Editor's note: This story was updated to clarify that a coronavirus case at the El Paso State Supported Living Center was revealed in a letter state Rep. César Blanco and other members of the El Paso legislative delegation sent Gov. Greg Abbott.

El Paso health and civic leaders warned of an impending public health crisis in El Paso in early March as the novel coronavirus began infecting communities across the country.

With minimal direction on how to prevent virus transmission and little to no personal protective equipment, El Paso Psychiatric Center employees continued feeding, bathing, socializing with, and at times even physically restraining patients, putting them in close contact with one another.

By early April, the 74-bed state-owned mental health facility had become one of the first hotspots for COVID-19 cases in El Paso County.

Case clusters tied to the facility ballooned from 11 on April 9 to 42 on April 21, the most recent data the city has shared. A psychiatric nursing assistant who was in his 50s died in mid-April, the county's fifth virus-related death.

Despite the growing number of cases, and even the death tied to the state hospital, local officials, citing past practices and patient confidentiality, have declined to share the center's name, only referring to it as a "health care facility." The Texas Health and Human Services Commission, which manages the state hospital, confirmed an individual there tested positive for COVID-19, but provided no other detailsas to whether that person was a patient or an employee.

An El Paso Psychiatric Center response plan and interviews with half a dozen employees reveal the center's administration did not act promptly to protect staff and patients, which resulted in the state hospital becoming El Paso’s largest coronavirus infection site.

"The whole attitude in the beginning concerning COVID-19, and still to this day with some employees … is that COVID-19 is not that serious unless you have underlying (health) issues," said Marcy Ortiz, a former social worker at the center who resigned April 14after she was unable to find child care.

El Paso Psychiatric Center Superintendent Zulema Carrillo did not respond to an interview request. She instead notified someone at HHSC of the request, and HHSC spokeswoman Christine Mann sent a statement and responded to questions via email.

El Paso Psychiatric Center is one of 10 state hospitals that treat Texas children, adolescents and adults with serious mental illnesses. The Texas State Employees Union said the outbreak in El Paso is reflective of larger issues at state health care facilities.

"Very little has been done to protect both Clients and Staff at State Supported Living Centers, State Hospitals and State Health Science Centers," TSEU said in an April 15 news release. As of that date, TSEU said it had received reports of 228 COVID-19 cases involving employees and patients at state supported living centers and state hospitals throughout Texas.

HHSC does not operate health science centers, Mann said.

'No one knew what to do'

The first El Paso Psychiatric Center employee tested positive for COVID-19 around March 25, and by the end of that month, three employees had tested positive, an employee said. With the exception of Ortiz, the other six employees the El Paso Times spoke with requested anonymity out of fear of losing their job if they spoke out publicly.

By April 3, a patient had also tested positive in addition to the three employees, according to information contained in a COVID-19 response plan dated March 30.The hospital stopped admitting new patients on March 29, Mann said.

On April 14, 11 employees and 11 patients had contracted coronavirus, Ortiz said.

"It happened like wildfire," Ortiz said of how quickly the virus spread between those inside the hospital.

"By the beginning of April, people were running around like ants, like 'what do we do.' No one knew what to do, and that tells you how much preparation and thought head administration actually put into preparing for COVID-19 at the hospital."

The city reported the psychiatric nursing assistant's death on April 15. His sister confirmed his death, but declined an interview request. City health officials have only said the man was 51-years-old and had underlying health conditions.

COVID-19 news:How many ventilators does El Paso have? And is that enough?

Multiple employees told the Times the first employee who tested positive for COVID-19 traveled to Mexico in early March and did not self-quarantine after returning to El Paso.

In March, the El Paso Psychiatric Center was only screening staff for travel to areas the Centers for Disease Control and Prevention identified as high risk for contracting coronavirus, like China, Iran and parts of Europe, Mann said. The screening went into effect March 5, the day after Texas reported its first case. Only employees who had visited, or had contact with someone who had traveled to these countries, were required to self-isolate for 14 days and allowed use of paid leave.

Using paid leave to quarantine if employees had visited Mexico or another part of the state wasn't an option, Ortiz said, and the only way they could use sick time was if they had received a positive COVID-19 test result.

"When you have to choose between feeding your family and paying your bills, what are you going to do? You're put in a tight place, so of course they were going to go to work," she said.

