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On April 3, Stephanie Gilmore, a 34-year-old nurse working on the Diamond Hill nursing dwelling in Troy, New York, was summoned to a supervisor’s workplace. The house’s administrator and nursing director had been there to relay some distressing information.
Gilmore mentioned they informed her {that a} resident within the dwelling had not too long ago gone to the hospital, the place she examined constructive for COVID-19. The resident was set to return to Diamond Hill, making her the primary confirmed COVID-19 case on the 120-bed facility north of Albany.
The dangers to the house’s employees and different residents had been apparent: The virus was ravaging nursing houses throughout the nation.
However the week earlier than, New York Gov. Andrew Cuomo and his well being commissioner, Howard Zucker, had all however made such discharges necessary. If a hospital decided a affected person who wanted nursing dwelling care was medically steady, the house needed to settle for them, even when they’d been handled for COVID-19. Furthermore, the nursing dwelling couldn’t take a look at any such potential residents — these handled for COVID-19 or these hospitalized for different causes — to see in the event that they had been newly contaminated or maybe nonetheless contagious regardless of their therapy. It was all specified by a proper order, efficient March 25. New York was the one state within the nation that barred testing of these being positioned or returning to nursing houses.
Within the weeks that adopted the March 25 order, COVID-19 tore by New York state’s nursing services, killing greater than 6,000 individuals — about 6% of its greater than 100,000 nursing dwelling residents. In all, as many as 4,500 COVID-19 infected patients had been despatched to nursing houses throughout the state, in accordance with a rely performed by The Related Press.
The state declined to say if it knew what number of COVID-19 sufferers had been despatched or returned to Diamond Hill. Officers with Diamond Hill refused to reveal the quantity.
By June, 18 of Diamond Hill’s residents had died from the virus and 58 had been contaminated. At the very least 50 of the ability’s greater than 100 staff had additionally been sickened with COVID-19.
As Deaths Mounted at Diamond Hill, New COVID-19 Sufferers Had been Transferred In
States that issued orders just like Cuomo’s recorded comparably grim outcomes. Michigan misplaced 5% of roughly 38,000 nursing dwelling residents to COVID-19 because the outbreak started. New Jersey misplaced 12% of its greater than 43,000 residents.
In Florida, the place such transfers had been barred, simply 1.6% of 73,000 nursing dwelling residents died of the virus. California, after initially transferring towards a coverage like New York’s, rapidly revised it. Up to now, it has misplaced 2% of its 103,000 nursing dwelling residents.
The choice by Cuomo and Zucker, whose division regulates all nursing houses within the state, drew fireplace as quickly because it was introduced from medical specialists, nursing dwelling operators and the households of residents. Cuomo himself had mentioned defending nursing dwelling residents was the state’s high precedence, as soon as calling the risk “fireplace by dry grass.”
Steve McLaughlin, the county govt the place Diamond Hill is situated, considered the state’s directive as insanity and selected to defy it, refusing to permit any COVID-19 sufferers to be returned to, or positioned in, the one nursing dwelling run by the county. The 320-bed facility, Van Rensselaer Manor, has not seen a single COVID-19 loss of life.
Cuomo and New Jersey Gov. Phil Murphy have defended their method as a method to open up essential beds at a second when it appeared hospitals could be overwhelmed by COVID-19 sufferers needing intensive care.
Charles Branas, who leads the epidemiology division at Columbia College’s Mailman Faculty of Public Well being, mentioned he might respect New York state’s concern a few scarcity of hospital beds in hard-hit areas.
“The New York state advisory seems prefer it was meant as a ‘reverse triage’ technique to clear acute and demanding care hospital beds, no matter whether or not these beds had individuals with COVID-19 or not,” Branas mentioned. “Presumably, the constructive trade-off they’d in thoughts with the coverage was that extra lives could be saved with extra open crucial care beds than could be misplaced in switch to nursing houses.”
However Branas mentioned he believes the coverage might nicely have elevated New York’s COVID-19 loss of life toll by a magnitude that can be decided by future researchers. “In the event you introduce 4,500 individuals sick with a probably deadly illness right into a susceptible and notoriously imperfectly monitored inhabitants,” he mentioned, “persons are apt to die.”
