Report: TorC vets’ home violated virus safety rules

by Colleen Heild | January 28, 2021
5 min read
Exterior of New Mexico State Veterans' Home
Other findings of the federal investigation of the home: failure to clearly communicate residents' COVID-19 status to nursing staff and failure of staff to change personal protective equipment as they traveled between zones Photograph courtesy of the New Mexico Department of Health

Reprinted from the Albuquerque Journal, E-edition 1/28/2021, copyright © 2021

As the deadly COVID-19 virus invaded the New Mexico State Veterans’ Home in Truth or Consequences last November, a certified nursing assistant came to work reporting she didn’t feel well and had a fever. A rapid test showed she had the coronavirus. Instead of being sent home, she was instructed to continue her shift, passing out food trays and helping transfer both COVID-19-positive and COVID-19-free residents from unit to unit, according to a new inspection report released by the state Department of Health, which oversees the home.

An infection prevention specialist at the site told inspectors the assistant “should have been sent home because she had tested positive and presented with symptoms but, due to staffing challenges, stayed working at the facility,” the report stated.

By the time the nursing assistant finished her work that day, Nov. 27, she had developed a sore throat, headache and cough. Another nursing assistant who worked with her that day tested positive for the virus 48 hours later.

In the weeks that followed, the state’s only home for military veterans and their spouses—touted in the late spring for its excellent record on keeping the virus at bay—became one of the worst “hot spots” for it. The DOH said Wednesday that 36 residents had died of COVID-19, more than 110 positive cases among residents have been reported and there were at least 78 cases among staff members.

To try and stem the virus transmission, at least a dozen residents were transferred out of the home in early December to an assisted living home in Las Cruces.

Acting on a complaint, state surveyors conducted an unannounced visit on Dec. 7 and, within days, put the home on notice that its infection control deficiencies put residents and staff in “Immediate Jeopardy” of risking health and safety.

The designation was lifted days later after a thorough cleaning and with a corrective plan of prevention in place, according to the 12-page report from the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services. The home was expected to be in substantial compliance by this week.

Sun Exclusive: Centers-for-Medicare-and-Medicaid-Services-Report-1.25.21Download

The administrator of the home, which provides skilled nursing services and assisted-living housing, remains on administrative leave.

The virus has hit long-term care facilities especially hard in New Mexico over the past 11 months, with more than 100 nursing homes or assisted-living facilities reporting at least one positive case in the past 28 days.

But the veterans’ home had been virus-free until Oct. 23, when its first positive case was reported, the inspection report stated.

The report faulted the facility for:

• Allowing a COVID-19-positive staff member with symptoms to continue providing care to COVID-19-positive and nonpositive residents. Such facilities are supposed to take precautions to prevent the spread of infection, including prohibiting employees with a communicable disease from direct contact with residents or their food if that would transmit the disease.

• Failing to clearly communicate residents’ COVID-19 status to nursing staff.

• Failing to provide a barrier between green zones (for non-COVID) patients and red zones for COVID-19-positive areas and staff were observed passing between zones.

• Staff failing to change such personal protective equipment as gowns, masks and gloves between red, yellow and green zones that separate COVID-19-positive residents from those who may have been exposed to the virus and needed to be isolated, and those who don’t have COVID-19.

• Failing to thoroughly clean a red zone for COVID-19-positive residents before converting it to a green zone for non-COVID residents.

“This deficient practice likely resulted in the spread of potentially deadly infectious diseases to other residents and staff,” the report stated.

Back in April, the veterans’ home created contingency staffing strategies to allow

asymptomatic staff who had been exposed to the coronavirus to continue working when they had a normal temperature and lack of symptoms every day before reporting to work. They were required to wear a face mask at work for 14 days after the exposure event. They also had to stop any resident care activities, report to their supervisor and leave the facility if even mild symptoms develop.

The report said that, on Nov. 23, the home obtained a two-week approval—it doesn’t say from whom—of a “crisis staffing” plan that allowed asymptomatic COVID-19 staff to work only with COVID-19-positive residents. They were barred from entering any other units in the facility.

Among the interviews with staff, the report cited one person, who asked to remain anonymous, who had complained that residents were moved from unit to unit too quickly before their rooms could be adequately cleaned, the report stated.