Ortiz began having her temperature taken at the start of her shift during the second to last week of March. The El Paso Psychiatric Center's March 30 response plan indicates at that point it was taking employees' temperatures twice a shift, but Ortiz said that didn't happen to her until April 6.

The plan also notes patients were having their vitals checked daily.

The University Medical Center of El Paso provided El Paso Psychiatric Center with 50 COVID-19 test kits on April 3, UMC spokesman Ryan Mielke said. El Paso Psychiatric Center employees said these kits were used to test patients and staff.

Poor infection control practices contributed to coronavirus spread

Mann said staff had access to surgical masks, gowns and hand sanitizer prior to a confirmed case of COVID-19 and HHSC "provided additional PPE, such as gowns, N95 masks and face shields to staff immediately after an individual tested positive for COVID-19." She declined to provide the date employees were given additional personal protective equipment, or PPE.

But multiple employees told the Times they were not given surgical masks until late March after colleagues contracted coronavirus.

A March 31 text message between two employees who routinely interacted with patients reads in Spanish: "They gave us a cheap mask and told us it should last a week. Each day when we finish our shift, (they said) we should put it in a paper bag." The text was sent the same day they learned three colleagues had the virus.

Ortiz did not see nurses and psychiatric nursing assistants regularly wearing surgical masks until at least the third week of March, at which point she said at least one employee had tested positive for COVID-19. She herself was not provided a surgical mask until the last week of March, like other employees.

The center's response plan noted, as of March 30, "all staff are currently wearing masks."

The employee who sent the text message said in an April 16 interview they hadn't received additional gear beyond a surgical mask, and had they bought a N95 mask with their own money to wear when interacting with patients.

Nurses and psychiatric nursing assistants who did receive gowns were told to reuse them for up to a week, the employee said. Ortiz saw these staff wiping down their gowns and masks with alcohol wipes upon leaving the area of the hospital that had been designated for COVID-19 positive patients.

"People were still not being educated on not bringing down your PPE from the units where there's infected people down to the non-patient units," Ortiz said of staff practices in mid-March, after the city announced the first local case on March 13. "People were taking off their PPE attire in the non-patient units and actually throwing their attire in trash bins outside of the hospital."

"How is that infection control? Anyone can look through the trash. Anyone can be close to the trash and because it's (the virus) on that PPE, breathe in the COVID-19 and spread it."

Ortiz said infection control practices were improving in the days before she left.

Few teleworking options made available to staff

The response plan noted El Paso Psychiatric Center leadership "identified telework options for people who can perform their duties either part or full-time offsite to reduce the number of staff coming and going from campus." Though leadership were "working to increase the number of staff who can work from home," the lack of full-time remote work was Ortiz's main motivation in resigning.

She struggled to find child care after schools and day cares closed, and was only given the option of working remotely part of the day, a policy that went into effect for her department the third week of March. The center suspended individual therapy the last week of March and group therapy the first week of April, Ortiz said, so she felt she could have completed all her work from home.

None of the other six employees who spoke to the Times between April 13 and 16 indicated they had been given telework options.

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Ortiz last reported to work April 7 because she went into quarantine the next day. She got tested for COVID-19 at the city's drive-thru test site on April 9 because she'd had contact with patients who tested positive and began to exhibit symptoms herself, including fatigue and cough.

She did not get her negative test result back until April 13 and said she felt pressured by administrators to get the result as soon as possible so she could be cleared to return to work.

Another factor in her decision to resign was her hesitation about being told by her supervisor that if the center became short-staffed, social workers would need to perform tasks assigned to psychiatric nursing assistants, like giving medications, taking temperatures or restraining patients. She worried if she did something wrong, a patient or colleague could report her to Adult Protective Services, putting her at risk of losing her license.

Parent of COVID-19 patient questions why positive patients were discharged

Three COVID-19 positive patients had been discharged by the date Ortiz resigned, she said.

A parent of a patient hospitalized at the El Paso Psychiatric Center told the Times the center would have discharged their adult child had they not intervened and asked for the patient to remain at the facility until they tested negative. The parent asked to remain anonymous out of fear their child would be penalized by staff.

The parent's child tested positive in early April, and the parent believes their child contracted the virus from the patient with whom the child had been rooming with and sharing a bathroom. Thatroommate experienced diarrhea and coughing, the parent said, which led their child to ask staff to be moved to another room, something that only happened after the roommate tested positive.

