Care of the COVID-19 Patient

Care of the COVID Resident in Long Term Care Facilities

Across the province, Long Term Care Facilities (LTCF) are home to thousands of Nova Scotians who are more susceptible to acquiring COVID-19 and suffering related complications due to increased frailty, high prevalence of underlying chronic health conditions, and living in a congregate facility.

Long-term care facilities licensed and funded by the Department of Health and Wellness provide services for people who need ongoing care; either on a long-term basis (permanent placement) or short-term basis (respite care). There are two types of long-term care facilities available, nursing homes and residential care facilities.

Nursing homes provide nursing and personal care on a 24-hour basis including care given under the supervision of a nurse, administration of medication and assistance with daily living.

Residential care facilities provide assistance with personal care such as, bathing and dressing, and reminders about daily routines..

A Care in Place model is used for nursing home residents with active COVID-19, including residents who reside and receive care in Residential Care Facilities (RCF). Ideally, a COVID-19 unit in an entirely separate unit or area of the facility is established. At a minimum, the COVID-19 unit may be a grouping of rooms at the end of a hall that is separated from the other rooms and common spaces by a barrier (temporary as needed), and treated as a separate care space.

LTC facilities must follow the most recent direction outlined by the Department of Health and Wellness (DHW):

The following recommendations and supply checklist provide guidance for LTC facilities planning to house a COVID-19 unit:

Outbreak Management

Outbreaks of respiratory tract infections occur in long-term care (LTC) facilities (LTCF) throughout the year, but are more common during the winter months. Residents in LTC settings are likely to be older, frailer, and have chronic conditions that weaken their immune systems or impair their ability to clear secretions from their lungs and airways.

The goal of Covid-19 Outbreak Management in Long term care is to, as much as possible prevent the introduction of the Sars Co-V2 Virus into the facility and or prevent transmission between residents and staff.

As outbreaks occur at Long Term Care (LTC) facilities, the initial first days will be stressful. Outbreak response needs will vary dependent on the number of residents in the LTC facility, the number of staff and the amount of support and resources available at the LTC facility. Each response will require its own specific set of objectives based on the needs.

  • The Outbreak Response Team Toolkit - Continuing Care / Long Term Care (Excel document) is designed to help Long-Term Care (LTC) facilities prepare for, respond to and recover from Coronavirus Disease 2019 (COVID-19) outbreaks in their facility.
  • Staff must know and be familiar with the case definition for COVID-19 outbreak. Long term care facilities who provide care in place for COVID positive Residents will receive the level and type of care as outlined in their Goals of Care. Residents requiring a higher level of care, if within their goals of care, will be referred for admission to an acute care facility. They will be cared for according to NS Health policies and procedures
  • Residents with COVID-19 in long-term care should be managed in a a dedicated area within their facility.
  • Due to the complexity of this population (environment change, frailty, multiple health conditions), health care teams will need to consider how they will frequently and safely communicate resident concerns. Consideration to increasing team huddles, SBAR communication during transfer of accountability (report) and the potential of adding various health disciplines to the skill mix (i.e PT, OT, dietitian or rehab aide) to provide a range of care interventions.

Clinical Pathways for Care in Place

It is very important to note that residents in LTC facilities may be symptomatic or asymptomatic for COVID-19. Residents must be monitored TWICE per day (AM and PM) for new onset of symptoms and fever.

If the resident develops fever (greater than 37.8 C) or any of the following symptoms contact the MRHP (most responsible healthcare provider) to determine if resident requires test for COVID−19. Place resident on Droplet and Contact Precautions and notify local Infection Prevention and Control.

The following is a list of resources that can be utilized once an outbreak is determined:

A Medical Support Team has been established to provide support services to long-term care medical directors and physicians including formal consultation services and immediate advice from internists. NSHA Medical Support Service for LTC Medical Directors/Physicians can provide necessary support with goals of care, acute medical management advice and coordination of care and disposition planning.

Approved care in place LTC facilities may utilize the following Order Set - Long Term Care Facility Resident with Known or Suspected COVID-19
to guide treatments that are in line with the resident's Goals of Care.

