The race to vaccinate nursing home residents against Covid-19 is on. The world waits with great anticipation that the unprecedented devastation of this vulnerable population will eventually come to an end. Despite the huge potential, there are significant circumstances that must be taken into consideration. As states move to rapidly administer the medicine, it is crucial that the rush to protect doesn’t blind us to the need for appropriate planning.
At the beginning of this pandemic there was a similar sense of urgency to act. In March, CMS issued a number of directives in an attempt to “stem the fire in dry grass.” As a result, numerous rights were waived with the stroke of a pen. Residents were involuntarily cut off from the outside world, prevented from visiting in person with loved ones, deprived of social interactions, forced to eat alone, and made to go without crucial support services. The consequences included, among other things, extreme weight loss, severe depression and emotional trauma. And, despite no systematic effort to evaluate the degree of harm being caused, there is no doubt that thousands of residents who were never infected by Covid-19 needlessly died. Such consequences must now be avoided at all cost.
The vaccination process for long term care residents will not be just a matter of giving shots. There are significant issues that must be considered to protect against serious unintended consequences. Those include:
· Resident Assessments for Potential Side Effects – Without a doubt, there will be residents with a history of allergies that put them at risk of side effects from the vaccinations. Evaluating each residents’ history prior to administering the medication will be crucial. Some residents may not be able to communicate their history and reliance on their medical record may not be enough. Where questions about allergies to medications are commonly asked when people are admitted, specifics regarding vaccinations may not be. Open communication with family members, guardians or conservators will also be very important. Over reliance on potentially incomplete medical records or partial information from other sources will result in mistakes that can be very costly.
· Resources for Responding to Side Effects and Medical complications - As was learned in Great Britain, there will be people who experience serious side effects from the vaccinations. Many more will experience less severe reactions, including things like headaches, fever, aches and pains etc. With a nursing home population any side effects, severe or mild, can be dangerous and will require prompt and appropriate attention. How all those side effects will be treated, when and by whom, should be part of all facility plans. It is well known that long term care facilities are experiencing severe staffing shortages. Having qualified medical staff ready to respond and supplies of necessary resources available will be critical.
Therefore, facility plans should call for proceeding with vaccinations in stages to assure necessary resources are available at all times. It is very important to use a staggered distribution plan for long term care facilities to ensure that all staff and all residents do not receive the vaccine at the same time. If there are vaccine side effects as reported, it is possible that vaccinated staff will be unable to work for 24 – 72 hours after receipt of the vaccine. Using a staggered distribution plan will ensure there will be staff available to provide care to residents while the vaccinated staff recover.
· Residents’ Right to Refuse to be Vaccinated – Without a doubt, there are going to be a percentage of residents who refuse to be vaccinated. Residents have an absolute right to refuse treatment that must be protected. Those who refuse must be allowed to do so. If a resident is unable to make decisions, proper procedures for determining resident capacity and for appointing a substitute decision maker must be followed. No facility can make a presumption that a resident is incompetent simply because they appear confused, and medicate them anyway.
· Facility Response to a Refusal - Facilities will need to develop plans for how they will be responding to a residents’ refusal to receive a vaccination. Providers are prohibited from retaliating against anyone for exercising their rights. Residents who refuse vaccination should not be prevented from participating in group activities, restricted from receiving visitors, not be allowed to attend resident council meetings, etc.
· Impact on Visitations – How the availability of vaccinations is going to impact facility visitation procedures is another area of concern. There needs to be clear guidelines regarding what is appropriate and allowable. As we’ve learned over the last 9 months, a residents’ right to receive visitors is extremely valuable. Whether or not a potential visitor has gotten a vaccination should not impede on the residents right to receive that visitor. As facilities have begun to open up to visitations, numerous alternatives for allowing family members and loved ones to have contact have been developed. That process must be allowed to continue.
The availability of the vaccine for Covid-19 is a big step forward. Where the potential for returning to more normal operations is finally real, we also need to remember the principle of “do no harm.” How vaccinations are administered in long term care facilities now becomes a critical task. Careful planning and consideration of the lessons learned since the beginning of the pandemic needs to occur.