Eugene Forti survived repeated combat missions in World War II riding in a glass bubble of a ball turret, manning the anti-aircraft gun of a U.S. bomber. And it appeared that, at age 96, he was winning a battle with COVID-19 after 10 days of treatment at William Beaumont Army Medical Center in El Paso.
“We thought, oh my God, here’s a 96-year-old — I’m going to have to say kind of frail, physically frail little gnome of a man — and he’s going to beat this thing,” said his daughter, Mary Kay Dieterich.
But on May 24, four days after being discharged from Beaumont and returning to the Ambrosio Guillen Texas State Veterans Home in Northeast El Paso, Forti died. He is among 12 residents who died of COVID-19 at the nursing home between mid-May and mid-June, according to records filed with federal regulators.
Dieterich has spent the months since her father’s death trying to find out how he got sick and why he declined so rapidly after being returned to the nursing home. Her efforts have been stymied. The Texas Veterans Land Board, which operates the nursing home, has used a loophole in state open records laws to withhold documents, requested by El Paso Matters, about how it prepared for and responded to the COVID-19 pandemic.
“I believe that the Veterans Land Board’s lack of transparency is direct evidence that they were extremely negligent, extremely negligent,” said Dieterich, who lives in North Carolina.
The Veterans Land Board, which operates nine nursing homes across Texas, is part of the General Land Office, overseen by Texas Land Commissioner George P. Bush. In a statement, the Veterans Land Board said its nursing homes “are exceptionally high-risk facilities during COVID-19 and we are doing everything in our power to ensure the health and safety of America’s finest.”
No COVID-19 deaths have been reported at the Ambrosio Guillen Texas State Veterans Home since June.
Eugene Forti’s life
Forti was born, raised and died in El Paso. His gregarious nature led him to car sales, a job he did into his 80s.
Eugene Forti enlisted in the Army Air Corps at age 19 during World War II and was sent to Europe.
“Because of his stature, he was a ball turret gunner on a B-17 called the Classy Chassy. So he was the short guy that got put in that Plexiglas ball at the bottom of the big old plane,” Dieterich said. “He survived 31 missions. The standard was 25. He got inducted into the Lucky Bastard Club,” an informal group of bomber crew members who survived their missions in the European theater.
When he returned from the war, Forti worked first as a mechanic at various auto dealerships in El Paso, but later switched to sales. “Because my dad never met a stranger and because he was bilingual, he sold the hell out of cars. He was salesman of the year, year after year after year,” Dieterich said.
Forti and his wife, Kathalea,moved into a private room at Ambrosio Guillen Texas State Veterans Home in 2015. Forti continued to live in a private room after Kathalea died in 2018.
“He was elderly and he was confined to a wheelchair. But he worked the halls of Ambrosio every single day. He was gracious. They loved him. He was out and about. He was social,” Dieterich said.
COVID-19 and nursing home risks
Forti celebrated his 96th birthday on March 6, as the COVID-19 pandemic began sweeping across the country. The nation’s first major outbreak was ravaging a nursing home outside Seattle as Forti marked his birthday with his family.
By the end of March, the Centers for Disease Control and Prevention warned that nursing homes were at high risk of COVID-19 outbreaks, in part because employees often worked at multiple facilities and could spread the illness.
U.S. nursing homes had a history of poor infection control measures before the pandemic hit, the Government Accountability Office warned on May 20. Two of every five nursing homes had an infection control violation during inspections each year since 2013, the GAO said.
That included Ambrosio Guillen. On March 12, six days after Forti’s birthday, a surveyor from the Texas Health and Human Services Commission made an unannounced visit to the nursing home in response to a complaint.
The surveyor found that a certified nurse aide didn’t wash her hands after touching a dirty linen barrel. She made up beds in two rooms after touching the dirty linen barrel, the surveyor said in a report obtained by El Paso Matters from HHSC under the Texas Public Information Act.
Follow-up visits in April and May found no violations, so no fines were levied against Ambrosio Guillen. HHSC is the state regulator of nursing homes.