Former staff and households of sufferers painting Diamond Hill as a case research of a facility ill-prepared to deal with the complexities of containing the virus. The day Gilmore was informed of the resident with COVID-19, she mentioned she was additionally informed that the knowledge shouldn’t be shared with different staffers or sufferers — the administration didn’t wish to provoke panic. Gilmore mentioned she refused to go alongside and was later fired.
Three days after Diamond Hill was knowledgeable of its first case, six different residents examined constructive, suggesting the virus had been current on the dwelling for days, possibly weeks. The resident with COVID-19 who was returned to the house may need offered extra gasoline for the virus’s unfold.
Gilmore mentioned the house made insufficient changes to attempt to look after its residents’ safely. The COVID-19 sufferers weren’t remoted in a separate unit, and the ability lacked enough protecting gear for workers, she mentioned. Gilmore and county officers mentioned staffers who’d been uncovered had been inspired to interrupt their quarantines and return to work.
All informed, the virus has claimed the lives of 9 girls and 9 males at Diamond Hill, three youthful than 60, three older than 90. Amongst these misplaced: a church deacon, a bowling alley supervisor, a former nurse and a beloved grandfather referred to as Pop Pop by his grandchildren.
“Uncalled for, pointless, ought to by no means have occurred, and wouldn’t have however for a tragically misguided order from the state,” McLaughlin, the Rensselaer County govt, mentioned of the outcomes at Diamond Hill.
The state Well being Division mentioned its personnel visited the house not less than twice in April as a part of broader efforts to trace and management the virus contained in the state’s nursing houses. They deemed Diamond Hill able to caring for its residents. Paperwork present Zucker, the well being commissioner, was absolutely conscious of occasions at Diamond Hill and reassured native leaders that the division had supplied assist transferring sufferers to different services, however was informed it wasn’t wanted.
Cuomo and Zucker, after escalating criticism, revoked the March 25 directive on Could 10.
The Cuomo administration wouldn’t say who conceived of the order or reply the query of whether or not it believed the order had led to extra deaths. The administration mentioned the Well being Division was conducting “an intensive evaluation” of COVID-19’s influence on nursing houses.
“Science will decide whether or not the unfold in nursing houses got here because of returning residents or from asymptomatic employees who had been already there,” mentioned Jonah Bruno, a spokesman for the New York Well being Division.
(Eduardo Munoz Alvarez/Getty Photographs)
Officers have mentioned the directive was primarily based on federal steering saying that nursing houses might settle for residents with COVID-19 so long as they’d sufficient private protecting tools, might disinfect medical tools usually, might restrict the motion of sufferers, might home them in their very own rooms if crucial and meet different necessities. It’s not clear, nonetheless, who in New York was liable for assessing this — the discharging hospitals, the receiving nursing houses or the state.
The state Well being Division mentioned Diamond Hill instituted “common isolation precautions” however didn’t clarify what that meant. The state additionally mentioned the house ceased taking COVID-19 sufferers in late April however didn’t say what led to that growth.
A complicating think about evaluating the impact of the March 25 directive is that the state Well being Division didn’t monitor in actual time what occurred when COVID-19 sufferers had been transferred from hospitals to nursing houses. One senior nursing dwelling trade official mentioned the state Well being Division didn’t even start comprehensively counting COVID-19 deaths in these services till nicely into April, though the division has disputed that declare.
Bruno mentioned the company had adjusted the best way it tracked deaths because the pandemic progressed. He added that the state did a whole lot of security checks on houses all through the state and cited scores for varied shortcomings. However he wouldn’t say if that data had been shared with the hospitals and households making choices in regards to the suitability of houses to obtain COVID-19 sufferers.
Diamond Hill despatched ProPublica an announcement saying that its administration workforce had taken over the ability not too long ago, and that it had taken dozens of measures to guard the ability from the coronavirus, knowledgeable residents and their households of the presence of the virus, and labored with the county and state to maintain sufferers and employees protected. The ability seems to have modified its identify not too long ago to Collar Metropolis Nursing and Rehabilitation. The assertion didn’t reply questions on Gilmore’s particular allegations, citing “labor legal guidelines.”
“Regardless of our stepped up efforts, the stealth virus entered our neighborhood in early April possible by somebody who appeared completely wholesome,” the assertion mentioned. “Whereas we had been possible profitable in delaying infections and lowering unfold, like 1000’s of different expert nursing services affected, we weren’t in a position to absolutely quash the virus.”
