Updated at 7 p.m., April 3: Revised to reflect that other residential facilities are now experiencing similarly sized outbreaks of COVID-19.

Staff at the Denton State Supported Living Center are being sent to work with residents who have tested positive for the coronavirus but say they lack appropriate personal protective equipment and fear for their safety.

Those who refuse to work where they are assigned will be written up for insubordination — and anyone who resigns over concerns about the virus “would never be rehired,” according to an email sent to staff members and obtained by The Dallas Morning News.

Though employees were screened daily for coronavirus symptoms before the outbreak began, all staff were not provided face masks until Monday — 10 days after the first resident tested positive.

Bukola Amodu was reassigned over the weekend to care for residents who tested positive for the virus, even though she has health problems that put her at risk, she said. When Amodu raised her concerns, she said she was told to work in the unit or resign, which she did.

“This is detrimental to my health,” Amodu wrote in a resignation letter dated March 27. “I am sorry for any inconvenience this might cause.”

Fifty residents and 25 staff members at the state-run facility, which houses over 400 people with intellectual and developmental disabilities, have tested positive for the virus.

The center that employs over 1,400 people has seen one of the largest outbreaks of COVID-19 of any Texas residential institution, according to state health officials.

The Health and Human Services Commission, which oversees the facility, denied many of the employees’ accounts and said staff members with health problems can work in homes where no one has a positive diagnosis. In accordance with federal guidelines, the center has isolated patients in certain homes, dedicated staff to work with them and outfitted those workers with protective gear, including masks, gowns, face shields and gloves, spokeswoman Christine Mann said.

“We have adequate supplies,” Mann said. “We’re working with staff to ensure they call when the supplies in their homes get low instead of waiting until it completely runs out.”

Mann said Amodu left of her own volition and was “not in any way prompted or asked to resign.”

“In fact, in cases where employees demonstrated underlying health conditions that could increase their risk of COVID-19, they were given assignments on other homes that would reduce their risk,” Mann said.

She was one of 13 workers who resigned last week, Mann said. Three others retired.

Turnover

Before the virus hit, the state-run facility already had a high turnover rate — 37% in 2018.

“There’s a staff shortage so they are trying to get anyone to fill in,” said Francisco Santillan, a North Texas organizer for the Texas State Employees Union who used to work at the center. “They weren’t ready for this.”

Meanwhile, parents of residents at the facility — who have not been able to visit their loved ones for weeks since the campus suspended non-essential visits — have said they’re grateful for the staff at the center.

“I think it’s just important to recognize the staff that are committed to coming to work every single day and taking care of our loved ones,” said one parent, Debbie Waddy Cates, whose 32-year-old son lives at the facility. “They give me the ability to sleep at night even though I want to get worried.”

A staff person uses a thermometer to measure a visitor's temperature before entering the Denton State Supported Living Center in Denton on March 22, 2020. (Tom Fox / Staff Photographer)

Denton County health officials don’t know who brought the virus onto the sprawling campus, but they suspect it was carried in from the community.

One nurse said she rotated between working with residents who tested positive for COVID-19 and those who were not diagnosed with the disease — which she fears could cause the virus to spread around the 189-acre campus.

“What I am worried about is I don’t want to be a carrier who spreads coronavirus cases all over this facility,” said the nurse. When working with sick patients, the nurse said, she did not receive a face shield or gown. The nurse was one of four employees who spoke to The News and requested anonymity because they fear retaliation.

Mann said the state was not aware “of any staff working between homes with COVID-19 positive residents, and homes in which no residents have tested positive or exhibited symptoms, and we have procedures in place to prohibit this.”

Stopping the spread

Infection control measures are important because some studies show at least 25% percent of sick patients never show symptoms, said Dr. Charles Lerner, a member of the Texas Medical Association COVID-19 Task Force.

They are also crucial at state-supported living centers where staff help residents with daily tasks, from bathing and dressing to eating meals, which makes social distancing nearly impossible.

The U.S. Centers for Disease Control and Prevention recommends all staff wear face masks once a long-term care facility identifies a case of COVID-19. And it suggests putting hand sanitizer in every resident’s room, ideally both inside and outside the door. The CDC also recommends separating ill residents and dedicating certain staff members to work with them.