In a November 2019 inspection report, the Centers for Medicare and Medicaid Services — the federal regulator of nursing homes — issued eight citations to Ambrosio Guillen.
One of the violations cited in the report was for failure to conduct an annual review of its infection prevention and control program, as required.
The federal regulators give Ambrosio Guillen a one-star rating on its five-star scale, meaning that it performs much below average on key health and safety measures.
Withholding documents on COVID-19 preparation
El Paso Matters asked the Veterans Land Board to provide documents on how Ambrosio Guillen prepared for COVID-19. In response to the request made under the Texas Public Information Act, the VLB provided two emails — one from the state comptroller on March 25 on sales tax collections during the pandemic, and one from a pharmaceutical company on March 3 saying it didn’t expect supply chain disruptions during the pandemic.
The VLB said it wouldn’t release other documents about COVID-19 protection because officials believed they were exempt from disclosure under state law.
Ordinarily, Texas government agencies cannot withhold requested documents without obtaining a ruling from the state Office of the Attorney General. But during the pandemic, some government agencies have essentially suspended open records laws, using a provision added to the law after Hurricane Harvey.
The provision took effect in September 2019 and allows governments to provide a “catastrophe notice” that suspends transparency requirements. Texas Attorney General Ken Paxton has said that Public Information Act requirements don’t apply as long as government offices are closed because of the pandemic.
Hadassah Schloss, the GLO’s public information officer, said the agency would seek an attorney general ruling on the El Paso Matters request “when our physical offices reopen.” The agency has not said when its offices might reopen.
Eugene Forti goes to the hospital and is diagnosed with COVID-19
On May 1, Ambrosio Guillen Texas State Veterans Home learned that a nurse and an aide had COVID-19 symptoms and were being tested, said Karina Erickson, a spokeswoman for the Veterans Land Board. “At that point, we immediately began testing all residents,” she said.
A resident tested positive on May 2 and all legal representatives of residents were notified the following day that the novel coronavirus had been detected at the facility, she said.
Dieterich said her brother, Guy Forti, who has their father’s medical power of attorney, does not have a record of receiving such a notice. She said he did receive a notice that their father had been tested for COVID-19, and was negative.
On May 10, Eugene Forti was sent to William Beaumont Army Medical Center with a fever, shortness of breath and low oxygen levels.
“When Guy got the call that they were transporting Dad to Beaumont and Guy heard the symptoms, he said, well, how many cases of COVID do you have there? And they said, we’re not allowed to give you that information,” Dieterich said.
Erickson, the Veterans Land Board spokeswoman, said legal representatives such as Guy Forti were routinely updated on the number of COVID-19 cases at Ambrosio Guillen. “Communication with the responsible party for each resident in the home has occurred on a weekly, if not more frequent, basis, including reports of how many COVID-19 cases are currently in the home,” she said.
Shortly after arriving at the hospital, Eugene Forti tested positive for COVID-19.
“How long had he been sick before they decided to send him to Beaumont? How long had he been infectious and contagious?” his daughter wondered.
Forti was hospitalized for 10 days and received convalescent plasma as part of his treatment. He was never placed on a ventilator, Dieterich said.
He recovered well enough to be discharged on May 20, according to his medical chart, which Dieterich provided to El Paso Matters.
“By the day of discharge, the patient had a stable, improved (oxygen) requirement, and he was hemodynamically stable and afebrile for several days prior,” his chart said.
On the afternoon of May 20, Forti was taken by ambulance back to Ambrosio Guillen Texas State Veterans Home.
New surroundings, and a rapid decline
When Forti returned to the nursing home, he was not placed back in his private room. Instead, he was put in a room with other COVID-19 patients. Dieterich has repeatedly asked why that decision was made, but has received no explanation.
“He was recovering until they decided, whoever in their infinite wisdom, to send him back. And instead of installing him in a private room, which he had a private room with his own bed, they put him in a room with other infected people,” she said.
Erickson, the Veterans Land Board spokeswoman, said privacy laws prevent the agency from publicly discussing individual cases.
