What Happened In New Jersey’s Nursing Homes?

New York has been, far and away, the worst state to be in for the coronavirus epidemic in the United States. Especially for elderly Americans with illnesses that require they live in nursing homes or long term care facilities, where one single poorly-considered policy implemented after the state's governor and public health officials began to panic when the going got tough has needlessly cost thousands of lives.

New Jersey has been the second most-impacted state or territory in the U.S. thanks to its proximity to New York City, which has been the nation's epicenter for the coronavirus epidemic. In fact, you can tell which counties of New Jersey can be considered to be part of New York City's greater metropolitan area just from a map indicating the number of confirmed COVID-19 cases have been recorded in each.

That close proximity to New York means that New Jersey has shared a very similar experience in dealing with the SARS-CoV-2 coronavirus. The following charts show the daily progression of the epidemic in New Jersey, the amount and results of medical testing in the state, and also the rolling 7-day totals for newly confirmed cases and deaths, all of which have generally tracked along with New York, although in the third, rightmost chart, you can see New Jersey was more successful in flattening its curve compared with how the spread of the coronavirus played out in New York.

New Jersey: Daily Progression of COVID-19, Daily Test Positivity Rate, and Rolling 7-Day Totals for Newly Confirmed Cases and Deaths, 10 March 2020 through 20 May 2020

While New Jersey's situation has improved significantly from what it was just three weeks ago, it too has seen an outsized number of deaths occurring in the state's nursing homes and long term care facilities, with numbers similar to New York. Unfortunately, the reason that is the case is the same: New Jersey Governor Phil Murphy and the state's public health officials copied what Governor Cuomo did in New York in mandating the state's nursing homes and long term care facilities admit patients known to be infected with the SARS-CoV-2 coronavirus, which ran rampant through the nursing homes, needlessly contributing to the premature deaths of thousands of New Jersey's most vulnerable residents. The following chart shows the results of that policy has been since it was adopted on 31 March 2020:

The question is why did New Jersey Governor Phil Murphy copy such a misguided policy? When the state of New York's Department of Health issued its infamous directive on 25 March 2020, the policy was slammed in the pages of the Wall Street Journal the next day. Less noticed however was a press release issued by the Committee to Reduce Infection Deaths on the same day, in which the anti-hospital infection public interest advocacy group also slammed New York's policy, but which cited an example from New Jersey for how the state should work to prevent the spread of coronavirus infections within the state's nursing homes.

Dear RID Friends and Healthcare Providers:

The State of New York is adopting a dangerous new policy requiring nursing homes to blindly admit patients infected with Covid-19, according to a new report in The Wall Street Journal.

Cuomo's edict, if reported correctly, dooms thousands of elderly to illness and likely death. Basic infection control says to identify and contain. Cuomo's edict does the opposite: conceal and spread. It spreads the infections to nursing homes and forcing homes to operate in the blind, not even knowing which incoming patients are coronavirus carriers.

A model of what should be done is how CareOne, an exemplary facility in New Jersey, knowingly emptied one of its locations to protect other uninfected residents and then welcomed coronavirus patients from St. Josephs to that facility.

You can find out more about the model New Jersey was setting here. Clearly, something dramatic changed, because just six days later, the Murphy administration issued a directive with the following instruction mandating that nursing homes and long term care facilities in New Jersey to admit patients with contagious coronavirus infections (the underlining is contained in the original document):

No patient/resident shall be denied re-admission or admission to the post-acute care setting solely based on a confirmed diagnosis of COVID-19 … Post-acute care facilities are prohibited from requiring a hospitalized patient/resident who is determined medically stable to be tested for COVID-19 prior to admission or readmission.

What changed? We've pieced together the story as best we can from contemporary reports, where the first indication that Governor Murphy would soon follow Governor Cuomo's bad example came on 28 March 2020, as a number of hospitals in northern New Jersey began to divert, or to not accept, new patients for 4-hour blocks of time because they were either at or near their full capacity.

The timing of these events coincides with the worst case projections the influential Institute for Health Metrics and Evaluation (IHME) has issued for New Jersey, which as in New York, was used by state policymakers to make decisions. In this case, we think those early diversions prompted New Jersey's leaders into thinking they were facing a worst-case scenario. The following chart shows what the IHME's projection for the number of hospital beds above New Jersey's available capacity looked like on 30 March 2020, just before Governor Murphy's administration implemented its policy that would allow hospitals to move as many asymptomatic or partially recovered coronavirus patients as they could to other medical facilities, which in the case of elderly patients, would mean moving them to nursing homes and long term care facilities throughout the state.

So the motive for Governor Murphy's administration to adopt the same policy that Governor Cuomo had less than a week earlier is the same. For Governor Murphy however, the lack of condemnation or criticism for Governor Cuomo's disastrous move other than in the Wall Street Journal cleared a path to act with impunity, where he could safely assume his own deadly action would not be challenged by the nation's media.

To understand what happened, let's take a moment to review the chart showing the 7-day rolling total for new coronavirus cases in New Jersey. On 31 March 2020, the number of confirmed cases was rocketing upward, which would go on to peak at 25,437 new cases per week on 7 April 2020. After that point, the state's curve flattened out under that level for the next three weeks, before the incidence of newly confirmed cases began to fall rapidly after that point.

