Hello, I'm Morgan Katz and we're going to take a minute today to talk about some of the unique challenges experienced in assisted living communities throughout the course of this pandemic. We are really lucky today to have Leslie Hardesty, who is the co-founder of Esther's Place, a group of four assisted living communities in Maryland ranging from insides from 12 to 40 beds. She is an RN and is now working as a manager of Esther's Place, and we are so happy to have her here today to discuss her experiences. Leslie, thank you again for joining us. I know we were talking through that initial outbreak that you had, I think it was in early April, and I was hoping that you could highlight some of the significant challenges you've faced with an outbreak and your assisted living community when you were trying to address that outbreak. Was there anything specific that was particularly challenging? Yeah, for assisted living as well as nursing home, the biggest obstacle we faced was the complete inability to get any, and I mean any, PPE equipment. We couldn't get mask, we couldn't get gowns, I had gloves, so that was a good thing. But in early January, when everybody was reporting on what was happening in China, common sense said there's no way you're not going to keep this out of this country. I grew increasingly alarmed in February that it didn't seem like anybody on our side of the pond was doing much to get ready for what I thought was going to be something really terrible. I reached out to suppliers and started ordering masks, and they were always surprised like, "Oh, why do you want that?" I was like, "I just think we need to be prepared." I also began reaching out to our vendors, our food suppliers, and stockpiling what we could, stuff that could stay and be kept on shelves. I started stockpiling that and also started stockpiling cleaning supplies. This would've been in February when I was placing the orders to try to get the mask, I'm not sure I'd asked for gowns at that point, just mask. I started getting early March, the supplies got diverted. Instead of coming to us, they got diverted to the hospitals. I kept calling the vendor saying, "Where's our stuff?" And they're like, "Well, we had to send it to x, y, z, we had to send it to this hospital.", so we couldn't get a mask, we couldn't get a surgical mask. Now let's say it's was March 12th, and I'm still wondering why the state hasn't said, "We need to close things, we need to shut down things." I had at that point all of my residents and all of our locations, would go out at least three days a week to daycare centers. I'm thinking they're pointing up at daycare centers, I can't control who they're coming in contact with, I can't control the environment on the buses or any of that, so I made the decision before the state did to close to visitors and to daycares, which daycares weren't happening because of course, that impacted their revenue and they kept insisting they had nurses there and they could manage. I sent out an email to the families of all of our residents that same day and explained my position and what I thought and why I was doing what I was doing. I had across the board no pushback from family members. They all understood and they knew from dealing with us that our primary interest was in protecting these residents. We closed March 16th to visitors and to daycare, and I think a week later, it was when the governor announced closures to different public spaces or whatever. We stayed closed and we didn't have our first outbreak until, I think it was April 15th or 16th, and when it came, it came like a tsunami. I had a patient who took ill at one of our locations. If I'm giving too much detail tell me. No, that's good. I had a patient who became ill at one location and we sent him to baby test him and he turned out to be positive COVID. He and a roommate, so it made sense if he had it, his roommate was going to have it. It took a couple of days because you could not get testing done. It took a couple of days, but Hopkins pace program was able to send someone out to test a couple of their residents. They had a number of residents in that location, so they came and tested their own residents, which everyone came back positive. Then it was at some point we were able to get some test through an outside vendor. It turned out that virtually we had almost a 100 percent infection in that house. With that said, only two, three people ended up in the hospital. The rest were managed symptomatically because our symptoms, we did not have as much of a respiratory problem with our residents as we did a GI problem. Their appetites fell off drastically, they were having severe diarrhea. Hydration became the critical piece. If we could keep them hydrated and manage their symptoms, then the goal was to keep it from going to the hospital where we were worried that things might get even worse. At the same time, second house, the largest house, started having patients fall ill. Within about 10 days, I had two houses that were virtually a 100 percent infected and I still wasn't a getting mask. We were actually using cloth mask that I'd gone online and had found a person or a little company that was helping by making homemade mask. I was ordering anywhere I could, the health department couldn't get us anything. We were placing orders everywhere I could reach and we just couldn't get them. Yeah. I want to take a minute now because I think you really highlighted some really important features of this. First of all, how important preparation is which really you were, despite being extremely proactive, a lot of the assisted living communities saw this and we've seen this across the board. A lot of these supplies were getting diverted not only from assisted living to nursing homes. The hospitals were taking a lot