CDC guidelines recommend that people being returned to nursing homes be placed in designated COVID-19 care units if they didn’t meet requirements for discontinuing what are known as “transmission-based precautions.” However, Forti’s medical charts indicate he met the requirements for discontinuing those precautions — 10 days had passed since diagnosis, he had gone more than 24 hours without a fever, and his symptoms had improved.
Dieterich said she believes her father was placed in a room with other sick patients because Ambrosio Guillen was experiencing staffing shortages because of COVID-19 infections and exposures among health care workers at the nursing home.
In a report filed with the Centers for Medicare and Medicaid Services, Ambrosio Guillen officials said the nursing home had a shortage of nurses and aides the week Forti died.
The report said 25 of the 143 residents at the nursing home that week had confirmed COVID-19 cases, and two others had suspected cases. Nine staff members had confirmed COVID-19 cases that week, and one other staff member had a suspected case. CDC guidelines call for health-care workers exposed to people with COVID-19 infections to isolate themselves for 14 days if they weren’t wearing all required personal protective equipment at the time of exposure.
When asked about Ambrosio Guillen’s self-reported staffing shortage the week of Forti’s death, Erickson said: “The home operator states that the staffing census had no impact on resident care. Open shifts were covered with staff working additional shifts.”
The nursing home has reported to regulators that it hasn’t experienced staffing shortages since the week ending May 31.
Forti’s condition, which had improved steadily while he was at William Beaumont Army Medical Center, deteriorated soon after his return to the nursing home.
“He died in four days from the day he returned. He started failing in two, and they sat and watched him die until Sunday night when he finally passed away. And when he died he was on 10 liters of oxygen and gasping for breath. When he returned from Beaumont to Ambrosio, I think he was on 1.5 liters to give him a little help,” Dieterich said.
Shortly after her father died, Dieterich began seeking information about his care and the conditions at Ambrosio Guillen leading up to his illness.
She talked briefly on June 10 with Kenneth Shull, the administrator of the nursing home. She followed up the next day with an email that told her father’s life story and provided details about his hospitalization and death.
Dieterich ended the email with a question: “What the hell happened?”
Shull never replied, she said.
Dieterich has enlisted help from U.S. Rep. Veronica Escobar, state Rep. Joe Moody and El Paso Matters. That has yielded minimal information.
When Moody’s office sent a list of questions to the Veterans Land Board about preparations for COVID-19, testing, availability of personal protective equipment and positive cases among staff and residents, the agency demurred.
“On the advice of legal counsel, we are respectfully declining to answer the specific detailed questions attached to the correspondence,” Mark Havens, the secretary of the Veterans Land Board, said in a July 2 letter to Moody and Escobar.
Dieterich wants to know why her father was placed in a room with other COVID-19 patients rather than his own private room when he went back to Ambrosio Guillen. She wants to know why his condition suddenly worsened after he showed such improvement in the hospital.
“I believe he should have been returned to his room. But I’ll never get someone to tell me that. I’ll never find out. I’ll never get an answer because they have protected themselves,” she said.
Forti’s daughter wants to know how COVID-19 made its way into a nursing home packed with elderly veterans more than two months after it was clear the disease posed a lethal threat to residents of such facilities.
“Investigations are underway, and the homes have worked diligently to ensure that all protocols issued by the Center for Disease Control, Texas Health and Human Services Commission and Department of Veterans Affairs are being followed,” Erickson told El Paso Matters.
Dieterich despairs that she’ll never get the answers she’s seeking.
“Why don’t they know who brought it into the nursing home? Why don’t they know how it spread? There were just so many unanswered questions and I guess I’ll never know because they have a lawyer.”
How to report suspected abuse or neglect in Texas nursing homes
The Texas Health and Human Services Commission, which regulates nursing homes in the state, said people should call 800-458-9858 to report suspected abuse or neglect of people who are older or who have disabilities. That includes people in nursing homes, assisted living facilities or day activity and health services.
You can also report care concerns about home health and hospice agencies and intermediate care facilities.
Agents answer calls Monday through Friday from 6 a.m. – 6 p.m. MT. If you call outside those hours, leave a message; an employee will call you back by the next workday.