Mann said the state has followed CDC guidelines to protect workers and prevent spread. The campus is made up of free-standing buildings, so when the first case was identified only staff in the affected home were given personal protective equipment, she said. Staff began using face masks across the entire campus Monday.

The Denton State Supported Living Center on April 1, 2020, in Denton, Texas. (Smiley N. Pool / Staff Photographer)

Still, employees said they fear being sent to work in homes with patients who have tested positive because they worry about becoming infected and bringing the virus home. Direct care staff who work with residents receive base pay that starts around $25,000 a year. The state does not offer incentives, such as hazard pay, to work in homes with COVID-19. It’s not clear whether policymakers will address that.

“I feel like I am going to lose my life,” one direct care worker said. She works in a home where residents have tested negative for COVID-19 and said midweek that there was no more hand sanitizer or gloves. Nationwide, there have been shortages of personal protective equipment.

“I come home and I cry because I need my job,” she said. “I love my residents, but the way the people are doing the staff, they are treating them horrible.”

The email sent March 31 by a manager acknowledged a meeting to discuss “staff attendance, refusal, walking out, resignation during the crisis.”

When asked about the email, Mann said the agency is taking “this opportunity to reiterate to all supervisors that it’s our policy to accommodate any staff who need to be reassigned due to certain health conditions that make them at higher risk for infection.”

Testing residents and staff

All but about 10 of the residents have been tested for the coronavirus, but only the highest-risk staff members have been tested, Dr. Matt Richardson, director of Denton County Public Health, said at Tuesday’s County Commissioners meeting.

“There are so many employees left — at a lower risk — but still with some limited exposure,” he said. “But we don’t have a thousand tests at Public Health, obviously, right now.”

A spokeswoman for the health department said some residents haven’t been tested because they have trouble tolerating the test, which includes a swab like a long Q-tip being stuck in one’s nostril to collect cells from where the back of the nose meets the throat.

Keeping residents who’ve tested positive separate from those who’ve tested negative has also been disruptive for the staff and residents, Richardson said.

“These individuals, they’re very comfortable in their own living space with their own things,” he said. “This has been very disruptive for them, and the staff is doing their best to assist those residents.”

Beth Mitchell, a supervising attorney for Disability Rights Texas, said the center is right to test everyone so those who are sick can be identified and isolated.

“The problem you still have is you still have staff who are coming and going,” Mitchell said. She said that means having enough face masks and personal protective equipment will be “imperative to keep this under control.”

Contact tracing of positive cases is performed by the county health department, state officials said.

It is not clear how many residents and staff members are hospitalized or in critical condition. The center has stationed four ambulances on campus to provide transportation for any residents who may need to be hospitalized because of COVID-19, the facility’s director, Nancy Condon, wrote in a letter to parents and guardians Monday.

A timeline of COVID-19 cases and preparations at the Denton State Supported Living Center

March 13: State Supported Living Centers across Texas suspended all non-essential visitation and on-campus events.

March 19: An email from the infection preventionist at the Denton SSLC to staff said there had been no residents or staff members found to have COVID-19. “There is another rumor going around campus and it is just making a lot of people more stressed and scared,” the email read.

March 20: The next day, staff received an email saying one resident had tested positive the day before and urged staff who didn’t work at the affected apartment to stay in their own work areas to limit exposure.

March 21: Denton County Public Health issued its first news release about COVID-19 cases at the Denton center, announcing that four residents had tested positive and were hospitalized.

March 24: The health department said it had confirmed two more cases, bringing the total to six.

March 25: A seventh resident tested positive, according to the county health department.

March 26: The county reported that an eighth resident had tested positive.

March 27: The county reported that 31 more residents had tested positive for COVID-19, bringing the total to 39; two staff members had also tested positive.

March 28: Denton County reported a 40th positive case in a resident and another staff member testing positive.

March 29: Five more residents tested positive, along with nine more staff members.

March 30: Four more residents and 10 more staff members tested positive, bringing the total of residents to 49 and the staff total to 22. All staff began using face masks on the entire campus, officials said.

March 31: Two more cases were reported at the Denton center — one resident and one staff member, bringing the totals to 50 residents and 23 staff members.

April 1: No new cases were reported in residents or staff members, according to Denton County Public Health.

April 2: Two more staff tested positive for COVID-19, bringing the total to 25.