Dear Rita: My 88-year-old grandfather broke some bones from a fall and was admitted to a hospital for a surgical intervention. The hospital is attempting to discharge him to a nursing home for rehab. I am concerned about the Covid-19 pandemic and the current situation in nursing homes. How might my grandfather be impacted? — R.S., Oakland

Dear R.S.: I understand your concern and apprehension. Older adults with underlying conditions living in long-term care facilities and similar confined spaces are more susceptible to Covid-19 infection.

According to the New York Times, about one-fifth of U.S. coronavirus deaths are linked to nursing facilities. This has been seen in California (including a few nursing homes in the East Bay), Kansas, New Jersey, Virginia, Maryland, Washington and other states.

So far, more than 72 long-term care facilities (nursing homes, assisted living facilities and memory care facilities) have had deaths related to Covid-19.

According to California Association of Nursing Home Reform, by early April, there were 261 nursing homes that had reported Covid-19 infections involving either a resident or a staff member. In total, those facilities reported that 1,740 residents and 1,290 workers had tested positive for Covid-19. At least 370 people living and working in 94 assisted living facilities had also tested positive.

What lies behind this devastation?

Many long-term care settings were in crisis before the pandemic. Overall, the quality of care in these settings has declined over time. According to the California Department of Public Health, complaints against nursing homes have been exploding, and the state auditor reported that nursing home residents are suffering from increasing neglect at the same time that facilities’ fees have grown.

The caregivers on the front lines in these communities are heroes, taking care of the most vulnerable in our society. They are underpaid and the most overlooked players in the health care system.

Testing and protective gear have been scarce in these settings. Due to low pay, caregivers in the Bay Area often work multiple jobs at several facilities, creating more exposure. This puts them at increased risk of contracting the virus and bringing infections to different communities.

Many caregivers don’t get properly trained in several areas, most notably in infectious diseases. Understaffing is rampant and chronic, which can jeopardize resident’s lives.

And yet nursing homes continue to accept sicker and more frail older adults. Some are even accepting new Covid-19-positive residents, which puts other residents at risk. This practice is allowed as long as there is compliance with CDC guidelines for nursing homes, but the prevalence of people with preexisting conditions in long-term care settings is setting up the current disaster we’re seeing with Covid-19.

This moment calls attention to the need for policy changes, in particular increased transparency about the impact of the coronavirus within nursing home settings.

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The Centers for Medicare & Medicaid Services, which oversees nursing homes, are working with the U.S. Centers for Disease Control and Prevention to increase reporting and transparency (regarding facilities impacted by Covid-19).

You and your grandfather therefore have a difficult decision.

Any facility you choose will carry a risk of Covid-19 infection.

If your grandfather decides to go to rehab, and an outbreak were to occur, you will be faced with visitation restrictions and communication challenges.

Because your grandfather is at higher risk, you need to carefully research potential rehabilitation facilities. Infections, quality of care, staffing ratios and inspection results are some variables that may guide the decision.

Check on the facilities’ transparency policies, as well. Does it inform residents, families, staff members, state and local health departments and the local long-term care ombudsperson when residents or staff test positive for Covid-19? What steps does the facility take to treat infected residents? To protect other residents?

A safer option for your grandfather may be rehabbing at home.

If he’s been in the hospital for more than 72 hours, Medicare will cover some home health expenses, including a physical therapist who can come to the home. In addition, your grandfather could pay on his own for in-home, non-medical care to address activities such as bathing, dressing and cooking.

Having caregivers come into the home, however, also carries a risk. But with proper screening of caregivers (in particular, the home care agency checking for symptoms and taking temperatures) and with the use of masks and gloves, the risk of infection can be minimized. Consistency of care, with the same caregiver rather than a rotating cast, will also help decrease the risk.

Unfortunately, there is no clear solution to your dilemma.

It is important to consider your grandfather’s need for support while he recovers alongside the risk posed by going into a facility at this time. Taking precautions and maintaining strict cleanliness guidelines will go a long way with helping your grandfather get well. Your presence as a family caregiver is the most important support that your grandfather has, and your advocacy is invaluable.