In an interview, Ari Grinspan, Diamond Hill’s CEO, declined to reply to questions in regards to the state’s March 25 order, the house’s preparedness or the deaths of particular residents.
“Now will not be the time for a facility to be within the highlight,” he mentioned. “It provides others the possibility to select on you.”
“There can be a time when the pandemic mercifully ends, that we will speak on the report in regards to the position of services and the federal government in what has occurred.”
“It Was Chaos”
Gilmore began work at Diamond Hill on Oct. 31, 2019, months earlier than the primary virus case was reported in america. Even then, she mentioned, the ability was in “injury management” mode.
Members of the family visiting a affected person with dementia on her 74th birthday discovered her in a mattress dirty with urine and feces. The state Well being Division investigated, citing the house for failing to offer primary care, and the household shared footage with the media.
Diamond Hill’s homeowners introduced in new managers, Gilmore amongst them, however looking back, she mentioned, the transfer was primarily for optics. “So they might inform the information we have now new administration,” she mentioned.
(Kholood Eid for ProPublica)
Gilmore noticed no signal of significant enchancment. She and one other former nurse informed ProPublica the ability was chronically wanting employees and tools. Typically the ability had as few as 4 aides and one nurse taking care of as many as 80 sufferers on a single ground, every struggling a wide range of illnesses that screamed for consideration — incontinence, dementia, primary mobility.
In late February, she recalled an aged affected person being admitted from a neighborhood hospital. Gilmore mentioned she informed the directors the resident wanted a particular oxygen supply system to remain alive. Diamond Hill didn’t have one, however the directors took the admission anyway. Gilmore and one other former Diamond Hill nurse mentioned the affected person died the following day.
Diamond Hill didn’t reply to questions on that affected person.
Because the coronavirus started to grip New York Metropolis, 162 miles south of Troy, Gilmore’s considerations intensified. On March 13, she hammered out an e mail in all capital letters to the homeowners of the corporate, with the topic line: ATTEMPTING TO DO THE IMPOSSIBLE!
“As a nursing skilled, it’s unsafe to confess residents into the ability once we are crucial with staffing and unable to look after the residents already within the constructing… I’ve tried to help in any means that I can, nonetheless I’m being stretched means too skinny,” she wrote.
Gilmore informed ProPublica she advocated in conferences for hiring roughly 20 extra aides and 6 nurses.
Grinspan, the house’s CEO, tried to reassure her, she mentioned.
“We’re working feverishly on hiring and bettering the scenario, whereas we hope our appreciation to you and your friends are identified,” he mentioned in an e mail again.
Gilmore thanked him, however the scenario solely bought worse. She mentioned she checked in as many as 5 new sufferers per day coming into the ability’s 40-bed rehabilitation unit from all around the capital area. To her, it appeared solely a matter of time earlier than the virus started to unfold in a facility already straining to offer correct care.
In reviewing paperwork for brand spanking new residents, she grew to become much more troubled. There was no indication whether or not incoming sufferers had ever been examined for the coronavirus.
Gilmore mentioned her superiors dismissed her considerations, providing imprecise guarantees to isolate new residents. She noticed little proof that the house had the house or employees to try this.
Then got here the April Three assembly together with her superiors in regards to the lady who was identified with COVID-19. With the request to maintain it secret, her frustration boiled over.
“We aren’t going to inform the direct care employees that they had been uncovered?” she mentioned she requested.
“No,” she recalled her bosses saying. “We don’t wish to trigger a panic.”
“I used to be like, nicely, we will’t do this,” she mentioned. She thought it could be in opposition to the regulation.
Diamond Hill, in its assertion to ProPublica, mentioned it alerted all residents, their households and the state Well being Division of any coronavirus infections in a well timed and accountable method.
However Gilmore mentioned she left her boss’s workplace and referred to as the county Well being Division herself. By coincidence, she reached Shannon Testo, a registered nurse in control of communicable illness testing. Testo, who additionally spoke to ProPublica, informed Gilmore that she had tried to contact Diamond Hill earlier that day.
She wanted the directors there to inform her who the constructive affected person had been involved with, however she informed Gilmore the house’s directors had stopped returning her calls.