Within that period, the number of COVID-19 hospitalizations peaked on 14 April 2020, just within the state's available capacity to accommodate these patients at its hospitals, thanks in large part to efforts they had made to expand their capacity in the preceding weeks. In the following chart, we've pieced together the number of New Jersey's long term care facilities that reported housing coronavirus patients at various points throughout the state's coronavirus epidemic from various reports, along with the figures the state's Department of Health began reporting for these facilities on 20 April 2020.

Before Governor Murphy's directive forcing nursing homes to admit infected coronavirus patients on 31 May 2020, 73 long term care facilities in the state reported having infected patients. On 8 April 2020, that figure had risen to 123. Twelve days later, with the number of new coronavirus infections throughout the state reaching and holding near its peak, the state's Department of Health began reporting the number of cases within the state's nursing homes, where that number had skyrocketed to 425 facilities.

That figure has continued to grow, where though 20 May 2020, the New Jersey Department of Health reports a cumulative 529 of the state's nursing homes long term care facilities have housed coronavirus-infected patients.

That outcome did not happen by accident. Nursing homes and long term care facilities are geographically dispersed, where they can be thought of as relatively isolated islands, where an outbreak of infections at one would not travel to others on its own. It took a deliberate policy by the governor and the state's public health officials to make that happen. And once it did, with recently transferred contagious patients exposing nursing home staff members to the infection, who in turn spread it to previously uninfected, but especially vulnerable nursing home residents with fatal effect.

The spread of coronavirus infections within New Jersey nursing homes and long term care facilities resulting from the Murphy administration's policy can be seen in the following chart, where we find from the available data that the number of infections at these facilities begins to take off after 31 March 2020, where by 20 May 2020, New Jersey's nursing homes account for 19% of all confirmed coronavirus cases in the state:

Cumulative COVID-19 Confirmed Cases in New Jersey, Total Cases in State and in Long Term Care Facilities, 1 March 2020 - 20 May 2020

The deadly impact of the Murphy administration's policy can be seen in the next chart, where we find that New Jersey's nursing home residents account for over 51% of the deaths attributed to the COVID-19 coronavirus in New Jersey.

Cumulative COVID-19 Deaths in New Jersey, Total Deaths in State and in Long Term Care Facilities, 1 March 2020 through 20 May 2020

Were any of these nursing home deaths inevitable? It would be fair to assume that whatever portion of coronavirus infections that had made it into the 73 nursing homes that had them before Governor Murphy's policy went into effect on 31 March 2020 would be deadly, but only within those facilities. The Murphy administration's policy expanded the viral risk to hundreds of more facilities, where these COVID-19 attributed deaths could wholly have been avoided. If only Governor Murphy hadn't been a copycat of Governor Cuomo.


2019 Novel Coronavirus COVID-19 (2019-nCoV) Data Repository by Johns Hopkins CSSE. CSSE COVID-19 Time Series Data: Confirmed U.S. [CSV File]. Last updated 20 May 2020. Accessed 20 May 2020.

2019 Novel Coronavirus COVID-19 (2019-nCoV) Data Repository by Johns Hopkins CSSE. CSSE COVID-19 Time Series Data: Deaths U.S. [CSV File]. Last updated 20 May 2020. Accessed 20 May 2020.

New Jersey Department of Health. NJ Long Term Care Facilities with COVID-19 Outbreaks. [PDF Document]. Posted: 20-Apr-2020, 22-Apr-2020, 24-Apr-2020, 27-Apr-2020, 29-Apr-2020, 1-May-2020, 4-May-2020, 6-May-2020, 8-May-2020, 11-May-2020, 13-May-2020, 15-May-2020, 18-May-2020, 20-May-2020.

Arco, Matt. Number of coronavirus patients at N.J. hospitals drops to 3-week low with 5th straight day of declines. NJ.com. [Online Article]. 26 April 2020.

Associated Press. New Jersey reports 9 coronavirus deaths; elections postponed. Dayton 24/7 Now. [Online Article]. 19 March 2020.

Associated Press. NJ COVID-19 deaths climb by 17 to 44 in biggest jump yet. APNews.com. [Online Article]. 24 March 2020.

Associated Press. Coronavirus in 43 NJ nursing homes — death toll now at 81. New Jersey 101.5. [Online Article]. 27 March 2020.

Associated Press. 8 nursing home residents die of COVID-19, N.J. mayor says. Philadelphia Tribune. [Online Article]. 30 March 2020.

Broadt, Lisa. 3 deaths, 10 coronavirus cases ID’d at Mount Laurel nursing home. Burlington County Times. [Online Article]. 25 March 2020.

Institute for Health Metrics and Evaluation (IHME). COVID-19 Estimate Downloads. IHME. [Zip File]. 30 March 2020.

Washburn, Lindy. An unseen crisis: Coronavirus deaths mount at NJ nursing homes as virus spreads, staff dwindles. NorthJersey.com. [Online Article]. 8 April 2020.