Infection Prevention and Control Plan of Care

The goal of designating a specific care area of a facility for the care of residents with COVID-19 is to prevent the transmission of infection to other residents and to health care workers and to maximize health care personnel and non-personnel resources (Nova Scotia Health, 2021). All LTC facilities in Nova Scotia follow the COVID-19 Management in Long Term Care Facilities - Directive from OCMOH.

There are many IPAC guidance documents on the COVID HUB to guide practice. Please be sure to check them frequently in case IPAC guidance has changed. The following are a list of a few key features essential for caring for residents within LTC.

This resource index is a cheat sheet which lists and provides links for key IPAC resources for long term care.

Managing Visitors

Families are essential to care within LTC facilities and can often be a wealth of information for health care providers. Depending on the current IPAC guidance, it is important to keep the following in mind:

Proof of vaccination for visitors

Droplet and Contact Precautions Accommodation

  • Posters illustrating the correct method for putting on and removing personal protective equipment (PPE) should be displayed inside and outside of each COVID-19 resident's room or bed space and in the donning and doffing area for easy visual cues for care providers.
  • Door to the resident room may remain open (unless aerosol-generating medical procedure (AGMP) is being performed)

Hand Hygiene

  • Staff should perform hand hygiene frequently according to the Four Moments of Hand Hygiene using plain soap and water or an alcohol-based hand rub (ABHR) (70–90%). Soap and water should be used when hands are visibly soiled.
  • Residents should be taught how and provided with opportunities to perform proper hand hygiene.
  • Residents should have ABHRs made available to them and be assisted with hand hygiene by staff as needed. Staff may need to wash a resident's hands for them.
  • Place ABHR dispensers in hallway at entry to each resident room, in communal areas, and at point of care for each resident.

Personal Protective Equipment (PPE)

Appropriate PPE for droplet and contact precautions should be available for all individuals entering the unit. This includes:

  • Gloves,
  • Long-sleeved cuffed gown (cover front of body from neck to mid-thigh) — make sure gown covers clothing in front and back,
  • Procedure / surgical mask. The mask should be discarded and replaced when:
    • Visibly soiled
    • Direct contact with a resident
    • It becomes so moist / humid that its integrity is affected
  • Face / eye protection (i.e., face shield, mask with attached visor, or goggles).

N95 respirators are only necessary when conducting an AGMP. Staff must be fit tested for appropriate mask prior to use.

Whenever a mask is removed, it should be safely stored in a clean, dry paper bag (such as a brown paper lunch bag) clearly marked with the wearer's name.

Hand hygiene should be performed whenever indicated, paying particular attention to during and after removal of PPE, and after leaving the resident care environment.

Resident Care Equipment and Personal Items

Consider using single-use, disposable equipment and supplies as much as possible.

All reusable equipment and supplies, along with personal belongings, will be dedicated to the the use of the resident with COVID-19.

  • If use with other residents is necessary, the equipment and supplies will be cleaned and disinfected before reuse.
  • Items that cannot be properly cleaned and disinfected can be dedicated to the resident and then discarded upon transfer or discharge.

Ensure that any materials (e.g., electronic tablets or other devices, craft supplies, bingo cards, magazines, books, cooking utensils, linens, tools) are not shared among residents unless they are cleaned and disinfected between uses for each resident.

  • If the items cannot be easily cleaned and disinfected, they should not be shared among residents.

At discharge, room transfer, or death of a resident, any resident-owned items should be removed, any items with hard surfaces cleaned, and items placed in a bag for family or representative.

  • While risk of transmission of COVID-19 via these items is likely low, it is recommended that families store the items for 3 days prior to handling.

Aerosol-Generating Medical Procedures (AGMPs)

An AGMP is any procedure conducted on a resident that can induce production of aerosols of various sizes, including droplet nuclei. AGMPs are rarely performed on Long Term Care Facility (LTCF) residents, though potential examples in this setting may include:

  • Open suctioning in residents with a tracheostomy, or
  • Use of non-invasive positive pressure ventilation (CPAP) machines.

Avoid use of nebulizer and use alternatives such as metered-dose inhaler with spacer.

An AGMP on a resident with COVID-19 requires airborne precautions, including use of a fit-tested, seal-checked N95 respirator.

AGMP is only to be performed if:

  • It is medically necessary and performed by the most experienced person.
  • The minimum number of persons required to safely perform the procedure are present.
  • All persons in the room are wearing a fit-tested, seal-checked N95 respirator, gloves, gown, and face or eye protection.
  • The door of the room is closed.
  • Entry into the room of a resident on CPAP is minimized.

