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It began with a single nurse who felt ill after completing a shift last Wednesday.

The latest string of COVID-19 cases at Hale Nani Rehabilitation and Nursing Center, Oahu’s largest nursing facility, now involves two employees and eight residents, the Department of Health said Thursday. More cases will undoubtedly emerge in the coming days, health officials say.

It’s been nearly three months since the pandemic triggered stay-at-home orders and statewide shutdowns of businesses. But as other aspects of life return to normal, elderly care facilities like Hale Nani continue to be under strict lockdowns — no visitors are allowed, and symptom screening has become a regular part of the routine.

But in recent weeks, a few cases found among elderly care employees and now patients have been sounding alarm bells for some industry and senior advocates.

According to state officials, Hawaii has had very few COVID-19 cases that involve nursing home and other elderly care facilities.

This week’s events at Hale Nani show just how quickly COVID-19 can take hold, and sometimes the first viral diagnostic tests cannot even detect it. Some kupuna advocates are wary the state is not doing enough preemptive monitoring. They’re calling on the state to conduct more proactive surveillance, testing, and for more transparency overall in its reporting of such cases to the public.

“As the economy opens up, the potential exposure for at risk kupuna will increase substantially,” said Keali‘i Lopez, AARP Hawaii state director. “Our concern is we want assurance and the confidence that the state is prepared for the second wave.”

A Need For Transparency

Nationally, nursing homes have accounted for nearly 40% of all coronavirus deaths in the U.S.,

The Hale Nani cluster of cases is the largest associated with a Hawaii nursing facility to date, but it follows three recent cases that popped up among staff at two different care facilities last week.

Two kitchen staff members at the senior living community Kalākaua Gardens did not work directly with patients, but their diagnoses in early June prompted the testing of 175 employees, all of whom tested negative.

Another case also confirmed early this month was found in a worker at Maunalani Nursing and Rehabilitation Center, who is isolating in quarantine but otherwise healthy, the facility’s .

Back in April, an elderly resident of on Maui was believed by health officials to be infected while at Maui Memorial Medical Center before transfer to Hale Makua.

The state’s reports of such cases are frustratingly sporadic, said Lopez, noting she’d like to see an online listing provided by the state that includes information about tests conducted, the results, and whether there have been any deaths in that facility.

“At minimum the public should be able to go to a set website on the Department of Health website where they can readily determine whether a specific facility — meaning the name and address — has had someone test positive for the covid virus,” she said.

DOH Director Bruce Anderson says these cases are made known publicly as they arise via daily reports provided by the Hawaii COVID-19 Joint Information Center, or during press conferences.

There have not been a significant number of cases in long-term care facilities to merit an online tracker, he said, but if case numbers increase, the department would consider it.

“We don’t keep the facilities secret,” Anderson said in an interview with Civil Beat last week, before the new cases at Hale Nani were confirmed. “They do have to notify all the residents and family when they have a positive case. Undoubtedly they will.”

But because DOH doesn’t provide an online tracker of such cases, it wasn’t until recently that the public got a glimpse of such reporting: New federal rules require nursing homes to report suspected cases in staff and residents as well as provide updates about personal protective equipment and staffing levels.

Skilled nursing facilities are and to residents and their family members by 5 p.m. the following calendar day after a “provisional diagnosis,” meaning a likely diagnosis based on “clinical history and signs or symptoms, pending laboratory confirmation.”

However, the first batch of nursing home data is incomplete, and even state officials pointed out an erroneous death report. That federally mandated reporting may not always include smaller care home operations, which are common in Hawaii.

All the more reason for a more consolidated and timely reporting effort, said Suzie Schulberg, president and CEO of Arcadia Family of Companies, which operates Arcadia and 15 Craigside. In total, those facilities have 590 residents and another 170 home health and adult day care clients. She said she finds out about cases via the press or through the “coconut wireless.”

“When you talk about consistency and transparency, we’re running on fumes here because we share staff,” said Schulberg. “People are walking on eggshells. Covid is going to get into our buildings, there’s no doubt. We all have to be there to support each other and take the ego out of it.”

Already Under Lockdown For Months

A May 6 assessment by the Office of Health Care Assurance obtained by Civil Beat found Hale Nani staff to be in compliance with all of the recommended COVID-19 prevention protocol.

