Cook at Oregon State Hospital fell through COVID-19 testing cracks for weeks, ended up in coma

From the Salem Statesman JournalFrom the Salem Statesman Journal
May 5, 2020

Tony Villasenor had a persistent cough, flu-like symptoms and shortness of breath.

In his early 60s, with underlying medical conditions, he was seen by healthcare providers in the emergency rooms of two local hospitals and a clinic.

But each time, even as he got progressively worse, he was denied a COVID-19 test, told either he wasn’t sick enough or tests weren’t available.

Doctors suspected he had the coronavirus, and X-rays confirmed he had pneumonia.

But still, he was not tested.

Tony Villasenor, with his wife, Pressy, and their granddaughter, is recovering from COVID-19 at Salem Hospital after being refused testing four times.

Villasenor, his wife Pressy, and their adult children were astounded he was denied four times — until it was almost too late.

Tony was struggling to breathe when his wife called an ambulance to their northeast Salem home on April 2. He went into cardiac arrest while paramedics were there. They did CPR and revived him, then transported him to Salem Hospital, where his heart stopped again and he had to be revived.

He was admitted that morning and placed on a ventilator.

And yes, he tested positive for COVID-19, nearly three weeks after first seeking testing.

If a 61-year-old man with a history of diabetes and heart disease, presenting with a cough, shortness of breath, flu-like symptoms and active pneumonia couldn’t meet criteria, who could?

Or was this simply a rare case of someone falling through the testing cracks, multiple times, in the chaos of the surging pandemic?

Officials with the medical facilities involved responded to questions about testing protocol but could not speak specifically about this case because of HIPAA privacy rules.

“I can totally understand the frustration of this person and their family,” Dr. Tom Jeanne of Oregon Health Authority told the Statesman Journal. “Being undiagnosed is frustrating, to have it take a while, and not get tested right away.

“I have not heard a lot of stories of that kind of situation happening. That may have happened more earlier on in the epidemic when testing was in short supply and the guidance and all the information everybody had, including Oregon Health Authority, was changing rapidly.”

Hospital is not where you turn people away

Tony Villasenor, “Papa Tony” to family, came from humble beginnings and has worked hard all his life.

He grew up in a small village in the Philippines, walking hours to get to his job in the city. He and his wife, who’ve been married 39 years, emigrated to the United States in 1989 and worked in the fields in California.

He eventually found work in the food industry, and she became a certified nursing assistant.

They moved to Salem in 2006.

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Their children, who attended Lamb Elementary, Stephens Middle and McKay High schools, describe him as someone with a great sense of humor who enjoys karaoke and loves to cook.

His specialties include lumpia and pancit, Filipino versions of egg rolls and chow mein.

They said he’s a quiet man who doesn’t like drama, which makes them wonder how he’d feel about them sharing his medical information and talking about his ordeal.

He had just been moved from intensive care when they first reached out to the Statesman Journal.

“We just want to make some kind of impact,” son Lyndon Villasenor said, “where if it’s someone else’s loved one, they would be able to get the test, and they wouldn’t be turned away like my dad was.

“I don’t want anyone to be sentenced to die at home when they could be helped at a hospital. The hospital is not where you turn people away. It’s a place for healing.”

His father was at higher risk for severe illness from COVID-19 because he’s diabetic and has atrial fibrillation, or an irregular heartbeat. He’s had multiple cardiac arrests and double by-pass surgery.

All but one of the 101-plus Oregonians who have died had an underlying medical condition at the time of their death and nearly 60 percent had heart disease, according to state health officials.

Testing in Oregon not at full capacity

Widespread testing wasn’t available when Villasenor first sought care in mid-March, and it still isn’t.

Oregon Health Authority recently announced revised guidelines for COVID-19 testing to prioritize at-risk groups and front-line workers. But that was after Oregon was declared by the White House coronavirus task force to be among four states with the lowest testing capacity in the United States.

OHA’s guidelines, though, are just that. Testing is at the discretion of a provider, whether that be at a hospital, emergency department or clinic.

“That’s really been the case from the beginning,” said Dr. Jeanne, deputy health officer and deputy state epidemiologist for OHA.

As for the guidelines: “They can take it or leave it,” Jeanne said. “They don’t have to let us know or advise us or get approval to test.”

In Villasenor’s case, at least three different medical facilities — one twice — determined the coronavirus test either wasn’t needed or wasn’t available.

It’s plausible the places he visited weren’t capable of testing at that time. Lack of equipment and bureaucratic hurdles have curbed the testing process along the way.

Even now, a month later, Jeanne said the No. 1 barrier has been the supply chain for testing supplies, especially for smaller hospitals and clinics. There’s a shortage of reagents, for example, the chemicals used to analyze specimens.

“They’ve got machines, staff and capability,” Jeanne said. “But they don’t have enough actual test supplies to run tests.”

The state’s capacity for testing is about 3,000 per day, according to OHA, but only about 1,200 per day are being conducted.

Jeanne pointed out a three-day span this past week when the average increased to 1,600 per day, which indicated the new guidelines and expanded recommendations were resulting in more testing around the state.

“Testing will be a big part of allowing Oregon to start to reopen,” he said, “so we can keep an eye on new cases and keep the curve flat.”

Sent home with antibiotics, told to quarantine

The list of people OHA recommends for COVID-19 testing includes healthcare workers and first responders, residents and staff in a care facility or group living setting, essential frontline workers who have contact with large numbers, people 60 and older, and people with underlying medical conditions.

