When state health inspectors arrived at the Willow Springs youth residential behavioral center on April 3 to investigate a coronavirus outbreak that had already killed one staff member, they found pandemonium.
The children living at the center had begun to riot, breaking ceiling tiles, charging at staff and chanting “Let us be free,” according to newly released state documents obtained by the Reno Gazette Journal. Many of them were already infected with COVID-19.
The center was severely short staffed, the inspectors found, with units of 10 or more children assigned a single mental health technician. A sole housekeeper was tasked with keeping the entire hospital disinfected. She was so exhausted trying to keep up that she was near tears when inspectors interviewed her.
“She expressed she was very concerned because so many people were sick and she was afraid,” the investigation report said.
When the team of investigators arrived on one of the units, a patient tried to escape the facility, kicking a nurse who was escorting the team. That same girl tried again to run out of the unit as the inspectors left.
“The children were involved in various activities which included: playing video games, coloring, running in and out of the rooms, and three girls were slamming a bedroom door,” the inspectors’ report said. “The (mental health technician) sat at the table in the middle of the unit and could not monitor the activities of all the patients on the unit.”
The technician was so busy just trying to keep tabs on the patients’ whereabouts that there was no time for cleaning, the report said.
The patients in one unit “rioted by breaking ceiling tiles, had disruptive behavior and aggression toward staff members,” the report said. “The unit had broken tile and debris all over the floor.”
By the time inspectors left, they had noted five violations of state regulations, including poor infection control, staffing shortages, a failure to properly train staff in infection control procedures and an unsafe physical environment.
The state fined the center $17,000 and the state’s chief medical officer ordered the hospital to implement a host of corrective actions, including hiring more staff, quarantining patients who had been exposed to the virus and increasing cleaning measures.
“Definitely there were concerns,” said Lisa Sherych, administrator of the Division of Public and Behavioral Health. “We took some swift action and outlined very specific things that we needed to occur to address those issues.”
As of Thursday, the coronavirus had burned out of the facility after infecting 41 children and 29 staff members. One person, a peer mentor in her 30s, died. Many of the children who tested positive did not become ill or show many symptoms.
Tricia Larmer, a spokeswoman for Willow Springs, said the center is working “collaboratively” with state inspectors to come into compliance with its regulations.
“We are confident that when the state returns to confirm our accepted actions, we will demonstrate that we are currently in full compliance,” she said. “Our commitment to the safety and well-being of our patients and staff is unwavering. The leadership and staff of Willow Springs take great pride in providing high-quality care to patients with special, and often complex, mental health needs.”
‘You need to come get me’
Conditions have improved dramatically, according to Nadine and Bob Hastings of Dayton, whose 13-year-old granddaughter is a patient at Willow Springs.
Nadine Hastings remembers the early days of the outbreak when information was scant and her granddaughter was scared to death. She called home hysterical about a mystery virus she knew little about.
“She fell apart,” Nadine Hastings said. “She said, ‘You need to come get me.’”
Her granddaughter had heard only that the virus attacked older people.
“She was completely freaked out and in tears and upset,” Bob Hastings said. “They only had limited information about what coronavirus was and what was going on. She said, ‘Grandma and Grandpa, you’re going to die. I’m stuck in here and I’m going to get it.’”
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Their granddaughter did end up testing positive, but came down with only a mild illness.
“In her case, other than some fatigue and a slight fever, she really didn’t have many effects,” Bob Hastings said. “They had that with a lot of the kids in there, fortunately.”
After initial confusion and chaos, Nadine Hastings said the center quickly brought the situation under control. Staff was brought in from the center’s sister hospitals in neighboring states, according to inspection documents.
“I will give the hospital a lot of credit,” she said. “They got their poop in a group and kept us and other families in loop. They had things sorted out. I’m really impressed with how they handled it.”
Anjeanette Damon is the government watchdog reporter for the RGJ. You can reach her at email@example.com or follow her on Twitter @AnjeanetteDamon. If you care about shining a bright light on decisions made by your elected officials, please consider subscribing to the Reno Gazette Journal.
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