in the Shadow
No Man's Land: Israel's Nursing Homes Have Turned Into Death Traps
Only 35,000 of the one million Israelis over the age of 65 reside in assisted living facilities, but they account for 20% of the total number of coronavirus mortalities. A lack of appropriate preparation by the Ministry of Health combined with confusing directives have turned assisted living facilities and nursing homes into the most dangerous places in the country. "You young people should take into consideration that when you are old, the country will also write you off."
April 5, 2020
"The Ministry of Health doesn't understand what is happening in the field. Assisted living facilities, and especially nursing homes, will become death traps. I keep begging them to come and test me and my staff because I don't know if we are endangering our residents, but they aren't coming. Even the ministry's instructions don't help, because they came too late and were too confusing, and so every assisted living facility director is working to the best of their understanding."
This is what a director of an assisted living facility in central Israel (name withheld) recently told Shomrim. He expressed deep frustration with the professional assistance and support he has received from the health ministry. "I have not received the sort of response I would have expected. I feel that the health ministry is shifting the responsibility onto us in preparation for an inquiry committee once the pandemic is over."
To reinforce this claim, he pulled out a letter sent last week by a senior health ministry official to nursing home directors. The official informed them that the first shipment of essential protection equipment had been delivered but added that: "Regardless of the Ministry of Health's assistance, the responsibility for maintaining safety rests on you. You are responsible for the safety of the staff and residents."
Alisa Har Dov: "We're not allowed to leave our apartments and are provided with everything we need. Food and medicine are brought to us by people in gloves and masks. The fact that all the residents are doing as told shows that they are all afraid. On the one hand, they are keeping us safe, but on the other hand, the loneliness is immense."
The dangers of the coronavirus, the general chaos, and the frustration of the directors are only some of the challenges of running assisted living and nursing facilities. The primary difficulty is the residents themselves, who have been locked in their rooms for weeks, afraid of infection and angry about not receiving adequate protection. "The truth must be told; we are a group of people who interest no one," said Avraham Ben David. He lives in Poleg Mansion, an assisted living facility located in Kibbutz Tel Yitzhak in central Israel and is the head of the Israeli Association of Nursing Home Residents. "We paid taxes and did something for this country, but now the prevailing attitude us is along the lines of 'they are old, they can die.'"
The Ministry of Health was not prepared
A quick look at the data demonstrates that the fears described by the unnamed nursing home director are quickly coming true. Last weekend, Israel recorded 44 coronavirus deaths, most among older adults. Nine of the deceased were residents of assisted living facilities – a high number considering their relatively small proportion of the general public. One million Israelis are aged 65 and over and most of them live at home. Some 35,000 people live in Israel's 300 assisted living facilities (which are privately־run and cater to seniors who can live independently) and nursing homes (which are mostly state־run and house seniors who are disabled or require nursing). In other words, only 3.5% of the over–65s live in facilities, but residents of these facilities made up 20% of coronavirus deaths as of last weekend.
From the moment that coronavirus started spreading throughout the world, it was clear that the first frontline would be the hospitals and the first to be hit would be senior citizens, who are more vulnerable to the disease. One could have expected that immediate steps would be taken to protect this group; however, as happened with the preparation of testing labs and the procurement of emergency equipment, the Ministry of Health did very little. In this context, a 2017 quote by Ministry of Health Director־General Moshe Bar Siman Tov rings rather ironic. Reacting to the exposure of a severe abuse case in one of Israel's state־run nursing homes in a discussion of the Knesset's State Control Committee, he said: "This is the most difficult event that I have encountered as director־general....This event is perceived as exceptionally severe in the history of the ministry also by people who have been in the office for many years. I hope we can fix this situation." Knesset members subsequently discussed with Bar Siman Tov and other senior health ministry officials ways to improve the care in state־run facilities and to deal with the lack of funds (a deficit of 30% according to Ron Ozeri, then head of the Israeli Association of Nursing Homes) and the massive shortage of skilled personnel.
Nursing home director: "I now have in my facility residents who cannot shower because their caregivers are not allowed to enter. They can't do it alone, and there are many other things they can't do. I have several dozen people like this."
The compassion shown toward the senior population during that discussion was absent when the coronavirus broke out. Moreover, everything said in the 2017 discussion – one of the few ever to address the issue of Israel's nursing homes – demonstrates the harsh reality of nursing homes today: inadequate and delayed management of the event by the ministry, an insufficient budget to enable the facilities to handle the situation, and zero emergency preparedness.
"The real blow is in the nursing and geriatric departments, particularly rehabilitation and respiratory treatment. They work in poor conditions as it is, and this crisis has caught them already on the edge. We were not provided with masks and medical robes in time and every director has had to make do with what little they have," said the director of the assisted living facility in central Israel .
Amir Akashah, director of the nursing home Eitanei Davrat in the north of Israel, paints a similar picture. From the very first moment, he said, it was clear that the coronavirus would claim many victims. "We saw the numbers and realized immediately that the most significant death toll would be among elderly people. It was clear to me that the decision to isolate should have come much earlier. The Ministry of Health doesn't have enough tools for working with geriatric facilities in this kind of situation, and the directives kept changing and still are. I decided to get organized by myself. We called vendors two weeks ago and begged for medical gloves and robes. We also realized that we had to close our doors and not let anyone out. But my staff need to come and go, so what can you do?"
Just like his colleague from central Israel, Akashah petitioned the Ministry of Health, requesting urgent coronavirus tests for his staff. He told us that the hundreds of residents in his facility are high־risk geriatric patients and that his staff are doing everything in their power to avoid infection, including working 12־hour emergency shifts, but they still have to go back home at the end of the shift, thus running the risk of catching and spreading the virus. "There has been no response to our request for tests. I heard that at the Hadassah Medical Center in Jerusalem they are giving their staff corona tests – maybe because it's Hadassah. We are not being heard, and I feel there is no one to answer our problems and shortages." Akashah added bitterly that "the directive we did receive was to check staff temperatures. In my opinion, that is pointless as we already know you can be an asymptomatic carrier, but this is the test that is available, so this is what we are doing."
