesota, Indiana, New Jersey, Florida and South Dakota have already approved similar plans. More than a dozen other states require nursing homes to make outdoor visits available to families with adequate social distancing. Alabama leaves decisions about video and outdoor visits to individual facilities, shutting out some families that have not been able to access video or outdoor meetings. In response, some relatives have taken extraordinary steps – even working inside a loved ones’ nursing home, to maintain contact.

So far, the Alabama Department of Public Health has not eased its restrictions on nursing homes, which closed to visitors on March 13. The state’s Safer at Home order still requires nursing homes to restrict visitation.

“ADPH Bureau of Health Provider Standards advises [long-term care facilities] that any visitation should take into account CMS guidance,” said Dr. Karen Landers, area health officer for north Alabama. “Some facilities have been able to implement some creative measures in accordance with [federal] guidance to allow some level of visitation.”

A Deadly Visitor

Authorities locked down nursing home to prevent the spread of COVID-19. The virus hit hard at long-term care facilities that house frail and elderly residents. Even with strict visitation guidelines, the virus infiltrated thousands of facilities across the country, infecting residents and staff. According to the U.S. Centers for Medicare and Medicaid Services, more than 5,300 nursing home residents in Alabama have contracted COVID-19 and almost 800 have died from the virus.

To protect residents, many nursing homes have taken extraordinary steps. They have closed communal dining rooms, suspended group activities and confined most residents to their rooms. Federal and state health officials have designated nursing homes as one of the last places that will reopen to the public.

All that isolation has its own health consequences.

“It is changing them mentally and it is changing them physically,” said Wendy Keeler of Madison. She works as a speech therapist at a nursing home in north Alabama.

“The virus is real and we want to keep them safe,” she said. “But we’re killing them too because of the isolation.”

Keeler’s father had the flu in January and struggled to recover. She had him transferred to the facility where she works for rehabilitation and was able to see him after the lockdown began. Medicare funding for his rehab ran out in May and he transferred to another nursing home.

Keeler made a video call soon after he moved, but her father couldn’t understand how to communicate with her.

“While he could see me, his dementia was such that it confused him,” Keeler said.

Less than a week after he moved, Keeler’s father fell, hit his head and died. She was able to see him briefly at the hospital before he passed.

At the nursing home where she works, residents have been mostly confined to their rooms for months as staff battles outbreaks of coronavirus. Residents without outlets for communication need her therapy now more than ever.

“There are so many skills that are going down,” Keeler said. “It’s heartbreaking. It really is. I sit in my car sometimes and I don’t want to go in. But I do it for the residents.”

Essential Caregivers

Janet Daniel’s mother lives in a Birmingham nursing home. She serves on a council of family members that regularly volunteered at the home by putting up decorations and holding events for residents.

Before lockdown, family members filled essential roles, often assuming caregiving tasks for overburdened staff. They wiped sleep from residents’ eyes, brushed their teeth and sat with them during meals to make sure they consumed enough food and water. Residents who can feed themselves now eat alone in their rooms without the kind of social stimulation they got in dining rooms. As a result, many may not be consuming enough calories.

“There are so many things my sister and I used to do for her,” Daniel said. “The essential caregiver role is vital to their ability to thrive.”

Brandon Farmer, president and CEO of the Alabama Nursing Home Association, said his organization understands why families want to resume visits, but cautioned the state should move with care.

“While reopening visitation is critically important, our top priority remains the health and safety of our residents and staff,” Farmer said. “Thanks to the hard work of our employees, we have made tremendous progress caring for those who are most vulnerable to this disease and many facilities that experienced outbreaks are now COVID-19-free or have very few cases. We want to be confident that we have made in-person visits as safe as possible before reopening. The last thing we want to do is jeopardize this progress and have to close our doors again after reopening them for visitation.”

Farmer said the organization is encouraging homes to reopen for in-person visits as soon as safely possible. Keeler said facilities with positive cases will not allow visitors, even under the strict guidelines issued for essential caregivers.

Meanwhile, Dawson is trying to make the most of video visits. Recently her mother lost her hearing aid and staff had to scramble to create another system for communication. Still, when she does hear, she can sing along as her other daughter plays the piano and laugh at her family’s jokes.

“Fortunately FaceTime has worked pretty well for us,” Dawson said. “The nurse will set the phone up so my mother can use it. She’s able to talk to us and laugh with us. But there’s a lot of things we have to do to make this call work, and we still miss seeing her in person.”


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