Tony Villasenor checked most of those boxes.

He’s a cook at the Oregon State Hospital in Salem, where he’s worked since 2008. He’s 61 and has underlying medical conditions. And, he had COVID-19 symptoms.

What we don’t know is whether he told any of the providers that he worked in food services at the state hospital, which feasibly could or should have moved him to the front of the line, although the guidelines were far more restrictive.

Tony was diagnosed with pneumonia in February but continued to work through around the end of the month.

The first time he sought care for what he believed could be the coronavirus was March 13 in the emergency department at Legacy Silverton Medical Center. He had an unresolved cough and a fever. The ER sent him home and told him to self-quarantine.

Within a few days, after feeling worse with flu-like symptoms, he returned to the same ER. Again, he was sent home and told to self-quarantine.

Legacy Silverton Medical Center had access to COVID-19 testing at the time, according to a spokesman. But he said that in mid-March, the state required patients have a severe lower respiratory infection and be admitted to a hospital to be eligible for testing.

Villasenor’s symptoms continued to worsen with shortness of breath and on March 29, his wife rushed him to the ER, this time in Salem. He was suspected of having COVID-19 — it’s noted on paperwork shared by his family — and an X-ray confirmed he had pneumonia.

But he still wasn’t considered sick enough.

He was sent home with antibiotics and told to continue to quarantine.

By that time, Salem Health had designated three of its clinics as testing sites. Due to a shortage of testing collection kits, the Salem Hospital emergency department still is not testing for COVID-19, according to a hospital spokesman.

Villasenor’s condition continued to decline. He and his family became worried and scared.

They managed to get him an appointment at Salem Health Medical Clinic on River Road S, one of those designated testing sites. Due to the coronavirus outbreak, it’s only seeing patients with flu-like and respiratory symptoms.

Again, the provider suspected COVID-19 but wouldn’t or couldn’t test him.

He was sent home once again, told to continue antibiotics and quarantine.

“My husband needed treatment,” his wife said. “I was so devastated.”

During all this time, his family said he did not leave the house other than to see those medical providers. And when he did, he wore a mask.

‘A person has to be dying’ to be tested

Watching his health deteriorate and witnessing the testing roadblocks were frustrating for his wife and two oldest children, who all work in the healthcare field.

“It just astounds me that a person has to be dying,” said son Lyndon Villasenor, who works at an emergency  psychiatric facility in Portland.

Tony’s wife, Pressy, is a Mental Health Therapist 1 at the state hospital. She’s worked there since 2007. His daughter, Fritzie Ortiz, is a nurse who works in case management in the Portland area.

The coronavirus attacked Tony Villasenor’s lungs, kidneys and liver. He was on a ventilator and in a coma for 2½ weeks. Doctors didn’t think he’d survive.

Nasal swab to test for COVID-19 are being administered to patients at Woodburn Health Center on April 13, 2020. Legacy Medical Group has drive-thru testing sites in Northwest Portland and Woodburn, with results available in one to two days. (Photo: MADELEINE COOK / STATESMAN JOURNAL)

Adding to the family’s trauma was the fact that they couldn’t be with him because of strict visitor restrictions at Salem Hospital. They butted heads with staff while discussing what an end-of-life visit would look like.

It was an emotional time, and they felt the staff was dismissive and had no empathy. It came to a head when a charge nurse hung up the phone on Fritzie. A recording of the phone call is included in a video the family made detailing Papa Tony’s story.

“I argued with the nurse. It was awful,” Fritzie said. “So many words were exchanged that day.”

By the time they had clarity from the hospital over end-of-life visiting protocol, her father’s condition had improved.

Her brother Lyndon reached out to social media groups for support, where he learned of others around the world whose family members died because the system failed. He was comforted to know they weren’t alone.

Family thankful for miracle recovery

Tony Villasenor was lucky. He survived a severe case of COVID-19, but his family wonders whether they all could have been spared the anguish if only he had been tested sooner.

“He had everything against him,” daughter Fritzie said. “It’s a miracle, honestly. The doctors said he had a miraculous recovery.”

His condition continues to improve, although he has a long road to recovery ahead. COVID-19 left him practically bedridden, and he remains on dialysis, which he may need for life.

He’s been working with physical and speech therapists and can now sit up and talk. His wife is thankful to be able to see and hear him via FaceTime.

“He’s still very weak, but he’s so happy,” Pressy said. “I told him God gave him a second life, and he cried.”

Her husband was transferred Friday morning to a rehabilitation center in Portland, but when he arrived officials said he couldn’t be admitted because the facility was not equipped to handle COVID-19 positive patients.

So the medical transport turned around and drove Villasenor back to Salem Hospital.

Pressy tested positive for coronavirus, too, but had only mild symptoms — a cough and occasional fever. She was tested several days after her husband was admitted to the hospital, along with their youngest son who lives at home. He tested negative.

She wants and needs to return to work and has passed the recommended 14 days quarantine and 72 hours without fever or cough. But still, she was worried about putting state hospital patients and staff at risk.

As of Wednesday, April 29, three staff members had tested positive for COVID-19, but no patients, according to a state hospital spokeswoman.

Pressy wanted to be retested but had no luck in Salem with the respiratory clinic her husband went to or her primary care physician. Her daughter, who lives in the Portland area, suggested she go to an urgent care clinic in Tualatin.

Pressy drove there Tuesday and received results the next day.

She tested negative for the coronavirus and hopes to return to work soon.