[Podcast] COVID-19: Diagnosing Liability

Listen on Spotify

Our new limited podcast series, COVID-19: Diagnosing Liability, is an open dialogue between industry experts and litigators discussing what negligence looks like in the age of COVID-19, assessing liability across industries, and uncovering insights into the kinds of lawsuits that may be viable.

Ep.1 Nursing Homes

The nursing home and assisted living industry has absorbed the tip of the deadly coronavirus’ spear. Although it has been argued that the comorbidities among advanced-age residents made a high death rate inevitable, many are not convinced nursing home staff have done all they can to protect these vulnerable populations. As nursing homes in many states scramble for immunity protections, we explore how eldercare facilities responded to testing and PPE shortages, the role communication played in the viral spread, and whether ageism may have been at play.

Hosted by: Wendy Ketner, M.D., SVP of Medical Affairs at Expert Institute

Special guests:

Disclaimer: The opinions expressed in this podcast are those of the experts and do not represent the views or opinions of Expert Institute or its members.

Audio Transcription

Dr. Ketner: Hi everyone, and welcome to the first episode of Expert Institute’s limited podcast series, COVID-19: Diagnosing Liability. I’m Dr. Wendy Ketner, and I’m the Senior Vice President of Medical Affairs at Expert Institute. On today’s episode, we’ll be discussing how nursing homes across the nation have been responding to the COVID-19 crisis since the first cases of the outbreak were reported. We’re also going to explore some of the gaps in the management and protocol that contributed to extremely high death rates in elder care facilities and discuss what gross negligence looks like in these establishments, what kinds of cases are being filed against nursing homes related to COVID-19, and where the liability lies for upcoming litigation.

I have three guests joining me today, all of whom are extremely passionate about what is happening in nursing homes across the country in response to COVID-19, and two of whom have really been boots on the ground, treating patients and keeping these facilities running throughout these last three months.

So first I’d like to introduce Dr. Marc Shepard. Dr. Shepard is the Medical Director of a nursing home in Maryland. He is board-certified in internal medicine, and has over 30 years of experience as a primary care internist. He’s also an attending primary care internist at a non-profit healthcare system in Washington D.C. specializing in the care of geriatric patients. Dr. Shepard received his medical degree from Northwestern University Medical School and has also worked as an associate professor of medicine at George Washington University. Thank you so much for being with us today, Dr. Shepard.

I also have with me Nurse Lorraine Doonan. Nurse Doonan is currently an assistant administrator at a home care agency and nurse supervisor at a rehabilitation and long term care facility in Connecticut. She is also the former executive director of an assisted living facility in Connecticut. She has more than 25 years of experience in hospice care, home health care, and acute care, and assisted living healthcare management. As well as extensive knowledge of federal and state regulations pertaining to hospice and home health care, and has developed and implemented policies pertaining to fall risk prevention. We’re delighted to get her opinions today.

Nrs. Doonan: Thank you.

Dr. Ketner: My last guest today is both an old colleague and a good friend, Mr. Alan Fuchsberg, Esq. Alan is Managing Partner of the Jacob Fuchsberg Law Firm in New York City and a nationally-recognized personal injury advocate. Alan’s experience spans the full spectrum of personal injury actions, medical malpractice, and wrongful death cases, including many nursing home negligence matters. Thank you for being here, Alan.

Mr. Fuchsberg: Thank you, particularly about being an old friend.

Dr. Ketner: Now before we dive into discussion with the experts, I’d like to share a few stats with all of you just to give some color and backdrop as to what is happening in nursing homes around the nation and how quickly things are unfolding in regard to COVID-19 in these scenarios.

By the Centers for Disease Control and Prevention’s latest estimate, the U.S. has about 15,600 nursing homes with some 1.3 million residents. One quarter of those residents, about 425,000 people, are over the age of 80. So far to date, we’ve had almost 82,000 deaths in the U.S. alone. Back on April 17th, The New York Times reported that one fifth of deaths from coronavirus were related to nursing homes. Two days later, on April 19th, the CDC started requiring them to report past and present cases across the nation. We know in Europe, 50% of COVID-19 deaths ended up being linked to nursing homes.

Dr. Shepard, I’ll start with you. Can you talk a little about the difficulty in accurately reporting the cases, knowing that nursing homes see deaths outside of the COVID sphere all the time?

Dr. Shepard: Well, initially we had a problem with access to testing. We had residents getting sick and some were suspicious, but we didn’t really have access to testing. And then, one of the staff tested positive for COVID. And then after that, we started testing more and we found more positives. And then after that we contacted The Department of Health, and they supplied us testing for all the residents, and we had all the residents tested.