Coincidentally, a second pre-scheduled site visit to check infection control measures was conducted on Tuesday. Results of that June 16 assessment showed Hale Nani was still in compliance with COVID-19 rules, said Keith Ridley, chief of OHCA.

Officials say Hale Nani has been doing what it was supposed to, in terms of preventing an outbreak.

At a Monday press conference, Anderson said Hale Nani had been doing a “perfect job” and noted staff were monitored for symptoms three times a day.

Nine of the 10 people infected have been residents or employees who worked or lived in the same nursing unit, according to the Hawaii COVID-19 Joint Information Center.

As of Thursday, 307 tests of Hale Nani staff have come back negative, according to DOH. Dr. Scott Miscovich, who is leading the testing, said another 247 residents have been tested as of Thursday. At the request of Hale Nani administration, there will be facility-wide testing of all staff and residents on a weekly basis until at least two weeks pass without new diagnoses, Miscovich said.

“When there has been exposure in a healthcare setting like this, resulting increase in infections are possible and unfortunate, but not unexpected. We could continue to see a number of new cases over the next two weeks,” said Dr. Sarah Kemble, Deputy State Epidemiologist.

Caretakers of the elderly are already under immense pressure across the state.

Back in March when lockdowns began, all facilities were asked to abide by new protocol: allow no visitors, screen staff for fevers or respiratory symptoms before they begin their shift, and monitor patients daily for the sometimes subtle signs and symptoms of respiratory infection, among other measures. ��

It’s been months of operating under “really stringent” guidelines, Schulberg said, which can take a mental toll on staff and residents alike.

But there’s good reason to be on alert. Many caretakers work at different companies, says Schulberg, who estimated at least 10% of Arcadia staff work other jobs.

“It’s a tight labor market, and when you look at facilities, you have people who have two or three jobs,” she said. “Sharing of staff has been the number one concern that a lot of care facilities have. We saw it happen in Washington (state) because the staff brought it into the building.”

Oversight of whether facilities are abiding by the COVID-19 protocol is conducted by the DOH Office of Health Care Assurance. Elderly care facilities are required to report to the state by telephone as soon as they have a provisional diagnosis of COVID-19.

Calls For More Testing

Diagnostic COVID-19 tests are not foolproof. A found some people tested too early in the course of their infections had false negative test results.

That’s one of the major reasons why Hawaii state health authorities have maintained that

In Hale Nani’s case, the initial move was to test everyone in the ‘affected unit’ immediately on Friday, according to Anderson. That initial round of testing yielded negative results. Once other cases arose early this week, more testing began across the entire facility.����

Schulberg and Lopez would rather see more regular testing as a preemptive approach.

It did take some time for testing to ramp up in Hawaii, but collectively, private laboratories and the DOH State Laboratories Division can test as many as 3,000 specimens daily. State officials have said it’s sufficient for current caseloads, and there’s even .����

That raises a question about why more routine testing is not currently implemented preemptively at elderly care facilities, some say.

Arcadia decided on its own accord to do a facility-wide screening, because Schulberg said she felt it was the “right thing to do” and she grew alarmed by the recent cases elsewhere on the island. There is also new guidance from the federal government that encourages such baseline testing.

Federal guidance has been Officials now recommend initial tests be conducted as a baseline and interval testing be conducted thereafter, especially in states looking to reopen the economy.

Arcadia’s hundreds of tests came back negative, but the peace of mind is only temporary, Schulberg said. To maintain a sense of reassurance, such testing would have to become routine, so Arcadia officials are considering how to maintain interval testing in the future, on top of symptom screening.

Despite the limitations of diagnostic testing, Lopez and Schulberg still say testing is an integral preventative step to avoiding such scenarios going forward.

“With the fear of asymptomatic staff walking around, there’s a real concern that the virus could spread silently as it does,” Schulberg said. “I get the science of it and the numbers behind it, but if we could be proactive in doing regular randomized interval testing, increased surveillance, or whatever it may be, that also is going to give a boost by lessening anxiety and fear for staff, residents and for families.”

Lopez added, “If the state doesn’t feel that it’s economically feasible to test everyone, I can only say that should there be a significant outbreak, the economic cost of that is going to be much higher than testing would be. Take steps to ensure and prevent and take precautions, rather than take the chances that we’ll catch it on the back end.”