Pritzker put on defensive by outbreak at VA home
COVID-19 tore through LaSalle facility with terrifying speed
As a young man in the Army Air Forces during World War II, Jerome Liesse flew around the globe, delivering supplies to farflung U.S. troops, his granddaughter said.
Because of the coronavirus, Liesse, 95 and no longer capable of getting around on his own, spent much of this year confined to his room at a state-run veterans home in LaSalle, a few miles from Starved Rock State Park.
Like other long-term care facilities across the state, the LaSalle Veterans’ Home shut down indoor, in-person visits in an effort to keep the deadly virus outside its walls. Liesse was only able to see Evelan, his wife of more than 40 years, twice during those eight months — once separated by plexiglass — and held her hand just one time, in August after she had a stroke, granddaughter Jill Funfsinn said.
“He was just so scared of getting it,” said Funfsinn, a Chicago nurse who visited him several times.
For months, the state was largely successful in its efforts to keep Liesse and the other veterans in its care at LaSalle safe. Through late October, only one resident and five staff members at the home tested positive for the coronavirus, according to the Illinois Department of Veterans’ Affairs. All six recovered.
But beginning Oct. 31, as the coronavirus pandemic was surging once again across the state, including in LaSalle County, an
outbreak tore through the home with terrifying speed, infecting more than 200 residents and staff members and killing at least 33 veterans, including Liesse.
The fallout has been equally swift. Initial federal and state inspections identified my riad problems at the home, including lax use of personal protective equipment and poor social distancing. State legislators have set hearings, and an investigation by a state inspector general has been launched.
Gov. J.B. Pritzker, who in his 2018 campaign for governor was highly critical of his Republican predecessor Bruce Rauner’s handling of a deadly Legionnaires’ disease outbreak at another state veterans home, is now on the defensive over his own VA home crisis.
“The governor owns this. This is his job,” said state Rep. Jim Durkin of Western Springs, the Illinois House Republican leader. “It’s the state’s job to provide for the care of the men and women who live and also work within that facility.”
Pritzker’s response accelerated Dec. 7, when he fired the home’s administrator. But the outbreak raged on, with the 33rd fatality announced on Thursday. Three staff members and 38 of 93 veterans, more than 40% of the facility’s population, were testing positive for COVID-19 as of late in theweek of Dec. 6.
Asked Friday if he bore any moral responsibility for deaths at LaSalle, the governor said, “I bear the responsibility of leadership of the state and that means that everything that happens across state government, to some degree or another, lands onmy shoulders.”
“These things can happen,” he added. “And I think most importantly, the question is: At the time that people become aware on site of what’s happening, what are their reactions? Howdo they care for people there and make sure that they’re safe? And then what do we learn from that, very importantly, to carry on elsewhere tomake sure that we’re keeping all of our veterans safe?”
Internal emails show growing concern
The first sign of the outbreak among residents appeared on Halloween, when a LaSalle veteran sent to a hospital for another ailment was found to be positive forCOVID-19.
All residents were then
screened for symptoms of COVID-19, and some were found to be newly symptomatic. Results from a round of routine surveillance tests conducted days earlier returned, with positive results for two staff members and 22 residents, according to a report issued by federal and state infection-control specialists.
That triggered campuswide testing, which showed eight positive staff members and 48 positive residents. ByNov. 9, three of the LaSalle veterans who tested positive for COVID-19 had died.
Internal emails among state Department of Veterans’ Affairs officials and the LaSalle home’s then-administrator reveal a growing sense of concern over the outbreak’s severity. The emails, obtained through a Freedom of Information Act request, were heavily redacted by the state.
On Nov. 9, Angela Mehlbrech, who was the LaSalle VA home’s administrator, referred to the number of staff members who had become infected in an email to the state agency’s chief of staff and spokeswoman. Mehlbrech wrote that “the main theme of questions from family right nowis, howarewe continuing to take care of our residents whenwe have lost so many staff members?”
In response to an internal question about whether family members were asking about anything else, Mehlbrech wrote: “Not that I am hearing but always they seem to border on a ‘howdid this happen?!’ kind of question. I have done my best to explain that one small mistake can mean you get the virus and then it just spreads so quickly before you even know it’s there.
