By Thomas Goldsmith
Posted: Sunday, Dec. 26, 2010
RALEIGH This year's deadly outbreak of Hepatitis B in an N.C. assisted-living home unfolded like a singular nightmare, but state and national experts predict such events will only grow more common in years to come.
State public health officials say poorly trained staff - who weren't required to have high school diplomas - and unsafe diabetes care led to six fatal cases of the disease at Glen Care Mount Olive, a Wayne County assisted-living center, between June and late November. By the time the presence of Hepatitis B brought state investigators to the facility in October, the transmission of infection via re-use of glucometers and other devices had probably been going on for more than four months, their report said.
"What we saw were people who were not trained in fighting infection," said Julie Henry, spokeswoman for the state Division of Public Health. "It's not even sloppiness; it's really ignorance."
Glenn Kornegay, the facility's administrator, has denied the state's conclusions and says the infections could have originated elsewhere.
A Dec. 14 reinspection by state inspectors found no additional violations, but the facility faces fines of $20,000 or more for a Type A, or highest- level, violation found during a first round of investigation in October, said officials of the state Division of Health Service Regulation. Efforts to reach Kornegay this week were unsuccessful.
The deaths at Glen Care have fueled concerns about the training and supervision required of assisted-living staffers, the subject of a long-running debate in North Carolina.
Under state and federal law, only highly trained professionals such as registered and licensed practical nurses can administer insulin at nursing homes, designed for residents with higher levels of medical needs.
But the state-overseen assisted-living centers, once known as rest homes, have much looser guidelines. At these facilities, "med techs," who are unlicensed and may get only one-on-one training from a nurse on diabetes care, are allowed to take blood glucose samples and inject insulin for people with diabetes.
"We see this over and over again, where a staff member is providing care to multiple residents," said Nicola Thompson, an epidemiologist at the federal Centers for Disease Control in Atlanta. "We know that the majority of staff in assisted living are paraprofessionals that don't have a degree in health care.
"With more people with diabetes and more people in long-term care, the situation is unlikely to get any better."
State and national public health experts say they have tried for years to change this seeming contradiction in standards.
"There is a disconnect there," said Polly Johnson, former executive director of the state Board of Nursing and now CEO of the nonprofit Foundation for Nursing Excellence.
"Part of that disconnect is related to the way assisted living was set up - not as a health-focused system."
Assisted-living centers are an industry that grew out of county rest homes. They are cheaper than nursing homes, in part, because health care is supposedly incidental to simply helping residents with activities such as bathing and eating.
"The reality is that there are more people in assisted living with major health care needs," Johnson said.
Thompson said 29 million people, most older than 65, will have diabetes by 2050. In North Carolina today, about 1in 5 people older than 65 has diabetes.
The average age of the victims in the Glen Care outbreak of Hepatitis B was about 70. Their caregivers had not taken a state-approved infection control course, and there was no staff member named to coordinate infection control, investigators from the state Division of Public Health said.
Violations often found
Outbreaks of Hepatitis B have been identified as a public health problem for at least 20 years, Thompson said. With the first examples seen in hospitals, a notable shift followed in which the outbreaks occurred in nursing homes, and beginning in 2004, more often in assisted-living centers.
In North Carolina, state investigators often find violations of safe practice involving diabetes care; between November 2006 and this year, the state Division of Health Service Regulation fined 42 adult care homes a total of more than $238,000 for infractions involving insulin.
"Diabetes is an epidemic in this country," said Bob Konrad a member of the policy committee at the advocacy group Friends of Residents in Long Term Care.
"This is probably going to happen again and again and again as we have all these challenges in assisted living."
Dr. John Buse, a UNC Chapel Hill physician and former president of the American Diabetes Association, points out that many people with diabetes test their own blood sugar and administer insulin daily.
However, Buse also noted that insulin is a powerful drug that has to be administered with care.
"It is the drug that is most commonly associated with serious medical errors in medical facilities," Buse said. "Hopefully the people that own these facilities, that run these facilities, understand that insulin is a drug where the margin for error is very small."