The inspectors also faulted the home for failing to inform residents and their families in a timely fashion when someone tested positive for the virus or when three or more staff or residents showed respiratory symptoms within 72 hours of each other.

“Failure to notify residents of this status is likely to result in residents relying on rumor and fear when interpreting the isolation and need for precautions around other residents and staff in the facility,” the report said.

The administrator told inspectors on Dec. 9 that she sent letters to the residents and their representatives every week to two weeks, updating them about COVID-19 in the facility.

She also said she wasn’t aware of any guidance that required her to notify residents or resident representatives any time there was a positive case in the building, and she confirmed there had been no such notification within 24 hours of the facility’s receiving a positive test result.

UPDATE: The Sun has confirmed with a spokesperson for the New Mexico Department of Health the status of administrator Juliet Sullivan remains under review and that Derrick Wheeler, whose LinkedIn profile describes him as NMDOH’s facilities operation manager, is serving as the veteran’s home interim administrator.

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Colleen Heild is an investigative reporter for the Albuquerque Journal.

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HAVE YOU SEEN?

Understanding New Mexico's proposed new social studies standards for K-12 students

“The primary purpose of social studies is to help young people develop the ability to make informed and reasoned decisions for the public good as citizens of a culturally diverse, democratic society in an interdependent world.”
—National Council for the Social Studies 

Reader Michael L. Hayes of Las Cruces commented: What impresses me is that both the proposed standards and some of the criticisms of them are equally grotesque. I make this bold statement on the basis of my experience as a peripatetic high school and college English teacher for 45 years in many states with many students differing in race, religion, gender and socioeconomic background, and as a civic activist (PTA) in public education (My career, however, was as an independent consultant mainly in defense, energy and the environment.)

The proposed social studies standards are conceptually and instructionally flawed. For starters, a “performance standard” is not a standard at all; it is a task. Asking someone to explain something is not unlike asking someone to water the lawn. Nothing measures the performance, but without a measure, there is no standard. The teacher’s subjective judgment will be all that matters, and almost anything will count as satisfying a “performance standard,” even just trying. Students will be left to wonder “what is on the teacher’s mind?” or “have I sucked up enough.”

Four other quick criticisms of the performance standards. One, they are nearly unintelligible because they are written in jargon. PED’s use of jargon in a document intended for the public is worrisome. Bureaucrats often use jargon to confuse or conceal something uninformed, wrong or unworthy. As a result, most parents, some school board members and more than a few teachers do not understand them.

Two, the performance standards are so vague that they fail to define the education which teachers are supposed to teach, students are supposed to learn, and parents are supposed to understand. PED does not define words like “explain” or “describe” so that teachers can apply “standards” consistently and fairly. The standards do not indicate what teachers are supposed to know in order to teach or specify what students are supposed to learn. Supervisors cannot know whether teachers are teaching social studies well or poorly. The standards are so vague that the public, especially parents or guardians, cannot know the content of public education.

Three, many performance standards are simply unrealistic, especially at grade level. Under “Ethnic, Cultural and Identity Performance Standards”; then under “Diversity and Identity”; then under “Kindergarten,” one such standard is: “Identify how their family does things both the same as and different from how other people do things.” Do six-year-olds know how other people do things? Do they know whether these things are relevant to diversity and identity? Or another standard: “Describe their family history, culture, and past to current contributions of people in their main identity groups.” (A proficient writer would have hyphenated the compound adjective to avoid confusing the reader.) Do six-year-olds know so much about these things in relation to their “identity group”? Since teachers obviously do not teach them about these other people and have not taught them about these groups, why are these and similar items in the curriculum; or do teachers assign them to go home and collect this information?

Point four follows from “three”; some information relevant to some performance measures requires a disclosure of personal or family matters. The younger the students, the easier it is for teachers to invade their privacy and not only their privacy, but also the privacy of their parents or guardians, or neighbors, who may never be aware of these disclosures or not become aware of them until afterward. PED has no right to design a curriculum which requires teachers to ask students for information about themselves, parents or guardians, or neighbors, or puts teachers on the spot if the disclosures reveal criminal conduct. (Bill says Jeff’s father plays games in bed with his daughter. Lila says Angelo’s mother gives herself shots in the arm.) Since teacher-student communications have no legal protection to ensure privacy, those disclosures may become public accidentally or deliberately. The effect of these proposal standards is to turn New Mexico schools and teachers into investigative agents of the state and students into little informants or spies.