Dr. Ketner: And how many of them came back positive?

Dr. Shepard:We had about four or five deaths, which weren’t tested, but probably were related. And we now have 12 positive out of about 30 residents.

Dr. Ketner: And Alan, from a litigator’s perspective, what kinds of nursing home cases are individuals bringing to your door and you know, what kinds of nursing home cases is your firm preparing to litigate?

Mr. Fuchsberg: We’re about to file a suit that is a subcategory of nursing homes, which is assisted living facilities, where people have the same comorbidities and risk factors as people in nursing homes. And there are many people in assisted living facilities and they are also regulated by Medicare and Medicaid and are entitled to those services. Yet, whatever happens in the nursing home is almost magnified because the amount of money that they get to take care of each one of these patients that qualify is less. And so it’s the same problem—that there isn’t enough staffing.

People are critical from the other end that a lot of these assisted living facilities, just like nursing homes, are privately owned and profit becomes paramount, and therefore the staffing isn’t as much as it should be. So for example, The New York Times just reported a couple of days ago that the average amount of hours in a nursing home that a patient may get could be three and a half hours. And it’s that lack of time and together with experience of the staff to address a pandemic like this with people who are more at risk, that has contributed to a crisis and caused the numbers to be much higher than they need to be.

And whether there will be good lawsuits for damages and compensation is one thing because a lot of governors, and the U.S. government, has passed immunity from liability laws. But we are coming in for injunctive relief to demand that these facilities up their game and provide the services that are missing in order to cover the needs as Dr. Shepard was describing.

Dr. Ketner: And Nurse Doonan, I want to get your thoughts on this. Looking at, you know, stats of death rates in nursing homes, how did this happen? Can you describe your experience working in a nursing home during these past couple months?

Nrs. Doonan: Sure. Before I go into that, I want to follow up on Alan’s comment and say that in assisted living, part of the problem as I see it, is that the residents there should not be nursing home level residents. And yet, because they are privately owned and run, they’re held onto sometimes longer than they should be, when they should be moved to a higher level of care. And now with the spread of COVID-19, especially in locked dementia units, it seems to be spreading like wildfire. The issue is being magnified tenfold.

As far as what I saw as the start, very early on I was at a meeting at a university hospital setting. The meeting is actually called The Dream Team Meeting. And it’s called that because it’s meant to be a meeting amongst healthcare entities across the continuum. Well, this meeting became a discussion about COVID-19. And one of the issues that came up was the concern on the skilled nursing facility marketing staff to obtain the negative questionnaire that was starting to be asked of patients upon entry to the emergency department or to admission to the hospital in regards to risk factor for COVID-19. And a whole discussion went back and forth as to whether sharing that questionnaire with assisted livings, skilled nursing facilities, or home care agencies violated HIPAA. And the decision in the meeting was made that no, it didn’t, because the person you’re referring to has a vested interest in that information.

So the recommendation was made and agreed upon to go ahead and share the questionnaires. Have them be part of the referral process. But, on the other hand, as Alan mentioned about the assisted living and nursing homes, they’re privately owned. So we took that information back. But the decision whether to base your admission decision on that negative questionnaire, or even require it, is a facility by facility, or corporate, decision. I can recall a patient—the testing was an issue, but the patient was accepted with risk doctors and then turned out to be positive. I don’t think it’s an isolated case. I think that happened quite a bit.

And I think, I’ll be honest with you, I think there was a sense of denial going on. You know, we’d never seen this before. We could not have anticipated the magnitude. But, we also had safeguards we could’ve put into place. And I think in some ways the safeguards didn’t get put into place quick enough. And I think business went on as usual.

I think the lack of PPE equipment contributed. Unless it’s really, really a severe infectious case, we don’t typically wear PPE equipment all the time. Especially, you know, we’ve transitioned from calling nursing home “patients” to nursing home “residents.” It’s their home setting. Same in assisted living. You try to get away from such medical appearances. So there, and we don’t have the PPE equipment, and then there was an initial shying away from using it.

As this became more of a threat, or known entity, I was involved in the training of the staff. The fear factor was huge amongst the staff. It’s like nothing I’ve ever seen before. It’s always been your patient first, and here I was seeing the reaction that was, “It’s the patient in my family as well.” So the lack of PPE equipment became a very big issue, as did the lack of testing. And I think that’s what led to the rapid spread. I mean, what I’ve seen is once one patient gets it, it spreads and then a patient gets that, your staff gets it, and it goes amongst the departments.

