Eugene Forti at age 19, shortly after joining the Army Air Corps during World War II. (Photo courtesy of Mary Kay Dietrich)
This story has been updated with information from a letter sent Tuesday to Eugene Forti’s family from the Veterans Land Board.

Texas Land Commissioner George P. Bush has ordered a leadership shake-up at the Ambrosio Guillen Texas State Veterans Home in Northeast El Paso, hours after an El Paso Matters story raised questions about the COVID-19 death of a World War II veteran at the nursing home.

“Over the past several months, we have closely monitored the situation in our El Paso home, and have worked with our independent operator to implement many proactive policies at the VLB’s direction in an effort to prevent the spread of this invisible enemy. This afternoon (Monday), I issued correspondence to the home operator calling for a change in leadership of their operations team currently employed at the home,” Bush said in a statement to El Paso Matters on Tuesday.

Eugene Forti, 96, died of COVID-19 at Ambrosio Guillen on May 24, four days after he was released following 10 days of treatment at William Beaumont Army Medical Center. He was among 12 people to die of COVID-19 at the El Paso state veterans home between mid-May and mid-June, according to records filed with federal and state regulators.

Eugene Forti celebrated his 96th birthday on March 6 at Ambrosio Guillen Texas State Veterans Home. (Photo courtesy of Mary Kay Dietreich)

Forti’s daughter, Mary Kay Dieterich, has asked repeated questions about how Ambrosio Guilen prepared for COVID-19 in the late winter, and why her father was placed in a room with other COVID-19 patients when sent back to the nursing home, rather than going to his own private room that he had before the hospitalization.

Dieterich said she appreciated Bush’s actions, but said they don’t go far enough.

“This is an extraordinary time in our lives. My brother and I lost the most important person in our family to COVID-19, while under the care of a facility we trusted to protect and keep him safe. It seems, as his daughter, I should be entitled to answers that I am desperately seeking,” said Deiterich, who lives in North Carolina.

“I still have questions that remain unanswered,” Dieterich said. “I want to know why (Ambrosio Guillen) did not implement processes and procedures, or bring in pandemic and infectious disease specialists, until after the outbreak had started. I believe that these steps should have been taken long before this ‘break glass’ emergency.” 

Veterans Land Board provides some answers

The VLB on Tuesday sent a letter to Dieterich’s brother, Guy Forti of Colorado, that answered some questions about their father’s treatment. Guy Forti had his father’s medical power of attorney and had approved the agency providing information through the office of state Rep. Joe Moody, D-El Paso, who has been assisting Forti’s children in their search for answers.

The letter did not answer specific questions that Dieterich posed about conditions at Ambrosio Guillen leading up to the pandemic. Instead, VLB provided a prepared statement that it had previously released describing some pandemic preparations and responses. Dieterich provided a copy of the letter to El Paso Matters.

The agency had said in a July letter to Moody and U.S. Rep. Veronica Escobar that it wouldn’t answer Dieterich’s questions about pandemic preparations “on the advice of legal counsel.”

Eugene and Kathalea Forti moved into the Ambrosio Guillen Texas State Veterans Home in 2015. Kathalea died in 2018 and Eugene died of COVID-19 in May. They are pictured with their children, Mary Kay Dietrich and Guy Forti. (Photo courtesy of Mary Kay Dietrich)

Among Dieterich’s questions VLB has declined to answer: Was the dining room immediately closed to residents? Were the residents isolated to their rooms? Were the common areas immediately closed to residents? Were staff isolated while awaiting the results of their COVID-19 tests? Did the staff have adequate supplies of personal protective equipment? Were the residents required to wear masks and maintain social distancing?

Some of those questions were indirectly answered in response to Dieterich’s questions about her father’s case.

For example, the letter said Forti “was encouraged to stay in his room and wear a mask when leaving his room” and that “staff consistently monitored and encouraged residents to wear masks and practice social distancing.”

The letter doesn’t mention any mandatory isolation or mask requirements among residents.

Ambrosio Guillen reported to federal regulators in May that it had a shortage of nurses and aides. Several employees tested positive and, along with other staff exposed to them, were not allowed to return to work for two weeks.

In the letter to Guy Forti, VLB Executive Secretary Mark Havens said: “The Operator has represented that the staffing census had no impact on resident care. Open shifts were covered with staff working additional shifts. The Operator has represented that they are unable to determine how Mr. Forti contracted Covid-19.”