Refer to the following document, which provides recommendations and a list of activities considered to be AGMPs:

Additional IPAC Resources

LMS Modules

  • Routine Practices (Code 0479)
  • Additional Precautions (Code 0023)
  • Personal Protective Equipment (Code 0373)
  • Point of Care Risk Assessment (Code 0419)
  • Hand Hygiene

Care Plan Essentials

Care of the resident within designated units requires care planning that is centred on:

  • Residents' goals of care
  • IPAC principles
  • Fundamentals of care

Here's an example of a care plan that can be used:

The following acronym, A SAFE MIND, can be used as a guide to support care for residents within Care in place Long Term care facilities.

Assess goals of care

Skin breakdown (pressure injury prevention)

Agitation (delirium)




Incontinence (bowel and bladder care)

Nutrition (feeding / fluids)

De-escalation in care

Let’s break down some important considerations in caring for the LTC resident:

Assess Resident Goals of Care

At Nova Scotia Health, the Medical Support Service for Long Term Care (MED-LTC) has outlined the following indicators for framing resident goals of care:

  • Assessment of the resident’s baseline frailty status and health trajectory (i.e., before they developed COVID-19)
  • In-depth discussion of potential risks and benefits of interventions for COVID-19 in the setting of respiratory and/or hemodynamic decompensation, which considers risks specific to the acute illness as well as risks specific to the patient’s health status
  • Messaging about Ethics for LTC
  • Co-development of a care plan, with input from the primary care provider and resident/family, which considers the impact of frailty

Residents within LTC who are COVID-19 positive are to have goals of care completed ideally before transfer to hospital. The following can help health care providers guide those discussions:

Refer to the following documents for Residents who have an identified need for acute oxygen therapy:

For Residents that require oxygen support and can tolerate laying on their side or stomach, refer to page 3 of the following document:

The following guidelines will support staff working in Nova Scotia Health Long Term Care (LTC) in their response to a witnessed cardiac arrest in the LTC setting during the COVID-19 pandemic.

Skin Breakdown (Pressure Injury Prevention)

Preventing skin breakdown is crucial in providing good care to residents. Skin breakdown that leads to a pressure injury can result in longer length of stay, poor patient outcomes, and if not well controlled or able to be healed, can result in an increased risk of death.

A pressure injury is defined as localized damage to the skin and/or underlying tissue, usually over a bony prominence or related to a medical or other device (NPAUP, 2016). Pressure injuries are most prone to develop on head, ears, shoulder blades, elbows, tail bone and buttocks. A pressure injury can go unnoticed and result in something very serious. Prevention and ongoing monitoring are very important (RNAO, 2013).

Pressure injuries can result from:

  • Staying in one position for too long (pressure)
  • Skin rubbing against something (e.g., bed sheets) too much (friction)
  • Sliding or shifting in bed or chair (shearing)
  • Skin exposed to sweat, urine, or stool for a long time (maceration)

Pressure injuries can cause:

  • Pain
  • Infections
  • Open sore and reduce heal ability
  • Lead to further complications

Preventing pressure injuries can be integrated into the resident's daily routine. Strategies include:

  • Moving (repositioning at least every two hours) and shifting positions
  • Drinking and eating a nutritious and well-balanced diet to maintain healthy skin;
  • Keep skin clean (changing incontinence products regularly, as needed);
  • Observing and reporting changes in skin condition.

Be concerned about:

  • Reddened areas;
  • Blisters, red or darkened areas anywhere on the skin;
  • Opened or blackened area(s) on the skin.

Additional Resources

Agitation (Delirium)

According to Canadian Coalition for seniors' Mental Health, delirium:

  • is a sudden and severe disturbance in thinking
  • can cause changes in a person’s ability to stay alert, remember, be oriented to time or place, speak or reason clearly
  • is a common and serious condition often experienced by older people
  • can be caused by many things including having an infection, recent surgery, various medical conditions, untreated pain, starting, increasing or stopping some medicines, or not eating or sleeping well
  • is sometimes not recognized or is misdiagnosed as another condition such as dementia or depression
  • can often be prevented

Research is showing COVID-19 patients have increased amounts of delirium. One theory is that delirium is related to acute hypoxic changes that COVID-19 patients often have, but the direct cause of delirium is often difficult to discern, as these patients may have infection, sedation, or even neurological impacts of COVID-19 (Cleveland Clinic, 2020).

