Two-thirds of residents infected, and the test results took twelve days

Nursing homes were where COVID-19 did its worst early work: in Minnesota,
**3,950 of 48,711 cases (8%) reported through 21 July 2020 were associated
with skilled nursing facilities**, and **35% of those were health care
personnel**, including six deaths.

Two facilities in the Minneapolis–St Paul area contacted the state health
department after finding multiple cases. From 30 April to 12 June 2020,
everyone was tested, and then tested again every 7–10 days.

Where the virus came from

**Whole genome sequencing showed SARS-CoV-2 genomes from staff and resident
specimens clustered by facility** — facility A's virus with facility A's, B's
with B's.

That distinguishes between two very different stories. Repeated introduction
from the community would produce a scatter of unrelated genomes. Clustering
means transmission inside the building, and it means the answer is
infection control rather than keeping the outside world out.

Three things that let it continue

The report names them:

1. Lapses in infection prevention and control practices
2. **Up to 12-day delays in receiving staff test results — 53% of them, at one
   facility**
3. Incomplete staff participation — 71%

The second is the one that turns a testing programme into paperwork. Tests
exist to remove an infectious person from the building. A result that arrives
twelve days later describes something that has already finished happening: the
person worked the whole time.

What facility A looked like from the inside

78 residents, 156 staff. Before serial testing began, **14 (18%) of
residents had confirmed COVID-19**, all symptomatic. In the **first round of
serial testing, 23 of 53 residents (43%) were positive** — most of them found
only because everyone was tested.

Among staff: 15 (10%) diagnosed by their own providers during 15–29 April,
and 14 of those 15 worked on the third floor, where **12 of the 14
positive residents lived.** Over the whole period, **108 of 156 staff (69%)
were tested and 38 (35%) were positive.**

And the argument for testing repeatedly: **23 staff were tested more than
once, and five of those (22%) were positive after an earlier negative.** One
negative test is a statement about one morning.

What they did, and what is recommended

Residents with positive results were **moved to a COVID-19 care unit within
the facility**; staff with positive results were **excluded from work for at
least 10 days**; staff were screened daily for symptoms and sent home if
symptomatic. State and CDC staff made **frequent on-site infection control
assessments** — cohorting, hand hygiene, PPE.

The recommendations follow the three failures exactly:

• Serial testing of residents and staff
• Maximise staff testing participation — and flexible medical leave,
  because a member of staff who cannot afford to be sent home has a reason not
  to be tested
• Assured availability of personal protective equipment
• Timely result reporting
• Enhanced infection prevention and control practices

Source: Centers for Disease Control and Prevention, MMWR.