Gilmore gave Testo a handwritten checklist of employees that had handled the affected person. She was on it. Testo informed her she must quarantine herself for 14 days. Gilmore signed an order from the county promising to take action.
Later that day, Diamond Hill’s administration circulated a memo to employees members informing them that the house had its first coronavirus case and that lots of them had been uncovered.
A number of staffers referred to as out sick. Some, like Gilmore, additionally quarantined themselves on the county’s request.
(Kholood Eid for ProPublica)
After Gilmore’s name, Testo and Lisa Phillips, the county Well being Division’s director of affected person companies, mentioned they reported the scenario to the state Division of Well being, which then examined 30 randomly chosen residents on April 6 utilizing the restricted variety of assessments out there on the time. The county mentioned not less than six assessments got here again constructive. The state informed ProPublica it examined 26 residents and three got here again constructive.
Testo and Phillips mentioned they tried to hint the contacts of the six constructive sufferers, however Diamond Hill declined to reply their questions.
“With different services, the directors gave us all the knowledge we would have liked about who the constructive sufferers might have had contact with,” Phillips mentioned. “However Diamond Hill, they stored telling us that the employees was protected, they’d PPE, and due to this fact they’d no contact, however then we began getting calls from different individuals who labored there saying they didn’t have PPE.”
Testo and Phillips additionally mentioned they later obtained studies from Diamond Hill staff that the administration tried to entice their staff to return to work earlier than they accomplished their 14-day quarantines.
“They had been providing Dunkin’ Donuts reward playing cards to employees members who had been sick however had no fever,” Testo mentioned.
Diamond Hill didn’t reply to the county’s particular claims about the way it managed the outbreak, but it surely insisted in its assertion that it had cooperated with each the state and county to fight the virus’s unfold.
Gilmore mentioned she twice obtained requests from Diamond Hill directors to come back again to work despite the county’s order that she keep dwelling. She examined destructive for the coronavirus and returned to work on April 13. When she got here again into the nursing dwelling, she couldn’t imagine her eyes.
The ability had fewer employees than ever, however extra sufferers. Gilmore mentioned not less than 4 aides and two nurses, together with one who dealt with an infection management, had give up. Others referred to as out sick for worry of publicity. Those that continued working usually had no protecting gear. Sufferers who had the coronavirus had been housed proper subsequent to those that didn’t, and even in the identical room. “It was chaos,” she mentioned.
“Their system was that they might hold everybody new to the ability in isolation for seven to 14 days, however a few of them usually are not coherent,” Gilmore mentioned. “They’ve dementia, they usually had been simply wandering round.”
At that time, Gilmore mentioned Diamond Hill’s company mother or father, the WeCare Facilities, dispatched a brand new nurse supervisor to assist carry some sense of order to the rising disaster. Gilmore mentioned the brand new supervisor made issues worse by persevering with to insist that the ability was doing simply high quality.
She mentioned she complained to him after which despatched one other e mail to Grinspan, the CEO, which she shared with ProPublica.
“I’d not have reached out, if this didn’t require rapid consideration,” she wrote. “These points have been an issue since earlier than this covid scenario. The employees are coming to me with considerations… about residents covid standing being withheld and PPE. The state already has points with the best way the ability dealt with the scenario.”
“I’ve seen nurses come and go as quick as they got here attributable to an absence of staffing, assist and appreciation,” she mentioned.
Gilmore mentioned she was fired on April 15, two days after she despatched her e mail to Grinspan.
She mentioned she was informed that she was not administration materials and was in reality “anti-management.”
To the shock of Testo and Phillips, even because the case counts and employees complaints grew at Diamond Hill, state well being officers appeared high quality with permitting extra COVID-19 sufferers to be discharged to the ability. The county officers mentioned they had been on weekly convention calls with the state Well being Division and the house’s high directors all through April.
“They had been telling the state that they had been in a position to take extra sufferers and the state wasn’t getting concerned. We didn’t essentially agree, as a result of we had been getting calls from their employees saying they had been in disaster mode,” Phillips mentioned. The state’s individuals raised no objections, nonetheless. “They had been saying, ‘If the [hospital] feels it’s protected to discharge residents there they usually say they will settle for the affected person, then that’s their resolution.’”
Paperwork present that Zucker, the well being commissioner, mentioned the ability had been assessed a number of occasions throughout April and into early Could, and that no deficiencies had been discovered.
