Communication Issues That Led To Deadly Vets’ Home COVID Outbreak Predated Pandemic: Investigator
The state inspector general who headed an investigation into the November COVID-19 outbreak that killed 36 residents at the LaSalle Veterans’ Home told lawmakers Tuesday that communication issues pinpointed as a root cause of the crisis predated the pandemic.
“There are folks at LaSalle home who were expressing frustrations about communication prior to COVID, prior to 2020…multiple people expressing these concerns,” Department of Human Services Inspector General Peter Neumer said.
Neumer appeared in front of the House Veterans’ Affairs Committee Tuesday, answering questions about the process behind his investigation. The committee’s hearing on the LaSalle home outbreak will continue Thursday, when the panel will grill representatives from the Department of Veterans’ Affairs, Department of Public Health and Gov. JB Pritzker’s office.
Tuesday’s hearing was much shorter than Thursday’s is likely to be, and Neumer mostly stuck to the methodology behind his investigation into the outbreak, which ended with more than a quarter of the LaSalle home’s population dead after testing positive for COVID.
After initiating the report a few weeks into the outbreak in November, Pritzker published Neumer’s damning report nearly five months later on April 30. The report assigns blame to a variety of factors, including lack of preparedness, lax COVID protocols, absentee leadership and poor communication both at the LaSalle home and at the IDVA, which oversees LaSalle and three other state-run veterans’ homes.
Communication issues are detailed repeatedly in the report, which says COVID “exposed longstanding communication and training deficiencies within the Home.”
Those communications failures had consequences.
For example, the investigation found that during the first few months of the pandemic last year, the facility mandated a two-week quarantine for residents coming back to the home after being out for any reason. But sometime during the summer, the quarantine protocol ended for residents returning from appointments at nearby St. Margaret’s Hospital, as those “visitations were considered ‘low risk,’” according to the report.
Nurses interviewed for the investigation said the first COVID cases of the outbreak in November were residents returning from St. Margaret’s who were not quarantined, as well as staff who accompanied them to the hospital.
The facility’s COVID policies were never written down, according to the report, and staff told investigators the quarantine policy “changed frequently.” The report says no one had a clear recollection about who made changes to that quarantine policy, but some nurses at the home were under the impression the facility’s medical director, Dr. Michael Morrow, directed changes.
However, the report also says Morrow was mostly focused on “general medical management, rather than on policy-making,” and “had a limited role in establishing policies or in advising the Home’s Administrator prior to the outbreak.”
Neumer told lawmakers he couldn’t pinpoint the source of the changes to the home’s quarantine policy, but said written COVID policies would have been far preferable to protocols spread by word-of-mouth.
“And so in absence of that written directive, it seems like it became a little bit more of a game of telephone,” Neumer said.