A Minnesota National Guard unit botched COVID-19 testing for 300 residents and staff members at a St. Paul nursing home Monday, leaving many with pain, discomfort and bloody noses.
In what one health official acknowledged was "a disaster," the test samples from Episcopal Church Home were later ruined because they were not stored in coolers while being transported to the Mayo Clinic in Rochester.
State officials quickly apologized to Episcopal Homes leaders and said they've already taken steps to ensure such mistakes aren't repeated. Nevertheless, an elder care advocate said the incident raises serious questions about whether Minnesota can accurately and effectively carry out widespread testing.
The National Guard unit was deployed to Episcopal Church Home as part of the state's effort to ramp up testing at nursing homes and long-term care facilities.
"This just further erodes any trust that we have had in the Department of Health," said Kris Sundberg, executive director of Elder Voice Family Advocates. "I think we have a long way to go to really have the clearly thought-out protocols we need in order to do [widespread] testing."
A statement Wednesday from the Minnesota State Lab Partnership acknowledged "that there was an isolated incident related to the packaging and shipment of specimens to one of the testing sites. Ensuring the temperature integrity of specimens is critical to testing. We are accelerating and strengthening our training program to ensure all specimen collections, packaging, and shipping are performed to the highest standards."
National Guard personnel were sent to Episcopal Church Home on Monday after the facility earlier reported several staff members and residents had tested positive for the coronavirus. It was their first deployment, Dr. John Hick, manager of the State Healthcare Coordination Center, said in an e-mail to Episcopal Homes officials.
A National Guard spokesman would not confirm that Wednesday, referring questions to the Minnesota Department of Health (MDH).
Episcopal Homes CEO Marvin Plakut, who was one of those tested, said the Guard members "were professional and polite, but they weren't all that experienced, as we might prefer."
Problems surfaced almost immediately.
Because Mayo Clinic didn't have enough swabs for the test, health officials got swabs from M Health Fairview in Minneapolis. However, the swabs the Guard used were oral swabs, not nasal swabs, Plakut said. Oral swabs are shorter and thicker — and uncomfortable when inserted in the nose.
After getting approval from Hick, who said in an e-mail to the Star Tribune that it's OK for oral swabs to be used for "mid-nasal" collection, the National Guard started collecting samples. But many residents and staff members said the test was painful, Plakut said. Some suffered bloody noses.
"It was uncomfortable," Plakut said of his own swab.
More problems soon followed.
Because of a shortage of lab capacity in the metro area, officials arranged to send the test samples to the Mayo Clinic in Rochester. But in making the arrangements, no one secured the coolers needed to store the samples during the drive to Rochester.
In his e-mail to Episcopal officials, Hick said previous test collections by a more experienced National Guard unit working with an experienced liaison from the MDH helped ensure that test swabs were placed in coolers.
On Monday, a less experienced liaison was on the scene, he said.
Mayo staffers told Episcopal officials that the samples were ruined by heat, Plakut said.
'Deeply apologetic'
Hick said officials did not realize "gaps" in the process until it was too late.
"In short, we failed you and your residents and for that I am deeply apologetic," he wrote in an e-mail to Melissa Schneider, Episcopal Church Home administrator. "We have changed our systems and approach and learned from this tragedy, but I am sorry that all I have is our sincere apologies to offer in return for this situation."
Jan Malcolm, state health commissioner, also apologized. In an e-mail to Plakut Wednesday, she said officials have been working to quickly develop new training and protocols for swabbing and infection control at long-term care facilities, but "in this rapid launch, important steps in the process were missed and there were miscommunications."
Gayle Kvenvold, president of LeadingAge Minnesota, a nursing home trade group, said she is confident what happened to Episcopal Church Home "is the exception and not the rule." She said she is also confident that what happened Monday won't be repeated as widespread testing ramps up across Minnesota.
"Widespread testing is an essential tool," she said. "There were missteps that resulted in a terrible outcome for Episcopal Homes. … We are learning as we go and the process will get better and more effective."
Episcopal Church Home's residents and staff members still need to be tested. But how, when and by whom is to be determined, Plakut said.
The home uses HealthEast for daily coronavirus testing, but the process can only handle 15 people per day. Eventually, Plakut said, all 800 residents and 480 employees at Episcopal's several facilities need to be tested.
As for the anger residents and staff members felt toward state officials Monday and Tuesday, Plakut said much had dissipated by Wednesday.
"We're not out for blood," he said. "Our goal is to simply inform the right people so this doesn't happen again."
