An Inspector General’s report released last week detailing November’s deadly COVID-19 outbreak at the La Salle Veterans Home is infuriating and heartbreaking.
Much comes down to lack of leadership from the state down to the local level.
The report details a lack of infection control planning, including accidentally putting positive and negative patients together in the same room. There were deficiencies in communication and training, and a lack of compliance with personal protective equipment. The list goes on.
And no one was taking ownership, demonstrating complete failure from the top down.
The result cost 36 veterans their lives, officials lost their jobs and some are even calling for a criminal investigation.
We previously pushed for a quick, but thorough turnaround for the independent report. Now, as we see what transpired and the mistakes made, we turn to the future and how to prevent such deadly outcomes going forward.
Gov. JB Pritzker requested the inspector general’s report that was released last week. Several Chicago media outlets reported that Pritzker said he asked for the investigation “so that we would all know what happened and we would all know how to fix it.”
When asked previously about the outbreak, the governor blamed the high rate of positive COVID-19 cases in La Salle County at that time. But other veterans homes in areas with high infection rates weren’t seeing the same spikes in cases and deaths.
Not long after the La Salle outbreak, Illinois Department of Veterans Affairs Director Linda Chapa LaVia resigned. Chapa LaVia, previously a state legislator, had been a “hasty appointment” by Pritzker after his initial appointee abruptly dropped out for unexplained reasons, Capitol Fax Publisher Rich Miller recently wrote in a column.
“She seemed like an ideal person to be able to root out our problems in our veterans homes,” Pritzker said at a news conference last week. “But I have to admit if I knew then what I know now, I would not have hired her.”
Since her resignation, Pritzker brought in a new acting director, Terry Prince, who spent 31 years with the Navy and brings experience in health care management from running Ohio’s veterans homes. We’re hopeful his leadership can help turn things around.
He shared some of his plans with Miller, including subjecting the veterans’ homes to accreditation and the federal government’s Medicaid rating system. He also intends to implement training drills to make sure employees are up to dealing with emergencies.
State Sen. Sue Rezin, R-Morris, who has been critical of the lack of urgency by the state in the outbreak aftermath and is insisting on more accountability by Pritzker, is pushing for an Auditor General investigation – the same office that issued recommendations after the deadly Legionnaires’ disease outbreak at the Quincy home that were unfortunately never implemented.
Rezin also has introduced a Senate bill that would require the Illinois Department of Public Health to make a site visit once an outbreak begins. The bill also defines the word “outbreak” as two or more people contracting a disease or virus within 48 hours, and further mandates veterans homes to notify the state immediately with a visit by the next business day. Rezin was right in being outraged that it took the state more than a week to visit the La Salle home.
While Rezin’s legislation focuses on state veterans homes, a wider net should be cast to include guidelines and policies for all long-term facilities. Sadly, the La Salle Veterans Home isn’t the only group facility to lose lives during a pandemic. Were many of those preventable? Quite possibly.
This report should be consumed by those working in all facilities that house large groups, including long-term care homes, corrections facilities, and even college dorms. The lessons here are universal.
After Pritzker was critical of former Gov. Bruce Rauner’s handling of the Legionnaire’s outbreak in Quincy, it’s understandable Republicans were going to be the first to ask for accountability from the governor. We don’t want to see this turn into a political squabble. While the governor seems to have taken the first steps toward accountability, recognizing there was an issue, we want to see his administration carry out an action plan — and we fully expect lawmakers from both sides of the aisle to hold him to it.
According to the La Salle report, “These incidents demonstrate confusion and complications that were avoidable with more deliberate outbreak procedures. A detailed outbreak plan was necessary based on the known risks and rising community positivity rates at that time. The absence of such a plan resulted in unnecessary and unsafe movement of positive and potentially positive veterans throughout the home, contributing to the outbreak’s rapid spread.”
Imagine your loved one died in the outbreak and you read this in the report. Imagine the fury, knowing your grandfather or mother could still be alive.
That’s what everyone should remember going forward. Overhaul the oversight, get the right people in place and follow through on the lessons learned.