Mr. Fuchsberg: Just to add to Lorraine about people with dementia, that’s very true in this population. I’m also working with an assisted living facility that has many psychiatric patients. This is a population that unlike if you or I were told that we need to socially distance ourselves, we need to stay in our rooms, we can’t hang out and roam in the hallways and look for friends, et cetera, et cetera—they cannot cognize this situation, this circumstance, so as to help whatever staff is there carry out what needs to be carried out. So you could publish instructions, but those are not necessarily followed, and that adds to the problem

So what we’re trying to argue in our case that we’re putting together under the Americans with Disabilities Act is that you’ve got to up your game to provide enough staff supervision, testing separation, regimentation to protect people in these facilities with these health issues. And some places obviously do a much better job. And there are amazing people around, like Lorraine and many of the people she works for. But other places are understaffed and under instructed.

So it’s not just the PPE equipment that isn’t being provided, but, in many instances, not enough people or enough instruction. And from a lawyer’s point of view, people with a certain level of disability have come to these facilities with the understanding that they would be afforded these protections, and should be afforded these protections.

Nrs. Doonan: I think that’s a very good point, Alan, and I also think their families are under the impression they’re going to be afforded certain protections. And with the coronavirus, they can’t visit them. So they’re fully trusting that there’s protections in place. And I can tell you in Connecticut, we had an issue with under-reporting.

For example, one skilled nursing facility reported nine deaths when at the time they had 34. And now they’re up to 43. They’ve surpassed the nursing home, and I believe it’s Kirkland, Washington, has the largest number of deaths in the United States as of today. And it was a matter of under-reporting. And now it’s at the point where bodies are being exhumed and tested after death.

Dr. Ketner: I want to go back and talk about the PPE, the personal protective equipment, because I think this has been such a big topic. Dr. Shepard, I believe your hospital got a nice donation, but maybe you can touch on, you know, what nursing homes are doing, others might be doing, to combat shortages? And, and then on top of that, what are the best practices for protecting staff and patients, especially in these situations where some of these patients need to be fed or need to be transferred by, you know, the hospital and nursing care?

Dr. Shepard: So I work at a Catholic home and they were fortunate enough to have a donor donate PPE. But they’re going through an awful lot of gloves and I understand that the price of a box of gloves that’s being charged has been exponentially increased. And they’re running low on gowns, so it’s still, it’s still a problem.

The dozen patients who are COVID-19 positive, they’re on droplet precautions. So staff going into the room has to have an N95 mask and all the protection. And the N95 mask, I understand, is a problem for some.

One other comment about staff. Lorraine talked about how terrified the staff are, which is correct. So at the nursing homes, a lot of the staff are calling in. Either they’re sick or they just don’t want to be there. And the nursing home has the dilemma, not only of having to staff the home, but find outside people, and the outside people could be bringing the virus into the home. In which case, people like my friend Alan could be suing the home for people coming into the home bringing the virus. So I really think the nursing home is in a pretty rough position as far as staffing goes.

Dr. Ketner: Nurse Doonan, I want to ask you this and then Dr. Shepard have you comment as well/ But you mentioned, you know, obviously we hear the word “unprecedented” all the time. You both have had tons of experience in your long careers, but what sort of emergency planning protocols are there for quarantining sick patients, if at all? Or even operating with, you know, half the amount of staff? Is this anything that people had thought about before? And in speaking about volunteers, what are best practices for controlling them?

Nrs. Doonan: I can speak for here in Connecticut, we had worked very diligently with The Department of Public Health when SARS was a factor and developing a pandemic plan. And we had the tools available to us. And we have a very strong, in the nursing home setting, mutual aid program. It’s a separate entity but it works with The Department of Public Health. And that will provide you resources, beds, throughout other facilities.

We didn’t activate it, I don’t believe soon enough. I think we had it in place. I think there was a hesitation until it became a crisis. It became crisis management. Which in my experience, and I will say we never experienced this before, but crisis management never works. Our purpose of developing a pandemic plan was to not have to do crisis management, and we did it again. I do think we’re learning from it. I think we’re further along now in the process, and people are being much more stringent, facilities are.