“Now we have been in frequent communication with Diamond Hill nursing and rehabilitation heart they usually have attested to the Division that they’re in full compliance with state and federal pointers and have said unequivocally that they’re in want of no additional help right now,” Zucker wrote in a May 10 letter to McLaughlin, the county govt.
Gilmore described her experience on native tv and has filed a criticism in opposition to her managers at Diamond Hill with the New York State Division of Human Rights, alleging employment discrimination.
ProPublica shared Gilmore’s story with the state Well being Division. In an announcement, it mentioned that it had no report of her criticism, however that her “allegations could be unacceptable if true.”
Phillips and Testo mentioned that if Gilmore hadn’t spoken up, the outbreak underway at Diamond Hill may need escaped scrutiny for a lot longer.
“With out these calls to us, the state by no means would have investigated,” Phillips mentioned. “She was frightened that the administration was not being forthcoming with data we would have liked. So she took it upon herself to alert us.”
The calls to the state got here too late for Cynthia Falle, 73, a quadriplegic lady who had spent three years at Diamond Hill.
(Kholood Eid for ProPublica)
In mid-March, she contracted pink eye and confirmed different indicators of failing well being. Her household mentioned they urged the administration to check her for the coronavirus. Twice, the ability refused, insisting a take a look at was pointless and all she wanted had been antibiotics.
Her brother, Robert Falle, mentioned that he complained to the state Division of Well being, and that by late March the division had ordered Diamond Hill to check her. The ability informed Sandra Wooden, Falle’s niece, the take a look at had been performed on April 4, and that on April 6 it had come again destructive.
On April 13, a deteriorating Falle was taken to Samaritan Hospital. Wooden mentioned the hospital employees informed her information they obtained from Diamond Hill didn’t mirror a COVID-19 take a look at of any sort.
Wooden mentioned Falle was examined at Samaritan, the outcome was constructive and she or he was lifeless inside every week.
Diamond Hill didn’t reply to questions on Falle’s care.
Falle had been identified with cerebral palsy at age Three and ultimately misplaced the power to maneuver her limbs, but her household mentioned her life remained remarkably full till COVID-19 took it away. She’d fallen in love, traveled together with her associate of 38 years, grew to become a church deacon and labored with well being care professionals to enhance look after individuals with disabilities.
“Cindy can be remembered for her indomitable spirit, humorousness, love, real curiosity within the individuals she knew and her wonderful capability to thrive even beneath what many would contemplate insurmountable odds,” her obituary learn.
(Kholood Eid for ProPublica)
“It Was Dictatorial”
McLaughlin, the Rensselaer County govt, watched the troubles unfold at Diamond Hill with a way of impotent fury. The house was the county’s worst scorching spot, its circumstances and deaths dwarfing these all over the place else.
He’d had a easy response to Cuomo and Zucker’s March 25 order — “No means. Not ever.” — and had blocked the switch of COVID-19 sufferers from hospitals to the county-run Van Rensselaer Manor except they examined destructive earlier than being moved. However he couldn’t do this at Diamond Hill, a privately run dwelling overseen by the state.
Some New York nursing dwelling professionals themselves, already hit laborious by the pandemic, say they’d considerations very like McLaughlin’s in regards to the New York order. These considerations had been then compounded, they mentioned, by the state appearing with out consulting them.
“We had been struggling and overwhelmed already,” mentioned Elaine Healy, a medical director for a New Rochelle nursing dwelling and appearing president of the New York Medical Administrators Affiliation. “When the directive got here, the factor that was most gorgeous was not solely the content material however the method by which it was delivered. It was a one-way communique with no alternative for dialogue and no alternative to specific considerations with the Division of Well being. It was dictatorial.”
Different states, notably California, adjusted their insurance policies on hospital discharges to nursing houses after getting the trade’s enter, mentioned Christopher Laxton, who heads the Society for Publish-Acute and Lengthy-Time period Care Medication, a corporation of some 55,000 nursing dwelling medical administrators, physicians, nurses and different well being care professionals.
Not New York, Laxton mentioned, the place Cuomo and Zucker “unaccountably failed to incorporate medical experience in operational management when these insurance policies had been fashioned and we don’t know why.”