Now they seem to want assurance that we have a plan to continue even if we are very lowon staff.”
OnNov. 10, theday before Pritzker appeared at a Veterans Day event — and as agency officials were preparing for questions from reporters about the outbreak — Mehlbrech wrote an email to the agency’s spokeswoman Bridget Dooley and chief of staff Tony Kolbeck that said, “For tomorrow … unfortunately the number of deaths might be higher by morning.”
Early on Veterans Day, Mehlbrech emailed Dooley under the subject line “press today” and sought to drawattention to the lack of known coronavirus cases connected to the home before the outbreak.
“I would really like people to remember that we kept the virus out of here for 8 months and only when our community numbers skyrocketed did we have an outbreak,” Mehlbrech wrote.
FederalVA visit finds numerous lapses
A report following a Nov. 13 visit by an infection control manager with the U.S. Department of Veterans Affairs identified a number of lapses that could have contributed to the virus entering thehomeand spreading. Those included lax social distancing among staff members and dispensers throughout the facility containing an alcohol-free hand sanitizer with a main ingredient that isn’t considered an effective agent against the highly contagious virus.
In multiple instances, the report urged staff members to avoid social gatherings outside of work, and to stagger their breaks and to avoid smoking together either inside or outside of personal vehicles.
The U.S. Department of Veterans Affairs declined through a spokeswoman a request for an interview with Infection Control Manager Amelia Bumsted, who authored the site visit report. A LaSalle County Health Department spokeswomansaid the department would not release findings of contact tracing efforts related to home employees who tested positive.
According to the federal VA report, staff members in full protective gear including gloves, gowns and bootees were observed walking through administrative areas, while three staffers were seen in the facility’s kitchen with their masks around their chins, eating less than 6 feet from one another. Some staff members were seen wearing gloves and touching patients and multiple surfaces without changing the gloves or washing their hands.
The site visit report also flagged ventilation concerns in the facility and noted that doors were left open with COVID-positive patients inside, which staff members said was due to the need to observe patients at risk for falls.
No one was stationed at the staff entrance at the time of the site visit to perform temperature monitoring, the report stated.
A follow-up site visit was conducted on Nov. 17 by an Illinois Department of Public Health infection control coordinator, who noted in a report “opportunities for transmission among some staffmay have occurred due to reported laxity of masking and social distancing while off duty and also during break periods while on duty. Increased monitoring has been initiated.”
By then, 74 of the 103 residents of the facility at that timehadtested positive for COVID-19, according to the IDPHreport.
A federal VA representative has been “on the ground at LaSalle” following up on pandemic concerns and protocols, and the Illinois National Guard has been called in to help the staff with screening, testing and data tracking, Pritzker said lastweek. TheNational Guard is expected onMonday at veterans homes in Manteno and in Quincy — where22staffmembersand 32 of 293 residents have tested positive.
‘Worst-case scenario’ becomes reality
Pritzker initially declined to say if anything specific led toMehlbrech’s firing on Dec. 7. He later said it was “an accumulation of things” that were “just unacceptable,” such as the use of hand sanitizer lacking virus-killing alcohol at the facility.
“Theworst-case scenario that Ihave tried every day to prevent is nowour reality in LaSalle,” Pritzker said. “WhatIknowis that our job right now is to make sure we do everything to protect the people who are at the LaSalle Veterans’ Home. We’ve been trying to do that all along.”
In making the Legionnaires’ outbreak at the Quincy VA home a core issue of his campaign for governor, Pritzker blasted Rauner for “fatal misman
agement.”
The two outbreaks have both parallels and differences, but the deaths of any veterans in state care becomes a powerful political issue where nuance and explanation quickly give way to criticism and attack.
Pritzker has sought to differentiate the two situations, in part by noting that Legionnaires’ disease is spread through the mist of contaminated water sources, while coronavirus is passed through the air by those who are infected. Legionnaires’ is “extraordinarily preventable,” Pritzker said Friday.