For instance, the first restriction was visitors. But then we allowed staff to come in from other states and not be licensed in our state for three months. We didn’t realize, yes we need the bodies, but don’t just think the visitors have the problem with the infection. It’s coming in from the outside. Patients are being kept in their rooms with the doors closed. But there’s times when you cannot do that. You have to be able to observe your patient. A door closed in a nursing home isn’t typically a good option. Assisted living, they’re living in apartments. The doors usually are closed, and surprisingly even in locked dementia units, but it’s not a great option in the nursing home setting for safety.

Dr. Ketner: And what do you think the hesitation was to not take this more seriously from the beginning?

Nrs. Doonan: In one word—financial. You know, you’re trying to keep business running as usual. I spoke to a nursing home today. I also coordinate a certified nursing program at a community college, and I called because our state DPH has let us know, go ahead with your clinical rotations for your nursing students and your nurse aid students. So in speaking to the clinical setting—and this is not a comment as to whether I agree with sending students in or not—but the nursing home that we’re contracted with, said, “No, we need the PPE for our staff. We’re not even going to consider bringing in students until September.” And they had stopped admissions except for their own patients who go out and come back. And the person said to me on the phone, “We’ve taken a major, a major financial hit because of our decision, but we feel it’s the right decision for our patients and our staff.”

So an answer to your question, I think much of the decision was financial. These are privately owned. Not all the patients had the requirements for a Medicare payment. And even if they did, if they were at risk, I think what they’re finding is we’re losing patients admissions, but we’d run a bigger risk of losing our patients if we expose them to COVID-19. Nursing homes are like incubators.

Dr. Ketner: Right, and Dr. Shepard, do you agree with that—that a lot of the decision making early on was financially related?

Dr. Shepard: I mean I don’t think it applied to my home, but like Lorraine said, it is unprecedented. In 40 years, I’ve never seen anything like it, and I don’t see how our quarterly meetings where we do emergency planning really never envisioned anything like this, and I don’t know that it was reasonable to envision anything like this.

I recall the swine flu in the seventies. They thought that might become a pandemic, and they had the vaccine, and the vaccine was used by quite a few people, and the vaccine turned out to have some side effects. So it’s like the inverse, a little bit, of what’s happening now where we don’t have a vaccine and we have the pandemic. So I think everyone was caught unprepared. I think the testing and the PPE, no one was prepared for a pandemic.

I guess I have a little problem with some of these articles coming out saying the nursing homes are at fault when even under the best of circumstances, this virus was going to get into nursing homes. And once it gets in, these are the most vulnerable patients in our society, and several of them were going to die.

Mr. Fuchsberg: I’m listening to Dr. Shepard, and I think it’s an interesting discussion. It’s been one that I’ve been having with myself and other experts that I’ve been talking to, both who specialize in nursing homes from a social work point of view (in other words, non-physicians), and from epidemiologists and infectious disease point of view. From both points of view—both very familiar with nursing homes. And you know what they say, we’re all swimming there, but when the water goes out, you know who’s wearing pants and who isn’t wearing pants.

So for example, they say that about a financial crisis. Many companies will go bankrupt, others will be better prepared. And I think that’s true of nursing homes. It’s true of businesses. It’s true of assisted living facilities. And so not every nursing home is prepared to the same degree, and not every assisted living facility is prepared to the same degree. And not everyone is operated as well.

So there are instances where things were not done as well as they could, and so you get these horrendous results. And while it’s true what Dr. Shepard said, this is a population that is at high risk unfortunately. I’ve been listening to Governor Cuomo on television saying very much the same thing. You know, it’s like, well this is a community that gets a snow storm. So this is where you really have to line up the plow trucks and line up all of the people to do the right thing because you have at risk more people. You’re going to lose more people.

So when you hear about nursing homes where these horrendous things, where the bodies piled up, for example—that was not inevitable, in my opinion. And at some point, what’s happened is because this was unexpected. But at some point it crosses a line and it goes beyond that, where the ball is completely dropped.

Dr. Ketner: What do you think is an acceptable degree? And I want to pose the same question to you, Nurse Doonan as well as Dr. Shepard about, you know, what constitutes gross negligence and what was just inevitable? Alan, why don’t we start with you?

Mr. Fuchsberg: I don’t know the answer to that yet. I can give you examples where people are not paid attention to, where you have a problem with the staff not wanting to be there and leaving, and where people were truly abandoned.

And on top of it, one of the reasons families are angry, in addition to what Lorraine has said, and I’m just going back to that for a moment, is that they were not called and told, “Maybe you want to pick up your family member that’s here because we’ve got pandemonium in this pandemic, and we don’t have enough staff. People are afraid to show up, and it might be safer to take them home if you can do that.” And people became confused with what the protocols are, not letting visitors in so people couldn’t see their family members. And they feel guilty leaving themselves at these facilities and not being communicated with. And families also feel very guilty because they care about their loved ones, had they only known.

