The VA Illiana Health Care System in Danville is part of the Veterans Integrated Service Network 12. The VISN service area includes Northern Illinois, the Upper Peninsula of Michigan, and large portions of Wisconsin. In late October of 2020, the Office of the Inspector General (OIG) of the Department of Health and Human Services received two separate complaints about facilities operated by the system in Danville that failed to adequately address the COVID-19 pandemic.
How did COVID-19 impact the Danville VA facility?
The reports to the OIG concerned two Community Living Centers operated by Illiana, known as Unity and Victory. An investigation by the OIG found that leadership at the facilities did indeed fail to contain a COVID-19 outbreak.
Near the beginning of the pandemic, the facility developed a pandemic action plan that was consistent with VA guidance. While it addressed many important issues, such as the need for PPE for staff, a COVID-19 screening process for staff and visitors, and education around the coronavirus threat, the plan did not include actions to address a potential outbreak.
How long did the outbreak last at the VA facility in Danville?
Cases within the CLC facilities began to ramp up in mid-October 2020. Four staff members at Unity, two at Victory, and several residents tested positive for COVID-19. The facilities transferred the residents to a quarantine space at Valor, another CLC campus. However, by late October 2020, leaders needed to open a second quarantine facility due to Valor’s limited capacity.
The time from the first resident testing positive to the last COVID-19 related death was approximately five weeks.
Who was affected by COVID-19 during the Danville outbreak?
During the outbreak, 92 staff members and 239 veterans tested positive for COVID-19. By the end of the height of the viral threat, 11 residents had died.
One staff member reported that they were exposed to COVID-19 at home but denied a test at work. After being told to finish their shift, the employee tested positive the following day. Other staff members described the situation as chaotic.
The daughter of a Marine Corps veteran who died of the virus told reporters that she believes the staff did the best they could but were left poorly prepared for the situation by management.
Of all the VA-operated CLC facilities, the one at Danville had the fifth-highest COVID-19 death rate. During the period of the outbreak, it rose to six percent.
How did the Danville facility mishandle the COVID-19 outbreak?
The official OIG report substantiated claims that the facility leaders failed to:
- Observe infection control practices
- Develop and implement plans for an outbreak
- Follow CDC recommendations for additional infection control
The report outlines several areas where poor management at the facilities led to suffering, illness, and death for its staff and residents, including:
Misuse of Face Coverings and Respiratory Protection
Wearing face coverings is a standard precaution to help avoid the spread of COVID-19 while indoors. However, residents at these facilities did not consistently do so until after the outbreak. Staff also failed to wear face coverings regularly, and when they did wear them, they did so ineffectively. During their visit, the OIG team found employees in a quarantined neighborhood wearing unapproved masks or failing to cover their noses and mouths fully.
Lack of PAPR Training
At the time of the outbreak, staff did not receive the direction that respiratory protection was required. PAPR respirators, consisting of headgear and a fan that filters incoming air, are used when N95 masks are not available or not well-tolerated by a staff member. However, for them to be effective, staff must be appropriately trained on how to use them. Unfortunately, no one at either facility received PAPR training before the outbreak occurred, and by the time it was over, the number was less than 7%.
Failure to Manage Positive Staff Exposures
Due to the highly contagious nature of COVID-19, anyone potentially exposed to the virus must remain in quarantine for several days. However, management told at least one staff member to continue their shift after being alerted of their direct exposure to the virus the day prior. The employee later tested positive.
Insufficient Plan for Transfer and Isolation
While there was an operational quarantine facility, the OIG noted a lack of planning for the transfer and isolation of anyone who tested positive. Surge planning didn’t begin until after the outbreak, and an overflow quarantine facility was late to open. In addition, staff reported a lack of direction regarding who should care for residents infected with the virus and which isolation protocols were in effect.
In one case, a healthy resident’s roommate tested positive for the virus but was not immediately isolated. The roommate that had not tested positive roamed the halls and visited communal areas, despite being exposed to the virus. He later tested positive as well.
Lack of Aerosol-Generating Procedures
Because COVID-19 is airborne, respiratory aerosols, such as those caused by coughing or sneezing, can spread it. Some procedures performed on patients can produce even higher concentrations of these infected aerosols. The CDC recommends several steps to take when these procedures are necessary.
The OIG review found that two patients needed treatment with a nebulizer, which is an aerosol-generating procedure. Staff members should have performed these procedures in a special negative-pressure room, but instead, the administration took place in the residents’ rooms. Afterward, staff failed to sanitize the rooms thoroughly. As a result, both residents tested positive for COVID-19 during the outbreak.
Continuation of Group Therapy Sessions
There are a variety of group activities that take place in CLCs. Often, socialization can help prevent residents from feeling disconnected and alone. However, early in the pandemic, the CDC recommended taking immediate steps to cancel all group activities. Although facility leaders were aware of the guidance, group therapy sessions continued without their knowledge.
Inadequate COVID-19 Testing
After performing baseline testing for COVID-19, the VHA calls for ongoing screening, monitoring, and testing. The OIG report found that facility leaders didn’t create an adequate post-baseline test plan. In addition, after receiving the report of a positive case, all residents and staff must be tested immediately and then once per week until no new cases surface for two weeks. However, the OIG found that testing at Unity and Victory following a positive case was inconsistent.
Contact an Attorney if Your Loved One Died at a Danville VA Facility During the COVID-19 Outbreak
If your loved one died of COVID-19 at one of the Danville facilities, their death might have been preventable. The failures of leadership at Unity and Victory resulted in needless risk to vulnerable populations. A lawyer can help you determine whether your loved one’s death was preventable and if you can seek legal compensation for the resulting emotional and financial burdens.
For nearly 30 years, Levin & Perconti has sought justice for those who lost loved ones due to avoidable circumstances. If you’re considering a wrongful death action after the loss of your family member, or you’re unsure if you have a valid case, contact us today for a free and confidential consultation.