of the PPEs, so it left a lot of assisted living communities, particularly the smaller communities, in a really challenging situation despite a lot of preparation. You really took herculean effort. I'm understanding because I talked to you throughout this. You were reaching out to acute care hospitals to get emergency crisis PPE stashes because you weren't able to get them from the health department. That's one avenue I think that can be really helpful. Then the next is communication that you've highlighted. How important this communication was; reaching out to family members. It sounds like because you provided that communication early on, they were understanding. It really shows how important having that communication to understand that all the decisions that you were making was to protect their loved ones. Because if you don't communicate that, I think it can be misconstrued and I think that has been lost a little bit in the course of this pandemic. I think that's great. Then finally, the testing issues and I think we saw this across the board. Can you talk a little bit about what you did in terms of addressing your crisis testing situation? Because I know early in this pandemic and for the first several months, we only had the capacity to test symptomatic residence, and even then, that was a challenge, right? Yeah. Absolutely it was. It occurred to me the reason I was finally able to get PPE was because the company that purchased or that we sold to are in Florida and North Carolina, they had nothing. They were looking at us like, "What are you doing up there?" I was actually getting PPE equipment shipped up from Florida and North Carolina because they had no problem getting it, they weren't in the midst of an outbreak. But then speaking to the communication piece, communication's always been the key to keeping families comfortable. Even if it's not great news you're telling them, if you're upfront with them and you tell them, I'm going to let you know when I know as soon as I can and as soon as I know it, then they will work with you. They certainly ran out of patience as time dragged on and they couldn't come in, but nobody ever [inaudible] some confrontation about coming out for visits. I think they were frankly afraid of us. But the testing, honestly, what we started doing once we started having these residents come back positive and then of course I had staff members come out positive, and we knew that people weren't going to be tested if they weren't sent to [inaudible]. Quite honestly, we just said here's what you tell them. You call, you give them this script and you tell them this is what the situation is and that's how I got most of my employees tested. Who then a handful out of all those locations, I had six at one location that were positive and I had seven or eight at the other. That of course creates a huge staffing problem when you're small. It isn't like I have a pool to pull from. Everyone of course pops up positive at once. At that point, the goal or the rules were, when they were positive, they left. It didn't matter, you couldn't have them there. Later the rule became if they're infected and asymptomatic and they're only working with infected residents, then they could stay, but that wasn't the case then. So it was a challenge for staffing reasons to try to manage that. But the testing It was it was just a tsunami of problems everywhere you turned. We are at one point the, what we called National Guard got involved. I thought that meant they were going to come out and help us with testing, or cleaning or whatever. They came out, there's eight of them. They walk through the building, and only two went into the resident's rooms and actually laid eyes on them. I really think it was just about seeing what condition where the residents that were in the building, what condition they were in. There was no help. They didn't bring any PPE with them and they have kept the PPE they were wearing. But the system just wasn't ready for this on any level. Yeah. Taught me now that you're through this outbreak. Can you talk to me a little bit about the resident morale, now that we're a couple months in and they have gone an extended period of time without seeing family members at this point. How have you dealt with that? Well, actually we've opened for visitors again because four locations, three, the last outbreak was in, say, May, and again it was a 100 percent attraction. Every resident in the building had it. Everyone survived. Thank God. I actually had a staff member who was so sick that he ended up in the hospital. He was the safest of all my ample reason. Unfortunately, by then, they'd discovered room does appear. They put him in the hospital, gave them all the support, him steroids and everything and meet. Great. Thankfully, I made it back out. But once the houses that had, had their infection had cleared and everybody had been deemed recovered. We started allowing visitors outside only with the resident wearing a mask. I wanted to eight feet apart instead of six feet for added insurance. They could come and visit for like an hour or two, no more than two visitors at a time. Everyone state mask. That's the way we ran for awhile. Then the latest from the governor's office said that basically if you were free of infection and, you hadn't had any outbreaks in so many days that visitation endorse was allowed. We are allowing three homes where we've had the operator visitors. But they had to call in advance so we can make sure that we don't have more than one person's family visiting at a time because the locations interiorly are nice size. But if you have ten residence and five of them show up with two visitors, you really can't handle that. It's too many people in that spot. Now, with the weather turning colder, the annual visitation