I have a story of somebody who came in and found their father on his death bed after not being allowed to go in for a week, and nobody was taking care of him. And he hadn’t eaten in a week, and she didn’t get a phone call, and he wasn’t moved to a hospital, and he wasn’t moved to Jacob Javits Center, and he wasn’t assessed properly because he did have the virus, and he was being left there to die. Courts in the future will say where that line gets drawn. It’s hard to say.

Dr. Ketner: It seems like communication and information were really key here. Do you think the nursing homes that did over-communicate with the families of residents and also with staff are in the clear for being transparent?

Dr. Shepard: You just mentioned two words, which I think summarize the thing in a nutshell: transparent and communication. I think the one most of us know about is Kirkwood in Washington state. Infections going on for weeks. They didn’t notify The Department of Health. They didn’t notify the families. So transparency and communication—the communication between nursing and the doctor, nursing and the family staff, I think are key. And if you have transparency, and you have communication, then I don’t think you should have a litigation issue.

Nrs. Doonan: I do agree with Dr. Shepard, that transparency and communication are very important, especially in any medical setting, because there’s the issue of trust. You know, in a nursing home, the caregiver that’s viewed as primarily is the nurse. By nature of being a nurse, it’s a trusted position in our country. And, in this case, the nurses are sick. They are not wanting to be there, I agree. But they’re trying. I want to make sure to say that there’s a lot of good staff out there. That it’s the system—it’s not the staff, in a lot of the cases. I don’t know too many nurses that don’t want to deliver good care to their patients. But if the system doesn’t allow for that, therein lies your problem.

I guess I have a question for Dr. Shepard. Is where you work a single entity, or are the decisions made at the corporate level? Because I think that also affects transparency, because if it’s not made on site, where you’re seeing what’s happening to your patients and your staff, it becomes less transparent. It’s sort of removed decision-making, and I think I’ve seen some of that happen as well.

Dr. Shepard: Where I’m working now is a Catholic home that’s part of an order that’s been taking care of the elderly poor for over a hundred years. So they have a little experience in the matter. But in the past, I’ve certainly worked at Medicaid-based facilities that I think more likely to have the problems that you and Alan are referring to. So I’ve worked at both. But either way, the key is, you have nurses who communicate with the doctor and communicate with the patients. And it’s really more of an individual thing that I see it as more than an institutional thing.

Dr. Ketner: Alan, I guess I’ll ask you, do you think more lawsuits will come from mourning families or disgruntled sick staff that weren’t given proper equipment to do their jobs and maybe brought this home to their own families?

Mr. Fuchsberg: I can’t say because laws were passed giving immunity to hospitals and nursing homes and assisted living facilities, immunity from liability during this pandemic crisis, particularly during the emergency period. And for example, in New York, the emergency period is still going on.

But I would like to respond to something else Dr. Shepard said, which is interesting. He said, the facility I work at, which is, well I’m assuming from, presuming from, the way he spoke, a well financed that does not just rely on Medicaid funding—we don’t have the problems that we may have in a facility that’s purely Medicaid-based, that’s serving a population that cannot afford to pay more.

And the question—the fundamental question—becomes, should people in a Medicaid facility, as opposed to a Medicaid-plus facility or Medicare facility, really not receive the same level of care during a crisis period like this? And therefore not just not have nicer features, but actually have their health put at risk? And I think it’s a very fundamental question, and it’s kind of the one that we would like to approach in our lawsuit under the Americans with Disabilities Act, and go into federal court and ask them to assess these people’s rights to care as opposed to the cost.

Interestingly, I was talking to a senior consultant on many nationally and internationally recognized organizations that look at the quality of care of alike nursing homes and assisted living facilities. And the issue that I just brought up came up in the state of Florida, where he was very active, and then they were investigating it, and then the state backed down because they realized the amount of money these facilities were receiving, they couldn’t afford to do more. And so rather than raise the bar, so that instead of maybe giving some people tax breaks, we would keep the tax money and raise our amount of money we give to these facilities, they stepped away from upping their regulations as to the quality of care that should be given at these facilities. It’s a, you know, an issue that we’re always talking about.