Bruno, the Well being Division spokesman, disputed that declare. In an e mail, he famous that the state had weekly webinars with well being care professionals starting Feb. 2 and mentioned it had engaged in ongoing dialogue with a spread of specialists, medical doctors, nurses, members of the family and advocates.
“There’s been no scarcity of trade, knowledgeable or stakeholder opinions in something we’ve performed throughout probably the most devastating world pandemic in a century,” he mentioned.
The state, in defending its efficiency in safeguarding nursing houses, informed ProPublica New York ranks 35th among the many 50 states when counting nursing dwelling deaths as a share of its statewide lack of greater than 30,000 lives.
McLaughlin inveighed in opposition to the state discharge order in interviews and on Twitter, attacking its logic in his extra rural a part of New York. In an April 28 letter petitioning Cuomo and Zucker to finish the coverage, he famous that hospitals in Rensselaer County had not been overwhelmed by the virus and that beds for COVID-19 sufferers remained out there.
He wrote again on Could 1, saying Diamond Hill was tied to 12 of the county’s 20 COVID-19 deaths to that time and asking why COVID-19 sufferers had been being discharged to a facility with long-standing care issues, significantly with an infection management. He famous Diamond Hill had been cited in a June 2019 federal report as needing particular oversight.
McLaughlin has lengthy been at odds with Cuomo over a wide range of points, and he has sharply criticized varied facets of the governor’s preparation for, and response to, the COVID-19 pandemic.
(Kholood Eid for ProPublica)
McLaughlin, in an interview with ProPublica, mentioned the governor was a bully who ran from duty when his insurance policies went awry.
Wealthy Azzopardi, an adviser to Cuomo, had acerbic phrases for McLaughlin.
“From the very starting of this world pandemic, our response has been primarily based on knowledge, science, and the power to regulate our method because the proof dictates,” he mentioned in an emailed assertion. “Steve McLaughlin’s response has been primarily based on political low-cost photographs, public relations stunts, and an incapacity to make fact-based choices.”
New York state lawmakers, Republicans and Democrats, have now referred to as for an impartial investigation of Cuomo’s coverage.
Richard Gottfried, chair of the New York Meeting Well being Committee, mentioned he has requested Legal professional Basic Letitia James to herald exterior counsel to look at not simply the March 25 directive, however the state’s long-term oversight, funding and requirements for nursing houses.
In an interview, he mentioned that the state has performed “nothing in regards to the continual downside of understaffing in nursing houses,” that it has stored “Medicaid funding for nursing houses sparse” and that state inspection groups are “significantly understaffed and have a monitor report of very lax enforcement.”
“All of that results in insufficient care, a tradition that tolerates poor care and doesn’t correctly assist the nursing houses which are making an attempt to offer high quality care,” Gottfried mentioned.
The Cuomo administration fired again at Gottfried.
“As long-time chair of the Meeting well being committee and with 30 years within the state legislature, no person in Albany has been in a greater place than Assemblyman Gottfried to have an effect on actual change within the long-term well being care system,” Azzopardi mentioned in his assertion. “We welcome him to the dialogue and applaud him for talking out in regards to the continual issues in nursing houses beneath his three many years of management.”
5 days after the Cuomo administration reversed its coverage on discharging COVID-19 sufferers to nursing houses, a 76-year-old lady died of COVID-19 at Samaritan Hospital after having been contaminated at Diamond Hill.
McLaughlin bumped into her son shortly after her loss of life. He had few phrases of consolation.
The son mentioned he’d final seen his mom on Feb. 25, however then all guests had been barred. He mentioned on the telephone at some point in April he seen a change in her voice. She was quickly hospitalized and spent three weeks in an intensive care unit earlier than dying.
Now he needs he’d introduced her to reside with him earlier than she bought COVID-19.
“I really feel like I might have introduced her dwelling in the event that they’d let me,” mentioned the son, who didn’t wish to be recognized by identify as a result of he’s exploring authorized motion in opposition to the house.
Diamond Hill didn’t reply to questions in regards to the case.
The girl had held a wide range of jobs throughout 30 years of her working life — for Montgomery Ward, for the state motorcar division, for a neighborhood bowling heart. She’d gone into Diamond Hill for what was presupposed to be a short stint of rehab.
“I believed I used to be placing her someplace protected,” her son mentioned. “As an alternative, I put her 6 ft beneath.”
Mollie Simon and Benjamin Hardy contributed reporting.