The initial 2015 outbreak at Quincy killed a dozen veterans, and subsequent annual outbreaks through 2018 led to at least two additional deaths and dozens more patients, family and staff members being sickened. Ultimately, the post-Civil War-era home’s water supply system was to blame, and the state is constructing a virtuallynew Quincy home.
While Legionnaires’ disease is relatively rare, the deaths at LaSalle fall into the larger picture of the globalCOVID-19 pandemic, which has grown so widespread despite governmental mitigation efforts that many people know someone who has tested positive for coronavirus, may have been hospitalized or even died.
But there’s another significant difference between Quincy and LaSalle. The Quincy issue surfaced long after the initial 2015 outbreak in reports by WBEZFM and drew attention because of the Rauner administration’s attempts to contain information about it.
“I think that some of the big anger in the Quincy issue was the Rauner administration didn’t want people to know and they didn’t want people to realize that they had made a mistake,” said state Sen. TomCullerton ofVilla Park, a Democrat who chairs the Senate Veterans Affairs Committee.
Unlike Quincy, LaSalle is happening in real time, Cullerton said, and the questions are about “people trying to solve the problems whereas with Quincy itwas everybody just hiding the whole thing.”
Differences from QuincyVA outbreak
One parallel between Quincy and LaSalle is the insistence by the Rauner and Pritzker administrations that they responded quickly to outbreaks.
Rauner, who dodged the
question three years ago when he was asked if he bore moral responsibility for the deaths at Quincy, said his administration had “done everything” that national experts including the Centers for Disease Control and Prevention had recommended fromthe beginning of the outbreak to dealing with subsequent annual outbreaks.
Symbolizing the political concerns, Rauner briefly moved into the Quincy home during his reelection campaign and invited Ivan Jackson, a resident, as a guest to hisState of theState address. But Jackson later was diagnosed with Legionnaires’ and died in May 2018.
An auditor general’s investigation found public health and Veterans’ Affairs officials in Rauner’s administration sought to downplay the potential seriousness of the Quincy outbreak in 2015 to residents, their families and staff.
An email to Quincy staff by veterans home officials on the outbreak’s fifth day assured they would not be put at risk if there was “an issue with Legionella” and urged them to “not panic and do not discuss this with residents” to prevent them from getting “worried and upset.”
In addition, then-state PublicHealth DirectorNirav Shah waited to call in the CDC, the audit said. By the time the agency arrived onsite in Quincy, the outbreak was in its 12th day and had killed seven people and caused 37 others to become ill. Even then, some changes recommended by the CDC were not implemented. With Quincy becoming a major liability to Rauner’s reelection, his director of veterans’ affairs, Erica Jeffries, stepped downinApril 2018.
A criminal investigation into Quincy was launched under then-Attorney General LisaMadigan, a Democrat. On Monday, a spokeswoman for Madigan’s successor, Democrat Kwame Raoul, said the investigation was closed after determining there was not a sufficient basis to bring criminal charges.
Like Rauner, Pritzker has insisted his administration was on top of the LaSalle outbreak from the start. He said the state has tried to do “everything to protect the people” at the home and that “since the moment we found out there was an outbreak, there’s been a lot of effort that’s been made to evaluate the problems at the home and to mitigate those problems.”
Pritzker’s decision to make personnel changes quickly, firing Mehlbrech and placing the LaSalle director of nursing on paid administrative leave pending the results of the investigation, reflected a proactive move by the administration.
Cullerton said state laws passed as a result of the Quincy outbreaks have led to more transparency in letting veterans home residents, their families and staff members know more quickly about disease outbreaks.
“I think the governor knows this looks bad. I think (Veterans’ Affairs Director Linda) Chapa LaVia knows this looks bad,” Cullerton said. “But I also know from the multiple conversations I’ve had, she’s trying to figure out the best way she can to stop it and make sure it doesn’t happen in the other homes aswell.”
On Tuesday, in what could become a test of the Pritzker administration’s transparency, Cullerton and ranking Republican on the veterans’ committee, Sen. Paul Schimpf of Waterloo, sent letters requesting all documents mentioning COVID-19 and the LaSalle home involving Pritzker and top administration staff as well as Public Health Director Ngozi Ezike and Chapa LaVia. The House Veterans’ Affairs committee is scheduled to hold its first hearing on the issue next week.