Forti tested negative for COVID-19 on May 4 but began showing symptoms on May 9 and was taken to William Beaumont Army Medical Center the following day, according to the letter. He tested positive for COVID-19 at the hospital and was treated there for 10 days.

Forti’s medical charts from William Beaumont, provided to El Paso Matters by Dieterich, showed that his breathing had improved after treatment and his fever had ended by the time he was discharged on May 20.

The VLB letter said his temperature became elevated on May 21 and his oxygen saturation levels dropped the following day. On May 23, Guy Forti was informed of his father’s condition and given the option of sending his father back to the hospital. Guy Forti declined that option and Eugene Forti died at the nursing home at 10:23 p.m. May 24, according to the letter.

Dieterich said her brother got a call from a nurse at Ambrosio Guillen on May 23, telling him that his father was dying.

“The choice fundamentally was, do you want him to die alone or, I will be here, I won’t leave his side. I’ll be here and I will hold his hand until he dies,” Dieterich said.

The letter said Eugene Fort was placed in a private room in the nursing home’s designated COVID-19 treatment area when he came back from Beaumont, his daughter said. That differs from what the family was told at the time, she said.

Her brother “said he was told distinctly that they had set aside an activity room and subdivided it, and that’s where they were putting their COVID positive patients,” Dieterich said.

The VLB also has refused to release documents about Ambrosio Guillen’s COVID-19 preparations requested by El Paso Matters on June 22 under the Texas Public Information Act. Governments usually can’t do that without permission from the Texas Attorney General’s Office, but VLB cited a provision in the law that allowed it to suspend transparency laws during the pandemic.

VLB spokeswoman Karina Erickson said the agency will now ask the Texas attorney general to rule on El Paso Matters’ request for documents on Ambrosio Guillen’s preparations for COVID-19.

“The GLO/VLB has complied with the AG’s directive under section 552.233 of the Government Code. However, as the COVID situation is now in its fifth month and our offices remain physically closed, the GLO/VLB has decided to begin referring requests to the Attorney General’s office for rulings on the disclosure of information,” she said.

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In a statement, Escobar called for full transparency by VLB.

“I am deeply saddened by the loss of life following a COVID-19 outbreak in the Ambrosio Guillen Texas State Veterans Home,”she said. “Mr. Forti’s family deserves answers and the public deserves full transparency. My office remains committed to working with the William Beaumont Army Medical Center and the Veterans Land Board to assist and ensure our veterans receive the highest quality medical they are owed and deserve.”

Leadership changes at the nursing home

Bush’s letter, and his statement sent to El Paso Matters, don’t specifically  mention VLB’s actions in response to Forti’s death and requests for information. The Veterans Land Board is part of the Texas General Land Office and Bush is the elected commissioner of the GLO.

 “As a military veteran myself, I have directed the Veterans Land Board to be as transparent as possible regarding the care of our veterans during COVID-19, while still complying with federal privacy laws,” Bush said in the statement. 

The entrance to Ambrosio Guillen Texas State Veterans Home in Northeast El Paso.

Bush on Monday sent a letter to William Biggs, the CEO of HMR Veterans Services, the South Carolina-based company that operates the nursing home for the state, expressing concern about issues raised in the El Paso Matters story.

“As chairman of the Veterans Land Board, I write to you today to express my strong disappointment and concern regarding the actions taken and/or failure to act by the management team at the Ambrosio Guillen Texas State Veterans Home in El Paso. I am deeply concerned by what has been reported in today’s edition of El Paso Matters,” Bush said.

Biggs hasn’t responded to a request for comment from El Paso Matters.

The letter says the VLB’s contract with HMR Veterans Services allows the board “to review the selection and continued employment of certain management staff.”

“As chairman, and on behalf of the Veterans Land Board, we are notifying you, in accordance with our agreement, that we have strong concerns that the management staff’s performance since the onset of the pandemic has not been adequate in accordance with usual and customary standards, specifically regarding what has been publicly reported today. I demand that you conduct a review of these individuals’ performance to determine if any further action is warranted.”

Kenneth Shull is the administrator at Ambrosio Guillen. Dieterich said she wrote him an email in May asking questions about COVID-19 preparations and her father’s death, but never received a response.

Cover photo: Eugene Forti at age 19, shortly after joining in the Army Air Corps during World War II.

This is a developing story that will be updated.

Robert Moore is the founder and CEO of El Paso Matters. He has been a journalist in the Texas Borderlands since 1986.