is going to become a little trickier in that we're just going to have to monitor the divine visitation. Hones and. sadly, with the elderly, we don't get a ton of visitor so far it hasn't been a problem. Good. Yeah. I know a lot of communities are struggling with planning their indoor visitation policies because it's just another challenge, and another potential point of entry. You think overall, so far it's been running relatively smoothly for you in terms of limiting the number of visitors, and making sure that their mask, and physically separated at all times. Correct. Did you have a staff member supervising that visited ought to ensure that they maintain that physical distancing, or how does that work? Yeah. We've been staff out are really good about because families in the staff. Our staff doesn't turn over much to the families know that staff members really well and they have good relationships. We haven't had any issue around too many people wanting to come in or things like that, honestly. After the outbreaks and even for like a month or two after everyone had recovered, our biggest challenge was trying to get the residents to come out of their rooms. Because you're in for a period of time, we were restricting them to their room. Then slowly as everyone seemed to recover, a couple of weeks later, I was allowing, we would stag, or who could come out to the common area. Half the resident were allowed to come out to the common area on Monday, and the other half came out on Tuesday, and it went back and forth like that. Then once that seemed to be okay, and it will affect King from that, then we still keep them separated as best we can, which is challenging if you have memory issues, which they all had. My challenge was to get them to come out of the room, I think watching the news, they are very fearful, they knew that people had been sick, and I literally would have to go up and coax them to come out. Fear is a big factor, especially when you're elderly and you recognize that disease that could strike you, could potentially kill you. They were feeling very safe cocooned in their rooms. That now has gotten better, they're known as reluctant to come out and be amongst each other, but that was an interesting phenomenon I didn't expect. Yeah, that's interesting. I actually haven't heard that so much yet, that's really interesting. I think you also highlight something else that's really important, and really the challenges with memory care residents with this pandemic and probably a lot of the reason why you did have such large outbreaks and insignificant transmission because it is so challenging to really implement these core infection prevention practices in memory care residents. It's hard to get them to wear a mask, it's hard to make sure that they're physically separated. Is there anything that you have seen that has worked in terms of that or any suggestion you have for other consistent living communities that have the majority of memory care residents? It's a challenge. Staff are really good about sending, and reminding them, and encouraging them but in the end of the day, some of the Alzheimer patients, they just didn't get it. If you try to persist with the mask wearing, they would become agitated. Now you've got an agitated person who's not wearing a mask, then they are wandering through the house, and that's the other thing where we can't lock them in their rooms, that's where it's not legal. If they're coming out of the room because they don't know that they shouldn't be wandering around, it's a real challenge. I don't know what the answer to that is, but I do know some of the regulations with the state in such may need to be relooked at when it comes to something like that. Yeah, I know many who are good with that. Thank you so much. This was really excellent information, and I think will be really helpful to other communities. Looking to the next couple of months coming up, is there anything specific that you would like to share with other communities that may help them to prepare for the future? I know you gave some really good information about communication, which I think is so important moving forward, especially when residents may be ready to go home for the holidays, and some of those challenges. Any thoughts you have to prepare them if they haven't dealt with an outbreak like this? Yeah. Well, yeah. I do expect family members or they even before now are starting to get and see about bringing their families home for a weekend. Out of fear, a lot of them are like, "well, I think we should take our mom home because we're afraid for her to be there," and I was always their choice, but what I made clear to them is that if you do, and at the time with the testing being the way it was so limited and hard to get a hold of. I was like, "you have to decide, can you manage this person's care for the next several months? Because once they leave, if I can't get them tested, I can't bring them back." I think communication is the biggest piece, and I think as our public becomes more educated about how this disease spreads, and the understanding that it's not going anywhere, I think that families are on board with it, and that's the key. It's a terrible position to be in. The idea that you can't see your loved one for months on end, is just a terrible thing, especially when you're dealing with people who are so elderly. I have a lady at one of our houses, 104 years old, she was alive for the Spanish flu, and she survived COVID. It just speaks to the spirits of humans that you can be a 104 years old and still survive two pandemics in your lifetime. That's amazing. Well I think that's a great way to close out this interview. Thank you so much. It was really wonderful to have you here, and I know many will appreciate your insight. Thanks again.