Delirium can often be seen in asymptomatic patients as well, and can potentially exacerbate the acute illness projection. There are a variety of delirium assessment tools that can be utilized in the management or prevention. Confusion Assessment Tool (CAM) is often one that is used in acute care to show a baseline and trend changes in patient’s cognition.

Managing delirium involves astute assessment and identification of triggers. Creating a care plan includes assessing for delirium in the older frail adult, including assessing for:

  1. Identify potential causes of delirium:
    • Are there any modifiable causes? This may include things like:
      • Unmet needs (i.e., hunger, thirst, pain, toileting, temperature, access to hearing aids, mobility)
      • Acute medical problems (i.e., infection, agitation, hypoxia)
      • Level of Stimulation (i.e., too much or not enough, lack of daily routine & structure, sleep pattern)
      • Consistent approach to care from staff
      • Pharmacological review of current medications and indications
    • Are there unmodifiable factors?
      • Existing medical conditions (i.e dementia stage & type)
  2. Be meticulous in describing and documenting what is happening with the resident / patient (i.e., when does it occur? What was the resident doing? Who was involved? What was the response? What are the residents emotions (crying / anger)?
  3. Analyze – are there trends that are readily identified? Are staff using a consistent approach to providing care? Are there triggers that can be identified as a direct cause or solution to delirium behaviour?

(Adapted from Alberta Health Services, 2021)

COVID-19 provides an added complexity to caring for residents with delirium and or dementia. Staff need to be creative in communication strategies when the resident isn’t able to see their mouth or expressions. The following are a list of strategies that can be considered for providing care during COVID-19 to residents with delirium. As always, it is a continual balance of mitigating risk of contamination with the virus and holding IPAC principles of appropriate PPE.

Additional Resources


Frailty is commonly defined as physiological decline with increased vulnerability leading to poorer health outcomes (Canadian Frailty Network, 2021).

Identifying Frailty Contributors and the Frailty Level Descriptions gives key indicators of the implications of a resident’s frailty scale and how to incorporate into their care plan.

As a health care provider, one of your key functions is to Identify frailty through screening. Frailty screening will be utilized to inform clinical decisions and care pathways.

Frailty has been linked to:

  • Increase in falls
  • Increased length of stay
  • Difficulty recovering from acute illness
  • Increased mortality

There are 10 key aspects of frailty that are important to understanding and planning a resident's / patient's plan of care. In particular, dementia and social function are key predictors and drivers of frailty. Think of those as you plan for care of COVID-19 residents / patients.

Atypical COVID-19 Presentations in Frail Older Adults

(University of Toronto, 2020)

Typical symptoms of COVID-19 such as fever, cough, and dyspnea may be absent in the elderly with COVID-19. The following outlines key considerations to monitor your patient with COVID-19 for an atypical presentation. Find the full resource at Regional Geriatric Program of Toronto.

  • Very low percents (20-30%) of older residents with COVID-19 present with fever
  • Atypical COVID-19 symptoms include delirium, falls, generalized weakness, general malaise, functional decline, and conjunctivitis, anorexia, increased sputum production, dizziness, headache, rhinorrhea, chest pain, hemoptysis, diarrhea, nausea/vomiting, abdominal pain, nasal congestion, and anosmia
  • Tachypnea, unexplained tachycardia, or decrease in blood pressure may be the presenting clinical presentation in older adults
  • Older age, frailty, and increasing number of comorbidities increase the probability of an atypical presentation
  • Older adults may present with mild symptoms that are disproportionate to the severity of their illness
  • Delirium may be a common sign in atypical COVID presentation
  • Frailty screening must be completed on all residents living in LTC.

Be sure to complete Using Frailty to Inform Care available on the Nova Scotia Health Learning Management System (LMS) and Frailty Case Studies to increase your knowledge and comfort with frailty in resident care.

Additional Resources


Moving a resident from their home within long term care in order to prevent a further outbreak of COVID-19 has the potential to cause distress to the resident, the resident's roommate, and family. It is important to recognize that if the resident is coming with any type of dementia or delirium, this change can potentially exacerbate their behaviours.