This PED proposal for social studies standards is a travesty of education despite its appeals to purportedly enlightened principles. It constitutes a clear and present danger to individual liberty and civil liberties. It should be repudiated; its development, investigated; its PED perpetrators, dismissed. No state curriculum should encourage or require the disclosure of private personal information.

I am equally outraged by the comments of some of T or C’s school board members: Christine LaFont and Julianne Stroup, two white Christian women, who belong to one of the larger minorities in America and assume white and Christian privileges. In different terms but for essentially the same reason, both oppose an education which includes lessons about historical events and trends, and social movements and developments, of other minorities. They object to the proposal for the new social studies standards because of its emphasis on individual and group identities not white or Christian. I am not going to reply with specific objections; they are too numerous and too pointed.

Ms. LaFont urges: “It’s better to address what’s similar with all Americans. It’s not good to differentiate.” Ms. Stroup adds: “Our country is not a racist country. We have to teach to respect each other. We have civil rights laws that protect everyone from discrimination. We need to teach civics, love and respect. We need to teach how to be color blind.”

Their desires for unity and homogeneity, and for mutual respect, are a contradiction and an impossibility. Aside from a shared citizenship, which implies acceptance of the Constitution, the rule of law and equality under the law, little else defines Americans. We are additionally defined by our race, religion, national origin, etc. So mutual respect requires individuals to respect others different from themselves. Disrespect desires blacks, Jews or Palestinians to assimilate or to suppress or conceal racial, religious or national origin aspects of their identity. The only people who want erasure of nonwhite, non-Christian, non-American origin aspects of identity are bigots. Ms. LaFont and Ms. Stroud want standards which, by stressing similarities and eliding differences, desire the erasure of such aspects. What they want will result in a social studies curriculum that enables white, Christian, native-born children to grow up to be bigots and all others to be their victims. This would be the academic equivalent of ethnic cleansing.

H.E.L.P.

This postmortem of a case involving a 75-year-old women who went missing from her home in Hillsboro last September sheds light on the bounds of law enforcement’s capacity to respond, especially in large rural jurisdictions such as Sierra County, and underscores the critical role the public, as well as concerned family and friends, can play in assisting a missing person’s search.

Reader Jane Debrott of Hillsboro commented: Thank you for your article on the tragic loss of Betsey. I am a resident of Hillsboro, a friend of Rick and Betsey, and a member of H.E.L.P. The thing that most distresses me now, is the emphasis on Rick’s mis-naming of the color of their car. I fear that this fact will cause Rick to feel that if he had only gotten the facts right, Betsey may have been rescued before it was too late. The incident was a series of unavoidable events, out of everyone’s control, and we will never know what place the correct color of her car may have had in the outcome. It breaks my heart to think that Rick has had one more thing added to his “what ifs” concerning this incident.

Diana Tittle responded: Dear Jane, the Sun undertook this investigation at the request of a Hillsboro resident concerned about the town’s inability to mount a prompt, coordinated response to the disappearance of a neighbor. From the beginning, I shared your concern about how our findings might affect Betsy’s family and friends. After I completed my research and began writing, I weighed each detail I eventually chose to include against my desire to cause no pain and the public’s right to know about the strengths and limitations of law enforcement’s response and the public’s need to know about how to be of meaningful assistance.

There was information I withheld about the state police investigation and the recovery. But I decided to include the issue of the car’s color because the individuals who spotted Betsy’s car emphasized how its color had been key to their identification of it as the vehicle described in Betsy’s Silver Alert. Because the misinformation was corrected within a couple of hours, I also included in this story the following editorial comment meant to put the error in perspective: “The fact that law enforcement throughout the state was on the lookout in the crucial early hours after Betsy’s disappearance for an elderly woman driving a “light blue” instead of a “silver” Accord would, in retrospect, likely not have changed the outcome of the search” [emphasis added].

I would also point to the story’s overarching conclusion about the inadvisability of assigning blame for what happened: “In this case, a perfect storm of unfortunate circumstances, many of them beyond human control, hindered the search that it would fall to Hamilton’s department to lead.”

It is my hope that any pain caused by my reporting will eventually be outweighed by its contribution to a better community understanding of what it will take in the future to mount a successful missing person’s search in rural Sierra County.

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