Nrs. Doonan: I have a question for Alan in regards to the civil immunity, because we have it here too. And my understanding was it was for individuals who had acts of omission that weren’t malicious or intentional. But it didn’t absolve healthcare workers from intentional neglect or abuse. And my question is, does it absolve the entity that owns, or is responsible for, the administration of a nursing home or assisted living? Is that the intent of it?

Mr. Fuchsberg: There are federal standards and there are state standards and there’s some overlap. Some of the federal has to do with what medications you give, like the malaria medication, and getting immunity to that.

But to answer your question—no, the facility would be at risk too. But the interesting word you used was “intentional”. And I don’t think you could say, this is where I’ll agree with Dr. Shepard—you’re not going to say anyone intentionally wanted harm to happen to anyone. So immunity is a very, very high bar. If you’re talking about intentional conduct.

Gross negligence could be not quite as high of a bar as compared to reckless indifference. I think maybe a good definition there is indifference. Not putting somebody in their room knowing they may be sick, leaving them alone for a week, knowing they’re not eating. No one’s taking care of them, not calling the family. You know, on one end you can say, “Look, I’m overwhelmed. What do you want me to do?” On the other hand, somebody else could say that’s gross negligence.

Nrs. Doonan: You know how on a national level, when it was thought we were going to have a shortage of ventilators, we’d been made aware that decisions would be made as to who would get put on a ventilator and who would not. And it would be in part based on the prognosis for that individual. Which obviously, if you had an elderly person versus somebody who’s 40, the decisions going to be made if there was a shortage. Do you think that mindset impacted how the care is going in the nursing homes through COVID-19—that it’s sort of ageism?

Mr. Fuchsberg: Lorraine, you are on the ground. I’m interested in what you, what you’re thinking.

Nrs. Doonan: It’s a horrible thought. But you have to wonder with the slowness of getting all these cases and the Washington Post article today that the cases are soaring. And are they really soaring or whether there was a delay in reporting getting treatment because of ageism? That has occurred to me, which….I hope that’s not what’s actually happening here.

Mr. Fuchsberg: The devil is in the detail. There’s going to be a lot of stories, individual stories that are going to come up. There’s going to be a lot of rash decisions.

I wrote an article on this that was recently published in Bloomberg News, and fortunately the CDC now and other people have come out with a lot of new guidelines to deal with the pandemic. I’m not saying that they’re inclusive of everything. And also hospitals and medical centers quickly came up with some guidelines. So even though faced with a choice like that, you’re in a panic state, you’ve got to slow down. Take a deep breath. Talk to the people around you. Look at what the rules are. Maybe committee the decision so you’re all in on it together, making a rational, rather than an impulsive decision.

But it’s a very hard one to make. And fortunately, in the end, I don’t think it was made too often. But some people might’ve felt they had to make that decision. And you wonder, in nursing homes where 30 people have died and so on, there must’ve been some really dark times and difficult and complicated decisions that were being made—rightfully or wrongfully.

Dr. Ketner: Alan, I couldn’t let you go without asking you: obviously we have two on the phone, but what kinds of expert witnesses you’ll likely start to source for some of these nursing home cases regarding COVID.

Mr. Fuchsberg: I have sourced an epidemiologist from Yale University. He’s very familiar with nursing homes, so from a medical point of view, that was very important.

The Expert Institute also introduced me to a prominent social worker, who is on several quality committees to take care of the kind of population that could be in a nursing home. But in his case, more often than not in assisted living facilities, who have the same comorbidities as people in nursing home by definition under Medicaid and Medicare in New York state, for example, but don’t need the same level of one on one attention and can move around to some degree independently.

So those are two excellent experts that work to explain my case from somebody that understands the needs of this population and understands nursing homes from an administrative point of view, and assisted living facilities, and somebody who understands the seriousness of COVID-19.

Dr. Ketner: Thank you, Alan. Nurse Doonan, any final thoughts before we wrap up here?

Nrs. Doonan: The only final thought would be thoughts to what’s going to be the outcome when this is all over for the healthcare environment. I don’t think we’re going to go back to the environment we were in before. I think it’s going to be a new normal, you know, whether there’ll be, as they’re predicting, PTSD experienced, it remains to be seen.

Dr. Ketner: And Dr. Shepard, I’ll give you the last word here.

Dr. Shepard: I agree that the new normal will not be the same as what it was before.

Dr. Ketner: That’s a wrap on our first episode of our limited podcast series of COVID-19: Diagnosing Liability. I really, again, just want to thank Dr. Shepard, Nurse Doonan, and Alan for joining us today and sharing your thoughts. It’s been incredibly insightful. To all of our listeners, please stay safe.