Use this document for guidance on safe transfer of residents within an LTC facility:

Inform resident's family of the move to another location/room within the LTC facility. Consider having extra staff that are familiar to the resident on hand to facilitate smooth transition.


Mobility is a key to prevent de-conditioning as well as prevention of nosocomial infections. Mobility can be a release for residents with delirium and dementia as well as provide a sense of connection to people in the COVID-19 pandemic.

When building your plan of care for COVID-19 residents, be sure to identify the level of activity the resident normally has. Determining a patient’s baseline mobility is critical to maintain throughout their diagnosis with COVID-19 infection.

Mobility is important for prevention of pressure injuries, prevention of nosocomial infections and maintenance and prevention of delirium. Utilizing IPAC principles for appropriate PPE for health care providers and COVID positive residents is very important and will maintain the health and safety of both resident and provider.

Additional Resources


As noted above, prevention of skin breakdown is critical in pressure injury prevention. Attention to bowel and bladder care for maintenance of continence is equally important in providing fundamentals of care.

A resident's delirium can be triggered by the primary need to use the bathroom, so frequent toileting and maintenance of continence would be necessary for any resident's plan.

Some considerations to manage skin damaged from incontinence would be:

  • Implement toileting schedule
  • Reduce exposure to irritants: avoid briefs, if pads used check them every 2 hours
  • Cleanse skin gently with either a no rinse pH balanced cleanser/moisturizer and protector (Baza Cleanse and Protect) product can be used
  • Apply a skin protectant (Critic-Aid Clear, Baza Protect II) following cleansing after each incontinent episode
  • Consider use of low-air-loss therapeutic surface

Be sure to read the following resources:


Often, residents within long term care require assistance with feeding. Many are at risk for choking and require supervision. The long-term care atmosphere provides an opportunity for residents to have socialization as well. COVID-19 presents a challenge to all those fundamental aspects of nutrition.

Assessing adequate nutrition on a resident is essential for ensuring they have the appropriate caloric needs for their bodies’ requirements. The Research Institute for Aging (2020) has produced the following guidelines for consideration with elderly and nutrition with COVID-19.

Social Interaction

Social interaction can stimulate appetite in older adults in LTC. During COVID-19, consider:

  • Have family or friends call the resident before a meal—talk about their day and what they are having for their next meal
  • Create fun events for residents that are food focused. For example, recreation team members can have themed snack options e.g. ice cream delivery, make your own sundae (resident sits at their door and instructs the team); bingo or other competitive events can have a food prize
  • Team members spend a few minutes discussing the meal choices with residents to stimulate interest in upcoming meals.

Increasing Appetite

Being alone in resident rooms can affect mood as well as result in less physical movement; both can reduce appetite. Some considerations to stimulate appetite:

  • When staff are setting up the meal, speak with the resident about how good the food smells, compliment how it looks, and that they anticipate it tastes good too.
  • Arrange daily opportunities for residents to leave their room, be outside in the nice weather etc.
  • Every interaction with staff should include a verbal interaction that can support the resident’s mood. Smile, ask how they are doing, share something you know they like to hear about.
  • Consider providing high energy and protein foods as the ‘standard’ for most residents when they are eating in their room.

Importance of Fluids

Inadequate fluid intake is a common concern when residents are eating alone in their rooms. Some considerations for increasing fluid intake:

  • Provide medications one at a time, encouraging a sip of fluid with each pill.
  • Offer the residents their preferred fluid several times a day.


Residents may lose capacity for self-feeding when isolated. Some considerations to support eating:

  • Resident may require modifications to their current diet during the course of illness. Consider dietician consult.
  • Have someone support opening packages, encouraging the resident and ensuring they have everything they need. Help with tray set up and positioning.

Additional Resources

De-Escalation in Care

Despite all the best efforts in providing care to residents with COVID-19, there may come a time when care needs increase and acuity changes. At that point in may be appropriate to reconsider the original care goals and consider de-escalation in acute interventions and a shift towards comfort measures.

Follow the link below to review several free COVID-19 palliative care modules that provide further information on palliative care:

Be sure to read NS Health Library Guide on Palliative Care for additional tools and resources.