In terms of deaths, no population in the country has been hit harder by COVID-19 than residents and staff of long-term nursing homes, said Fred Campbell, M.D., an internal medicine physician and associate professor of medicine at UT Health San Antonio.

“Basically, about one-third of all deaths from COVID-19 — roughly 30,000 to 35,000 of the 100,000 deaths in the U.S. — were people living in these facilities,” said Dr. Campbell, who is volunteering in a number of capacities in the battle against the coronavirus.

In mid-April, Dr. Campbell and about two dozen other UT Health San Antonio faculty-physicians, as well as School of Nursing faculty, were enlisted by San Antonio Metropolitan Health District to assess how well 67 nursing facilities in Bexar County were following federal and state guidelines meant to minimize the spread of the disease.

“There are all kinds of issues, such as how they handle the laundry and the food and the physical therapy and recreational opportunities,” Dr. Campbell said. “Control measures had to be in place, including disinfecting and physical separation, or preparing people who are high risk going to, for instance, dialysis, and how they would protect them on the way there and back.”

Nursing home residents “are in an incredible high-risk group,” he added. “The average age of folks in convalescent facilities is in the 70s. They’re at risk just because of their age alone. Most of them have numerous chronic medical problems — heart, lung, liver, kidney disease, or cancer or diabetes. Those are all high-risk chronic conditions.”

Dr. Campbell described convalescent facilities as “powder kegs” as far as the possibility of the virus being introduced and spread.

But, in general, he said, nursing homes in Bexar County “are operating well above standards in minimizing risks and are incredibly serious about keeping a lid on the situation. Most of us were favorably impressed.”

After the UT Health San Antonio faculty team completed the assessment, Metro Health began the arduous process of testing every resident and staff member in all 67 facilities, well before Texas Gov. Greg Abbott ordered such testing statewide on May 11.

“Bexar County right now is at around 70 deaths,” Dr. Campbell said. “We’re doing a superb job, considering the number of cases we have, in minimizing deaths from COVID-19. And that comes from being incredibly proactive in screening these nursing homes for essential infectious disease quarantine practices and, of course, now the process of screening every resident in a nursing facility.”

But the assessment did reveal some troubling realities, Dr. Campbell said.

“There is one facility [in San Antonio] that has a predominance of people with serious psychiatric disorders … and of course are elderly as well,” he said. This presents myriad challenges, he explained: patients unable to understand the need for social distancing to protect themselves from getting sick to those who do get sick unable to make decisions about their health care needs, treatment and end of life.

“Many of them have no relatives or other guardians other than a court-appointed legal guardian. That is not a good substitute for someone who cares about you. We’re talking about high-risk people who are not capable of making decisions that are among the most important they’ll ever have to make in their lives.”

That scenario, Dr. Campbell said, “is my recurring nightmare.”