While the administration didn’t make Chapa LaVia available for this story, she testified at a recent Senate hearing that she did not directly notify Pritzker of the outbreak despite the known potential for deaths among the elderly in congregate settings. She said he was informed through his staff.
At that hearing, Chapa LaVia said itwas “no coincidence” that COVID-19 cases in the home began to rise as they did so, dramatically, in the surrounding community.
“For eight months, the dedicated staff and administration at the LaSalle home rose above the abysmal infection rates of most of our long-term care facilities across the state,” she said.
In the week ending Oct. 4, LaSalle County had 109 new COVID-19 cases per 100,000 residents. By the beginning of November, the ratewas up to 390 cases per 100,000 residents, and it peaked at 961 cases during theweek ending Nov. 15.
But LaSalle County was far from alone in seeing such a surge during the fall. In Kankakee County, home to a state-run veterans home in Manteno, there were 95 cases per 100,000 residents in the week ending Oct. 4. The rate peaked at 1,369 cases per 100,000 residents during the week ending Nov. 15.
From Aug. 21 through Thursday, 18 residents and 33 employees at the Manteno home had tested positive for the coronavirus, and two veterans had died.
The story was similar in Adams County, where the Quincy home is located. The county surged from192 cases per 100,000 residents in theweek ending Oct. 4 to 1,225 cases during the week ending Nov. 22. Despite the ongoing outbreak at Quincy, there had yet to be any fatalities as of Thursday.
State Sen. Sue Rezin, a Morris Republican whose district includes the LaSalle home, takes issue with how long it took for an infection control visit.
“The administration waited 12 days, which, when you have a massive, rapid spread of a deadly disease within a very vulnerable population, the Department of Public Health should have sent a team out immediately to assess the situation and correct any deficiencies.”
She said she has continued to receive calls from LaSalle Veterans’ Home employees who said the facility lacked the basic quality control measures to ensure that the residents and employees were working and living “in a safe, protective environment,” she said.
“I’ve heard from the administration that the changes have been made to make sure that the proper procedures are in place now, from this point forward, to protect the veterans,” Rezin said. “I’m not convinced. I still hear from people that work in the home, and I have serious concerns about, to this day, breaches that are happening in protocol.”
Schimpf, the top Republican on the Senate veterans committee, said those issues point to the likely explanation for the LaSalle outbreak— a safety protocol breakdown.
“The thing that we will never know is if IDPH had sent a team out there as soon as they knew about the outbreak … would the changes that they made, would those have saved any lives?” Schimpf asked.
“The worst-case scenario that I have tried every day to prevent is now our reality in LaSalle. What I know is that our job right now is to make sure we do everything to protect the people who are at the LaSalle Veterans’ Home. We’ve been trying to do that all along.” — Gov. J.B. Pritzker
‘Sad, scared, without human touch’
For Jill Funfsinn and others whose family members have died while in the state’s care, the answers to those questions are important because they could help prevent future deaths at LaSalle and other veterans homes. But at this point, it would do little to ease the pain of their loss.
Funfsinn has questions of her own.
Staff members at the home often spent time with her grandfather in his room, she said, playing cards or helping him do puzzles. After his death, she’s been left wondering if that’s how he came into contact with the virus.
“He lived his last days depressed, sad, scared, without human touch, not being able to see and hold his wife … for what?” Funfsinn wrote to Pritzker in an email she sent via the Department of Public Health. “If the staff there were not going to be diligent in protecting these heroes, which also includes protecting themselves, what was all of this for?”
Funfsinn’s last visit with her grandfather through his window was Nov. 11. Three days later, his family learned he’d tested positive for the virus.
By then he was unresponsive, but Funfsinn was able to see her grandfather and touch him one last time during a Nov. 16 compassionate care visit, a privilege extended to residents who’ve tested positive for the virus. She left about 10 p.m. He died less than three hours later.
“Even though he was 95 and lived a full life, he just didn’t deserve to go in the way he did,” Funfsinn said. “He was at their mercy, and he trusted them to protect him. He didn’t have a choice.”