Report: TorC vets home violated virus safety rules
Ill worker not sent home, staff moved between red, green zones
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 COVID19-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 assistedliving 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 & Medicaid Services. The home was expected to be in substantial compliance by this week.
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 virusfree 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 non-positive 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 receiving a positive test result.