The lack of plans or policies by administrators at the Illinois Veterans Home in La Salle led to confusion among staff, and resulted in residents who tested positive for COVID-19 exposing residents who tested negative, exasperating a November outbreak that led to 36 resident deaths.
This discovery was one of several outlined in an investigative report released Friday by the Illinois Department of Human Services’ Office of the Inspector General and Armstrong Teasdale law firm.
The lack of a COVID-19 infection within the veterans home provided it time to develop and test comprehensive policies and plans, yet none were created.
This failure was evidenced by the home’s disorganization in moving veterans during the November outbreak, the report said.
“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.”— From the report conducted by he Illinois Department of Human Services' Office of the Inspector General
General guidance concerning the movement of veterans in the event of an outbreak was provided, but the cursory plan proved insufficient, the report said. While staff understood veterans required movement to the COVID-19 unit upon testing positive, simple details explaining this movement procedure were not conveyed.
For example, there was no guidance as to which staff or unit were responsible for the various aspects of a veteran’s transition to the COVID-19 unit, the report said. The home did not conduct any stress tests or drills to evaluate or identify inefficiencies within its outbreak plan.
When the outbreak began in November, this lack of preparedness or a detailed plan caused confusion amongst staff, according to the report. In total, there were 109 positive cases among residents during the outbreak and 116 cases among employees at the veterans home.
Several staff members indicated the northwest unit was unprepared as a COVID-19 unit and there was insufficient direction and supervision in the transition of positive veterans into the unit and negative veterans out of the unit.
“The testing and movement of 19 veterans at the start of the outbreak was described as a ‘whirlwind’ that was ‘frantic’ and ‘chaotic,’ as one nurse stated, ‘nobody seemed to know what to do.’ " the report said.
The report stated in the absence of any instruction during the testing of all veterans in the COVID-19 unit, staff simply yelled out veterans’ tests results while trying to isolate positive veterans together and remove all negative veterans from the unit.
This unstructured approach caused complications and cross-contamination of positive and negative veterans, the report said.
For example, in one instance during this testing and movement process, a nurse discovered a positive veteran and a negative veteran were accidentally placed in the same room awaiting additional movement.
Despite the negative veteran’s recent exposure to a positive veteran, a member of the management team instructed the negative veteran still be moved to a non-infected wing.
At this time, there was space in the quarantine unit for suspected positive veterans, but uncertainty in procedure and the immediate need to vacate rooms for confirmed positive veterans led to the recently exposed veteran not being quarantined or isolated at this time.
The failure to quarantine or isolate the exposed veteran was later acknowledged as an error.
Another nurse at the home recalled a similar instance in which two sets of roommates were tested and both sets of roommates contained one positive veteran and one negative veteran. Again, the negative veterans who were recently exposed to positive veterans were moved to a non-infected wing of the home without any quarantine period.
The following day, the same two veterans were rapid tested, and their results returned positive.
Testing and veterans’ transition during the outbreak was further complicated by the home’s half-measures the previous month, the report said.
In the beginning of October, the home decided to relocate 10 of the 20 veterans housed in the northwest unit to vacant rooms in other units to convert the northwest unit into a quarantine unit.
Although space was available elsewhere in the home, relocation of veterans stopped on Oct. 7, leaving 10 veterans in the future quarantine hall.
When the outbreak began just a few weeks later, these 10 Veterans required relocation, again causing avoidable movement and interaction amongst positive and negative veterans.
The home’s decision to leave half of the veterans regularly housed in the future quarantine hall demonstrates a lack of foresight that contributed to the prolonged outbreak in the home, the report said.
The home’s lack of prior planning was also exhibited in its movement of veterans throughout the outbreak, the report said.
There was little or no communication as to the procedure for moving veterans from a non-infected hall to the COVID-19 unit.
When a veteran tested positive in a non-infected hall, staff were instructed to move the veteran along with the veteran’s belongings and bed 20 without any prior decontamination. But when a veteran’s belongings were moved outside of the housekeeping department’s staffing hours, no procedure was in place to inform the incoming housekeeping staff the veteran’s belongings and vacated room required decontamination.
When IDPH conducted a site visit at the home on Nov. 12, the home still did not have appropriate procedures in place. The visiting IDPH nurse observed a staff member moving a veteran’s belongings wearing full PPE and gloves, but then later saw that staff member wearing the same gloves while touching other items.
“These incidents demonstrate confusion and complications that were avoidable with more deliberate outbreak procedures,” the report said. “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.”
Linda Chapa La Via, who was director of the Illinois Department of Veterans Affairs during the time of the outbreak, has since resigned after she was criticized during a legislative committee meeting for her response to the outbreak. La Salle veterans home administrator Angela Mehlbrech also was fired in December.