"(My child) went in for a mental issue, and now we have to deal with this, that (they're) positive," the parent said. Their child had their temperature taken by staff before being admitted during the third week of the March.

"I know (they have) a mental issue, but (they) have a voice, too. I go, 'you guys didn't listen to (them)," the parent said they told staff upon learning their child contracted coronavirus.

Coronavirus:El Paso nurse's headaches eventually led to positive COVID-19 test days before she died

The El Paso Psychiatric Center's March 30 response plan notes patients are required to be six feet apart during meal times and that positive COVID-19 patients will be "immediately" isolated from other patients.

The parent said theyrequested that their child, who soon after the test was eligible to be discharged, remain there. The parent feared their child wouldn't remain in isolation if they were released and could infect others, including the dozen adults the child lives with at a local foster home.

"I would feel guilty if one of the elderlies (residents) died because of my (child) because I just stood quiet. I didn't want to have that burden in my heart," the parent said.

Mann said if a state hospital patient is psychiatrically stable and ready to be discharged, the hospital "takes all precautions to prevent the spread of COVID-19 when discharging the individual to a safe environment, including coordinating discharge with the local mental health authority and family, and notifying the local health department."

Aside from the letter the parent received notifying them of their child's positive test, the parent has only received one other letter from the El Paso Psychiatric Center superintendent about a coronavirus case in the facility.

"I am writing to inform you that the El Paso Psychiatric Center has had a positive case of COVID-19. Our staff have been screening patients carefully, taking extra caution and we have tested all patients," the April 17 letter from Carrillo reads.

"We can provide you with this information because consent was given to us notifying you of the presence of COVID-19," it read. "Privacy laws prevent us from providing you detailed information in most cases, but we will make sure you have all the information we can give you. We won't be able to notify you about every single case going forward."

The letter did not mention that at least 11 patients and 11 staff had tested positive as of that date, nor did it mention the employee's death.

Asked about the discrepancy in numbers reported to families, Mann said HHSC "cannot confirm individual cases without consent of the individual or legally authorized representative."

El Paso legislative delegation calls on Gov. Abbott to protect patients

Initial media reports about the coronavirus outbreak at the El Paso Psychiatric Center and the death of an employee prompted the El Paso legislative delegation to write Gov. Greg Abbott on April 21 to express concern about staff and patient safety at both that center and the El Paso State Supported Living Center.

The El Paso State Supported Living Center, which is one of 13 centers across the state that supports people with intellectual and developmental disabilities, has at least one COVID-19 case, the letter noted.

The letter signed by state Sen. José Rodriguez and state Reps. César Blanco, Art Fierro, Mary Gonzalez, Joe Moody and Lina Ortega, asks Abbott to "immediately ensure" testing is available for frontline workers, providers and patients at these facilities and to "provide flexibility to state employees to work from home or take time to self-quarantine for 14 days to ensure their safety without fear of consequence or retaliation."

Additionally, the delegation asked the governor to ensure state employees have their temperatures taken at work and that workers and patients are informed of Centers for Disease Control and Prevention best practices to reduce virus transmission. They also called for increased funding to hire more staff to alleviate high turnover rates.

"We believe the state can and should do more to ensure that we're not risking the lives of patients and staff at the El Paso Psychiatric Center," Blanco told the Times. The delegation had reviewed the center's response plan and discussed safety protocols with its administration, he said.

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Like local lawmakers, the Texas State Employees Union has also called on Abbott to immediately test all workers at state hospitals and state supported living centers. On top of testing, HHSC must also inform workers and parents and guardians of patients of coronavirus infections at these facilities, said Aviv Rau, a union organizer.

According to Rau, TSEU has received reports that El Paso Psychiatric Center employees ceased receiving internal infection reports on April 17, seven days after the first news story about the outbreak there.

"Coming into work during COVID-19 is a calculated risk, and workers need facts in order to weigh out those risks," Rau said. "Keeping infections secret only heightens rumors and increases fear."

Ortiz also agrees cases at state hospitals should be made public for workers, patients and the community's safety.

"It's not a secret what's going on there. There are people getting sick. No, the right steps weren't always taken. Maybe now things are getting better. When I was leaving, things were actually getting better," Ortiz said.

Molly Smith may be reached at 915-546-6413; mksmith@elpasotimes.com; @smithmollyk on Twitter.