Understanding When Nursing Home COVID-19 Deaths Count

Certifying a cause of death for nursing home residents is not always straightforward. The onset of the pandemic, which resulted in more than 150,000 resident deaths nationwide, created chaos and made this process even more complicated.

What or who determines whether a COVID-19 nursing home death gets added to the official tally? Are there standard guidelines that define how to make this call?

In this third PKSD blog about the impact of COVID-19 on nursing homes, we look at a much debated topic. Specifically, how nursing homes decide when the cause of a nursing home death is COVID-19.

Why Identifying Nursing Home COVID-19 Deaths is Complicated

Even before the pandemic, determining a cause of death was not always cut and dry. Nursing home residents, who are already elderly and frail, often have several health issues that could lead to rapid deterioration and death.

On the other hand, if someone gets COVID-19 and then dies, it seems like it should be a simple answer to a short question. Yet, amid the hundreds of thousands of residents who have died during the pandemic, it has become a highly charged political debate.

When the first virus outbreak hit, there were no clearly defined guidelines to help facilities determine if a death was, for reporting purposes, due to COVID-19 or not. As a result, some states attempted to adopt their own reporting standards. The results of these standards were mixed. Many states did not capture the number of new cases and deaths at the facility level.

The CDC Creates a Federal Reporting Standard

The unclear reporting guidelines were only part of the reason for a significant underreporting of nursing home COVID-19 deaths early on. At the federal level, nursing homes initially had no requirement to report COVID-19 deaths or new cases of infection at their facilities.

As the virus spread, nursing homes began flooding the Centers for Disease Control and Prevention (CDC) with questions and recommendations for reporting. Finally, several months into the pandemic, the federal government implemented a standard approach for assessing cause of death due to COVID-19.

As of May 24, 2020, the Trump administration issued the order for nursing home facilities to begin reporting. Under the standard federal approach, nursing homes began weekly reporting of the number of COVID-19 deaths and new cases. Today, these reports are still sent weekly to the National Healthcare Safety Network (NHSN), which is operated by the CDC.

How Do CDC Guidelines Define a Nursing Home Death Due to COVID-19?

The NHSN defines nursing home COVID-19 resident deaths as those caused by complications related to SARS-CoV-2. This definition includes resident deaths that occurred at either the nursing home or at other locations if residents were transferred for further treatment or acute care.

The NHSN says resident deaths should also be counted as COVID-19 if a resident, before passing:

• Had a positive COVID-19 test
• Was showing signs or symptoms of COVID-19
• Had been placed on transmission-based precautions
• Was dying from ongoing complications related to a prior COVID-19 infection

The USA Today article also shared some of the scenarios the CDC/CMS provided to help further clarify when facilities should determine a cause of death due to COVID-19:

Resident Death in Hospital

A sickly or fragile resident may have lived in a nursing home for years prior to the pandemic. If that fragile resident becomes infected with COVID-19, gets transferred by ambulance to a local hospital for further treatment, and then later dies, it should still be counted as a nursing home death.

Death After Discharged From Nursing Home

Residents who are discharged from a nursing home with no expectation of returning should not be reported to the NHSN.

91 Days After Being Infected

The CDC guidelines set a 90-day benchmark for residents with a COVID-19 infection. So a death is reported to the NHSN if a resident had COVID-19, continued to exhibit symptoms and then died up to 90 days after becoming ill. If, however, that same resident died on the 91st day without symptoms, they are not included in NHSN reporting. However, the death certificate may still state COVID-19 as the primary cause of death.

Cause of Death is Unknown

The CDC says facilities should view the NHSN as a surveillance tool, rather than a clinical one. This tool helps provide critical details for policymakers who need to better understand trends over a specified time period. However, a patient’s record or death certificate still has the final say about the cause of death.

In some cases, a facility may initially exclude a death from NHSN reporting because there is no visible evidence of  COVID-19. However, if an autopsy later reveals a positive COVID-19 test result, the death should then be reported to the NHSN.

State Reported COVID-19 Deaths May Differ

When compared to the CDC’s NHSN system, state reported totals may differ. This is because a state’s reporting requirements and/or the definition of a COVID-19 death may not be the same.

Reporting Wrapped in a Political Debate

The pandemic did more than cause hundreds of thousands of nursing home COVID-19 deaths. It also magnified the widespread failures in the nursing home system and led to a heated political debate over mask-wearing and vaccines.

Priya Chidambaram is a senior policy analyst with the Kaiser Family Foundation, a nonprofit organization that focuses on health issues. In an interview with USA Today, Chidambaram said, “The reason this shocking level of mortality is frustrating and devastating is these aren’t new issues and more could have been done to prevent them.”

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