LaSalle VA Home Events/Actions
More information to be added as it becomes available.
Timeline:
NOVEMBER 2020
The LaSalle Veterans Home IDPH and Department of Veterans Affairs did briefings on COVID-19 on a daily basis with the Veterans home administrators.
11/1/2020
The first positive patient was found through testing at a medial appointment with the test conducted at a local hospital.
11/3/2020
Results came back from a routine screening done on 10/31/2020. These results identified 22 residents and 2 staff members.
11/10/2020
The first contact for on-site help with the situation at the LaSalle Veterans Home this “consultation request was to explore potential opportunities for containment/control not otherwise previously implemented or identified.” https://www2.illinois.gov/veterans/Documents/11-24-20%20IDVA%20LaSalle%20Release%20Reports.pdf
11/11/2020
Off Site review began to take place with IDPH and VISN-12
11/12/2020
On Site review of the LaSalle Veterans Home and report given 11/13/2020
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Continued daily off-site communication between IDVA, IDPH, and Visn-12 – Confirmed through VISN-12 Director call.
11/17/2020
Follow up consultation found that all measures had been put into place correcting any deficiencies.
11/23/2020
Department of Veterans Affairs VISN-12 epidemiologist on site at the LaSalle Veterans Home as well as all the other State Veterans Homes.– Confirmed through VISN-12 Director call.
11/24/2020
The Senate Veterans Affairs Committee held a hearing on the LaSalle Veterans Home.
11/28/2020
Study finds that non alcohol based hand sanitizer more specifically benzalkonium chloride hand sanitized used by the Veterans Home prior to 11/13/2020 site visit is effective at inactivating Covid-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700010/pdf/main.pdf
DECEMBER 2020
12/2/2020
The House Judicial Committee - Civil started its probe into the LaSalle Veterans Home https://capitolfax.com/2020/12/02/house-judiciary-committee-launches-its-own-probe-into-massive-outbreak-at-lasalle-veterans-home/
12/7/2020
The Administrator of the LaSalle Veterans Home is fired and the Director of Nursing put on Administrative Leave pending the results of the investigation by IDPH OIG. https://www2.illinois.gov/IISNews/22448-IDVA_Anncs_Asst_Director_Anthony_Vaughn_to_Serve_as_Interim_Administrator_of_LaSalle_Veterans%E2%80%99_Home.pdf
12/11/2020
Illinois Air National Guard medical units deployed to both LaSalle and Quincy Veterans Homes. They will be tasked with conducting and maintaining records of COVID-19 test as well as monitoring PPE usage by nursing staff. This is a step to take the burden off the nursing staff and allow them to focus on caring for our veterans.
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LaSalle has received seven Army National Guard Soldiers, one officer and six enlisted troops
12/14/2020
Manteno and Quincy VA Homes received a team of three Air National Guard Airmen, one manager (an officer or noncommissioned officer) and two enlisted troops.
12/16/2020
The House Veterans Affairs Committee held a public hearing on the LaSalle VA Home:
https://www.ilga.gov/house/committees/hearing.asp?CommitteeID=2315&GA=101
12/24/2020
Christmas Eve Quincy Veterans Home was vaccinated for COVID-19
https://wgem.com/2020/12/24/illinois-veterans-home-residents-and-staff-receive-covid-19-vaccine/
12/29/2020
The residents at the LaSalle Veterans Home were Vaccinated and tomorrow 12/30/2020 the staff will be vaccinated according to Bridget Dooley IDVA Public Information Officer.
ISSUES TO BE ADDRESSED
Issues from the 12/16/2020 Hearing to still be addressed:
Did the HVAC system play a role in the spread of COVID-19 in the home?
o The system brings in 80% of the air from the outside.
o Sometimes droplets can become airborne and may transmit but further testing will have to be done to investigate.
o The negative pressure rooms were not utilized properly as the doors had to be propped open. The doors were propped open because the veterans were fall risks and the nurses needed to see inside the rooms to make sure this hadn’t taken place. Tony Kolbeck stated that windows in the doors were not an option as they would need permission from the residents. This could be a privacy concern to have windows on the room doors. However, they do have windows at other IDVA nursing homes resident room doors.
https://www.nafahq.org/covid-19-corona-virus-and-air-filtration-frequently-asked-questions-faqs/
Was testing results latency a factor in causing the outbreak?
o 11/3/2020 results came back from a routine screening done on 10/31/2020.
These results identified 22 residents and 2 staff members testing positive for COVID-19.
o Tony Kolbeck stated he would get a timeline for all the testing conducted and the results so an assessment could be done to see in the latency or results played any role in the outbreak.
o It was stated repeatedly in the hearing though by Tony Kolbeck that the test results always came back in 2-3 days.
PPE Violations:
Was there a failure in the direct leadership at the home to properly supervise, motivate, and enforce PPE policies?
o COVID-19 fatigue is a real thing and needs to be dealt with through motivation and constant supervision.
Major issues addressed in the 12/16/2020 Hearing:
Hand Sanitizer:
The preliminary report from IDPH on 11/13/2020:
Tork brand alcohol free foam hand sanitizer (main ingredient--Benzalkonium Chloride 0.13%, not found to be an effective agent against COVID-19) found stocked in all the mounted dispensers in the facility, including in resident rooms. This could have significant impact on the transmission of COVID-19 within the facility. This was brought to the immediate attention of the facility and plans for correction included:
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Immediately place alcohol-based hand sanitizer pumps in all the clinical areas (in process while on site)
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Remove all product from the dispensers so they are not inadvertently used while awaiting replacements
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Have purchasing contact the vendor about replacement of the product with alcohol-based version (confirmed that Tork does make this). Potentially arrange with vendor for an exchange of product already on site.
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11/28/2020 study finds that non-alcohol based hand sanitizer more specifically benzalkonium chloride hand sanitized used by the Veterans Home prior to 11/13/2020 site visit is effective at inactivating Covid-19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7700010/pdf/main.pdf
Cleanliness of the Home:
The 11/13/2020 report stated the following about the Veterans Home cleanliness:
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The facility was very clean. There were no observed issues with high/low level dust, debris, or soiled surfaces in common areas or resident rooms. The resident rooms were very organized and generally free of clutter. Medication and nutrition rooms were sanitary, and supplies were appropriately stored. A terminally cleaned room was inspected and all furnishings and high-touch areas appeared sanitized. Housekeeping staff provided the facility’s checklist for regular terminal cleaning of resident rooms and was able to appropriately speak to their process.
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Recently added UV light disinfection to the facility protocols—recommend developing written standard operating procedure/policy & procedure for its use that reflects manufacturer’s recommendations for cleaning prior to using UV light for disinfection.
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Limited hours of service of housekeeping (not available on 3-11 shift) could create a concern for the adequacy of terminal cleaning after moving patients, such as the many bed movements that were necessary when initially separating the positive patients from the negative patients and consolidating wards.
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Tony Kolbeck spoke on this at the hearing stating that they are hiring personnel to cover the 3-11 shift.
Its also important to note that even though the 3-11 shift was noted as a deficiency all procedures and cleaning measures were being followed as well as the home was in very clean order as noted in the 11/13/2020 IDPH report.
ISSUES ADDRESSED
STATISTICS
