Two Reports Released on Cluster/Deaths at State Veterans Home in Hilo

September 21, 2020, 5:37 PM HST · Updated September 22, 5:28 AM
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Two reports detailing in-depth assessments of conditions and protocols at the Yukio Okutsu State Veterans Home in Hilo, were released. The assessments were conducted separately by the US Department of Veterans Affairs and the Hawai‘i Emergency Management Agency.

A third report by the state Department of Health’s Office of Health Care Assurance is still undergoing internal review and will be shared soon after the Veteran’s Home receives it.  The report is based on an inspection of infection control measures based on State and Centers for Medicare and Medicaid Services standards and requirements.

“With 24 deaths and 70 positive infections of our veterans, the VA’s report makes it clear that the facility’s management failed to take action to prevent this massive outbreak at a home entrusted with the responsibility of caring for our veterans,” said US Representative Tusli Gabbard.  “The culture of complacency that allowed this incredible loss of life and suffering must end. Those responsible for this must be held accountable. I will continue to support all efforts to conduct oversight and follow-through to ensure immediate action is taken to keep our veterans and their caregivers safe. Sadly, for many of the residents and their families, it’s too late.” 

The home is operated by Avalon Health Group, under contract to the State of Hawai‘i.

Each of the two assessments that were released highlight different observations, and in some cases places more emphasis on certain factors over others.

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Dr. K. Albert Yazawa, conducted the HI-EMA assessment  and wrote, “I believe the nursing home culture at YOSHV was one that remained entrenched in pre-COVID norms of respecting individual resident rights over the health of the general population.”

HI-EMA’s involvement was requested by the Hawai‘i Health Systems Corporation and Dr. Yazawa collaborated closely with the VA assessment team.

The VA report noted: “There was very little proactive preparation/planning for COVID. Many practices observed seemed as if they were a result of recent changes. Even though these are improvements, these are things that should have been in place from the pandemic onset and a major contributing factor towards the rapid spread. A basic understanding of segregation and workflow seemed to be lacking even approximately three weeks after [the] first positive.”

“Staff were in-serviced on facility policies and procedures, but it appears there was no follow-up to ensure appropriate behaviors or enforcement,” according to the OHCA report; further noting,

“The staff received education on COVID-19 Infection and Control during a meeting on June 10 to June 15, 2020.” That meeting included the Resident Screening Tool – keeping COVID out by detecting cases quickly and stopping transmission.” The HI-EMA assessment indicates in June full facility staff and resident mass testing was conducted and all tests came back negative.

The VA team sent seven medical and health care experts to visit the Yukio Okutsu State Veterans Home on Sept. 11. At that time the team reported 10 residents had died from coronavirus and another 35 were positive. The number of recovered patients and the status of the home’s staff members are contained in the VA report.

Neither the VA or HI-EMA report pinpoints the exact sources of infection. Both reports indicate some patients may have been exposed in early August after going for dialysis in Hilo.

 

Select Deficiencies  

Veterans Administration Assessment Hawai‘i Emergency Management Agency Assessment 
Residents not cohorted based on COVID statusPatient movement between units
Inconsistent mask usage by residentsWandering residents (dementia)
Intermixing of housekeeping/maintenance staff between unitsStaff gatherings at work and in the community
Little proactive preparationLack of physical distancing measures for staff and patients
Numerous examples of potential infection from cross-contaminationConcerns about continued staff positives after mass testing

 

Both the VA and HI-EMA assessments recommend immediate discontinuation of nebulizer use, with the HI-EMA report stating, “Discontinue all nebulizer treatments. This decision is not voluntary.

Select Recommendations 

Veterans Administration Assessment Hawai‘i Emergency Management Agency Assessment 
Additional hand sanitizer unitsOutsource testing to free up staff
Encourage staff breaks outdoorsContinue to halt new admissions
Consistent staff assignments to avoid cross-contaminationEmploy extremely low testing thresholds
Regular risk mitigation trainingHigher staff ratio for COVID-19 unit
Leadership presence on all shifts for compliance, accountability and risk identificationEliminate staff complacency toward safe practices, internally and externally

 

The Veterans Administration formed a 20-person “Tiger Team” to help implement recommendations, provide training and oversight, and to provide needed staffing support and respite, at the facility.

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