The case of Be'er Sheva's Mishan
Coronavirus was brought into the Mishan nursing home in Be'er Sheva by a worker at the facility. Two weeks later, Mishan recorded its fifth death. With 27 residents sick with coronavirus in the nursing unit alongside 13 staff members and two others who are not in the nursing unit, the situation is very difficult. In Mishan, as in other nursing homes where residents have caught the virus such as Bnei Brak's Vizhnitz and Ba'it Ba'Lev in Bat Yam, those testing positive are placed in self־isolation inside the facility.
Avraham Ben David, head of the Israeli Association of Nursing Home Residents: "The truth must be told: we are a group of people who interest no one. We paid taxes and did something for this country, but now the prevailing attitude is along the lines of 'they are old, they can die.'"
"Only after the families of Mishan residents made a fuss for a week did the Ministry of Health decide to check all 170 residents and staff members and found more than 40 people sick with coronavirus. And what was the ministry's decision? To leave them there," said Ben David angrily. "Why in Bnei Brak are they removing sick people even by force but not in nursing homes or assisted living? Is the blood of Bnei Brak's residents redder than ours? I'll tell you why, because it's easier for the government to lock down the elderly in one place. They've locked us in a cage and that's how they are dealing with this disease. If they don't perform tests in assisted living facilities and nursing homes, it will be very bad. If you lock down several hundred people and don't check them, it's obvious that if one person carries the virus, everyone will follow. I don't know many 70–80 year olds who haven't had bypass surgery or cancer or don't suffer from high blood pressure. If they don't evacuate the sick and don't test us, they're not giving us much of a chance. You young people should take into consideration that when you are old, the country will also write you off."
The elderly can't even shower
Most assisted living facilities and nursing homes began enforcing a full lockdown of residents inside their rooms. This policy has many problems. For example, early on in the crisis, the Ministry of Health issued a directive (and later reversed it) to prohibit the entrance of the caretakers who assist the residents with basic daily activities. "I now have in my facility residents who cannot shower because their caregivers aren't allowed in," said the nursing home director. "They can't do shower or do many other things on their own. I have several dozen people like this."
And it is not just the caregivers. Other professionals such as social workers, occupational therapists, psychologists, and many more are left outside or, in accordance with new regulations, forced to commit to working in just one facility. "When you have a geriatric nurse who works in more than one facility, there's no real oversight making sure that she does indeed limit her work to just one facility," the nursing home director said.
But perhaps the most challenging directive is the one forcing these facilities to transition to 12־hour shifts. At least two people we talked to confirmed that there is a critical budget problem for the four overtime hours these shifts entail. By law, facilities must pay 125% for a ninth daily work hour and 150% for every subsequent hour – sums these facilities just cannot afford. This is why, they told us, many facilities do not actually follow the directive and do not operate according to the emergency guidelines. "It is unclear whether the facilities will be compensated. Right now, there is no budget for these overtime hours and many nursing homes simply cannot afford it," said the director of the nursing home from central Israel. Akashah added that the facility he manages is run by a kibbutz which is covering the additional expenses for now, but no one knows what the future will bring.
And in the meantime, inside their small rooms
While the storm wreaks havoc outside, tens of thousands of older adults are sitting in small rooms trying to pass the time. Alisa Har Dov is one of them. She is 81 years old and lives in the Neve Hof nursing home in Rishon LeZion. Three weeks ago, she asked her caregiver not to come anymore. "It is very difficult, but I don't have a choice. I have serious health issues, and I'm very high risk," she said.
"Here we are under complete lockdown. We're not allowed to leave our apartments and are provided with everything we need. Food and medicine are brought to us by people in gloves and masks. They are running virtual activities and trying to keep busy. The fact that all the residents are doing as told shows that they are all afraid. On the one hand, they are keeping us safe, but on the other hand, the loneliness is immense."
Yankale Hameiri lives in an assisted living facility in Ganei Tikva with his wife who suffers from cognitive decline. His wife's caregiver has moved in with them due to the lockdown orders. "My wife spends all day in a wheelchair watching TV. No more visits to daycare facilities, no more physical activity," he said. "The lockdown is complete, and I pass the time watching nature movies and reading and re־reading the newspapers. It's very hard, but I understand that the staff are anxious for our safety. They don't let us do anything on our own; they are permanent staff and are fully protected. When my daughter comes to visit, I see her from the balcony like I'm in prison. At the weekend, the management organized a Shabbat eve ceremony, which they performed for the residents who watched from their balconies."
Michael Shiloh, 86, moved to the Nofey Yerushalayim assisted living facility in Jerusalem two months ago. One building over is the Nofim nursing home, where one resident recently died of coronavirus. Shiloh chose the facility because of his wife, a geriatric nursing patient who has lived in Nofim for the past three years. "Two weeks after I moved, I entered self־isolation after it was discovered that one of the nurses in the department where my wife is a patient has the virus. A short while after my self־isolation entered, we all went into full lockdown: all 15 floors and 170 apartments."
Shiloh has not seen his wife in over a month. "The staff who take care of her call me on Whatsapp and show her to me," he said. Shiloh said that he is managing the boredom well. "I still meet my gang on Zoom, read books, and watch movies. I order in from the restaurant downstairs. It's no great pleasure, but I understand that I am part of a high־risk group and that the death rate is higher at our age. The staff here are very dedicated, and I'm sure they are doing their best to make us feel protected."