WEST PALM BEACH, Fla. — In late May, Jean-Junior Vertu and Marie Julceus, two employees at a long-term care facility near West Palm Beach, Fla., took a routine test for the coronavirus and then went about their workday. They felt fine. Mr. Vertu, a dietary aide, pureed food for the residents while listening to Haitian dance music. Ms. Julceus, a nurse, helped them eat.
When their seven-hour shift ended, they went straight to their second seven-hour shifts, at different nursing homes.
Little did they know that, as they traveled several times that week from one facility to another, they had been taking the virus with them.
“When I got the message that said I was Covid positive, I got scared,” said Ms. Julceus, 50, who learned she had the virus at about the same time that Mr. Vertu did. “I took my temperature, I laid down and said, ‘Oh my God, oh my God.’”
Although it is often impossible to pinpoint exactly who spreads the virus and how, public health experts trying to understand the virus’s lightning surge through nursing homes have identified staff members working at multiple facilities as an important risk factor.
Florida, which has one of the country’s highest populations of older people, has for several months had a strict ban on visitations and prohibited hospitalized Covid-19 patients from returning to nursing homes until they had twice tested virus-free. Yet new outbreaks at the state’s nursing homes have continued to emerge, suggesting that staff members — especially those who travel from one facility to another — are the most likely explanation.
At Oasis Health and Rehabilitation Center in Palm Beach County, where Ms. Julceus worked nights, there have been 17 deaths and 73 cases among staff members and residents, infections whose origins have not been clearly identified. Recent research shows that the center is connected, via shared staff, to 25 other “high-risk” facilities that have also had outbreaks whose origins may be staff-related.
Health policy analysts say that poorly paid staff members working two or more nursing home jobs may be significant contributors — usually unwittingly — to the spread of the virus. Several nursing home employees in Florida have been terminated after being accused of coming to work sick.
“Unfortunately, staff have been the largest vector towards bringing Covid into nursing homes around the country,” David Grabowski, a professor of health care policy at Harvard Medical School, said.
“I don’t know that there’s a lot of other pathways in,” he said. “Florida is pretty closed down, and yet they’ve seen a rise in cases.”
Across the United States, more than 62,000 nursing home residents and staff members have died from Covid-19, about 40 percent of the nation’s coronavirus fatalities. Florida has counted 4,232 deaths at long-term care facilities, according to state data, with such facilities accounting for more than half of all Covid-19 deaths in June. Then in July, over a three-week period, the number of residents testing positive doubled.
A recent report by the National Bureau of Economic Research that looked at geolocation data found that 7 percent of smartphones appearing in a U.S. nursing home also appeared in at least one other elder facility, even after visits by patients’ friends and family members were restricted.
The typical nursing home has, on average, staff connections with 15 other facilities, said the report, which concluded that “eliminating staff linkages between nursing homes” could reduce coronavirus infections in nursing homes by 44 percent.
In Florida, the researchers found a web of interconnected nursing homes and assisted living facilities, particularly in Miami-Dade County, which has one of the highest concentrations of them in the country.
Oasis Health and Rehabilitation Center, where Ms. Julceus worked, has staff members who work at 25 other facilities, including one home that has employee connections to another 56. Golden Glades, which had an outbreak in May, is connected to 40 other facilities, many of which also had sizable outbreaks.
A lockdown on visitations and transfers of known coronavirus patients, in place after March, was initially thought to be the silver bullet that would clamp down on new nursing home infections.
“What our research is suggesting is that the real culprit here, epidemiologically, appears to be shared staff,” said Keith Chen, professor of behavioral economics at the U.C.L.A. Anderson School of Management and a lead author of the report.
Nursing homes generally struggle with finding enough staff and, faced with laws that require a certain number of staff hours per resident, “there’s a tremendous number of staffing agencies that spring up to spread workers across nursing homes,” he said.
“But that’s exactly what you don’t want in the middle of a respiratory pandemic,” he added.
Employees working at more than one facility are thought to have contributed to the country’s first coronavirus outbreak in a nursing home in Kirkland, Wash., according to the Centers for Disease Control and Prevention.
“Limitations in effective infection control and prevention and staff members working in multiple facilities contributed to intra- and interfacility spread,” the agency said at the time.
Life Care Centers of America, which operates about 200 facilities nationwide, including the Kirkland facility in Washington and 21 nursing homes in Florida, stopped using contract workers after the pandemic began, Davis Lundy, a spokesman for the company, said. Employees now work in only one building, he added.
