The past five or six months have been difficult for all Oklahomans. For the residents of long-term care facilities, the people who care for them, and the people who care about them, it has been especially so.
The vulnerability of long-term care facility patients makes them particularly susceptible to COVID-19, which has caused them to be locked into virtual isolation from the outside world and even each other. In many facilities, residents are restricted to their rooms most of the time and common areas such as dining halls are closed.
The caution, though, is well-founded. As of Thursday, 42% of Oklahoma deaths attributed to COVID-19 were long-term care residents or staff, according to state data.
This, despite those facilities accounting for only about 6% of all cases.
Still, families and friends think the isolation goes too far and has lasted too long. They worry about residents' mental and physical health, and say phone calls, Zoom chats and waving through windows is not enough.
An Oklahoma House of Representatives committee held an interim study on the issue Wednesday, with providers and patient advocates invited.
Rep. Tammy West, R-Bethany, said she requested the study to find out "what we have been doing, what we are doing and what we need to be doing."
West previously has addressed the use of psychiatric drugs to treat non-psychiatric residents, and is generally concerned that at least some residents are being neglected.
"We would not stand for this with children," she said, but conceded that "there is no magic bullet."
Some say long-term care facilities should be doing more to facilitate social interaction and oversight.
"We should not allow facilities to be the sole determiners of if and when there will be visitation," William Whited, who as state ombudsman mediates disputes between long-term care facilities and their residents and residents' families, told the interim study.
The facility operators say it's not that simple.
"I am empathetic and appreciate the need," said Steven Buck, executive director of Care Providers Oklahoma, an association of long-term care providers. "But there is going to have to be significant amount of caution and discretion."
Buck said operators never know how COVID-19 might be introduced into their facilities. He noted that an outbreak in an Altus nursing home appears to have originated with a visitor from Tulsa, and that another deadly outbreak seems to have begun with an asymptomatic staff member.
"We're being held accountable for every single thing, every single death," said Kimberly Green, chief operating officer of the Diakonos Group, which operates 21 facilities in Oklahoma.
"But it's being brought in from outside. We are COVID-free in the buildings now, but ... (COVID) is coming in from the outside," Green said.
"If society helps us out and will do the things it's supposed to," she said, contact with residents would not have to be so limited.
In Oklahoma, long-term care facilities are allowed to open under a three-phase process but are given considerable discretion in doing so. It appears none have removed all restrictions to this point and all are limiting access to residents and personnel.
"I've had people say ... staff gets to go in," said Green. "It's a weighted risk. I have to have the staff to take care of people. Have to."
Green said she knows people are angry and fearful and she's willing to let them take some of that out on her, but that she has to consider all the implications "so we don't see here what happened in Washington and New York."
Some family members and advocates, though, think management is at best overprotective and at worst reluctant to reveal just how thinly stretched they are. At Wednesday's interim study, a man from Ardmore detailed his lengthy struggle with a facility where his mother lived until her recent death.
Whited and Chad Mullen of AARP-Oklahoma said the state health department should set more definite visitation rules and should do more to enforce an existing provision for compassionate care exemptions.
"What I'm understanding is that a lot of the facilities are limiting it to hospice care or even the last three days of life," said Mullen.
"Residents do have a right to visitation," Whited told the interim study.
Whited went a step further, suggesting that restricted admission is leading to a lower quality of care.
"All of the sudden, in a blink of the eye, (facilities) are allowed to operate with little to no oversight from the outside," he said.
Green bristled at that suggestion.
"That's really offensive," she said. "We're doing the very best we can."
Green said instead of the usual annual state inspection, known as a survey, her facilities have been visited as many as four times by special state COVID-related teams.
"They don't just come in and look at your paperwork," she said. "They walk through your entire building and look at everything."
Diakonos facilities have seen varying degrees of infection but are generally at the low end of the scale — as, indeed, are most of the state's long-term care facilities. While many have had some cases, only 12 account for nearly half of the 333 long-term care facility deaths as tracked by the state.
So while the apparent lack of infection at most facilities may increase the frustrations of family and friends, it also illustrates how deadly the disease can be once it does get inside.
Dr. Alexander Frank, a long-term care specialist who spoke to the interim study, said the disease is so apparently random. He noted his own wife was "completely healthy" and wound up in the hospital with "COVID pneumonia."
"COVID-19 doesn't care who you are," Frank said. "It has hit every sector. It has hit every building type ... 5-star (rating), 3-star, 1-star, it doesn't care. There is asymptomatic, there is extremely symptomatic, and we can't figure out why.
"It's like a secret agent," he continued. "I've had patients in the same room not turn positive. I've had buildings with a whole wing (positive). Some with only staff members. There's no way to predict this."