One temporary staffing agency in Florida, Interim HealthCare, said it contracts employees to three nursing homes in the Miami area, all of which have had outbreaks. Krystal Bay Nursing and Rehabilitation Center reported seven deaths and at least 39 cases among staff and residents; West Gables Health Care Center, 10 deaths and 88 cases; and Seasons Gardens, no deaths but 36 cases.
Daniel Kern, a manager at Interim HealthCare, said he knew of about eight workers from his agency who had tested positive. All of them presumably would have worked at the affected facilities. But he said he was confident they did not transfer the virus because the agency provided its employees with ample personal protective equipment.
Officials at the nursing homes declined to discuss the matter. The Florida Department of Health, which has required nursing homes to test their staff members every two weeks, declined to discuss the role of staff members in the spread of the virus and did not make state nursing home inspectors available for interviews.
Steve Bahmer, the chief executive of LeadingAge Florida, a trade body for nursing homes, said the risk of staff-spread infections exists even without employees who work at multiple facilities.
“If there is significant community spread, staff are at risk of contracting the virus and bringing it into the nursing home or assisted living facility,” he said.
Nursing home experts say that spread of the disease can be exacerbated by low pay scales that force nurses and aides to seek work at more than one facility.
“We don’t value this work force, and if we paid them a full-time position or a living wage, they wouldn’t have to do all this moonlighting across facilities,” Dr. Grabowski of Harvard said.
Many staff members are not employed full time even though they essentially do two full-time jobs a day, sometimes 14-hour-long stretches separated by a break of just one or two hours. Most get paid close to minimum wage and do not get sick leave.
Mr. Vertu, 33, the dietary aide, said he gets paid about $9.80 an hour, a salary he says has remained roughly unchanged since he started working 14 years ago. Ms. Julceus, who is a certified nurse, earns about $12 an hour.
Sheryl Carlos, 56, works three jobs seven days a week in Port St. Lucie, north of West Palm Beach. One is at a nursing home and another at a retirement community; she earns extra income caring for a couple of people in private homes. She makes about $13 an hour.
“Let me tell you something, I don’t have a life,” she said recently as she drove back home in the early morning after finishing a nine-hour shift. “If some jobs were paying you enough, you wouldn’t have to be working like that.”
Nursing home advocates say that most facilities have little control over what other jobs staff have. It is hard to raise wages, they say, when revenue is fixed by the state or Medicare.
“There are really good owners out there who do a good job and try to pay people more,” said Dr. Alice Bonner, who advises on care of older adults at the Institute for Healthcare Improvement.
“But if you’re getting mostly Medicaid clients in your nursing home, and you’re getting very little money for those clients, and it’s not covering your costs, then it’s really hard to increase salaries and benefits too.”
In May and early June, one of Mr. Vertu and Ms. Julceus’s employers, Avante at Lake Worth Rehabilitation and Skilled Nursing, fired them on the grounds that they had violated policy by coming to work even though they had the coronavirus, according to the employees and their union, which has filed grievances over the dismissals.
Both had been tested at their other jobs, and had continued working while they waited for their results. They insist they had no way of knowing they were sick; they had no symptoms, and their tests, taken at other workplaces, had not come back yet.
“I didn’t bring in the virus,” said Mr. Vertu, who had worked at the facility since 2006. “They call me a criminal. It’s terrible.”
John Hornack, general counsel at Avante Group, said the company could not comment because a union grievance was pending on behalf of the two employees.
Some of those working at multiple nursing homes said they felt that the residents needed them during the pandemic more than ever.
Margalie Williams, 62, a certified nurse in Miami, has survived breast cancer, three strokes and, most recently, the coronavirus.
Ms. Williams said she believed she contracted the coronavirus in early March, after an 80-year-old resident she took care of at Golden Glades developed a high fever.
She was sent to the hospital, where she got tested, and came back. As she waited to receive her results, Ms. Williams continued treating her, and after her shift at Golden Glades was over, she went to her next job at Miami Shores.
Soon, Ms. Williams started feeling unwell too. When she got tested a few days later, the result came back positive.
Her recovery took nearly five months, but now she is back at her two nursing home jobs. The residents need her, she said.
“If they don’t see you one day they tell you, ‘Oh Maggie, I miss you,’” she said. “You can’t leave them.”