Danville VA nursing home where 11 residents died didn’t follow COVID guidelines, report finds

Leaders and staff at a federal veterans’ nursing home downstate mismanaged a coronavirus outbreak that killed 11 residents last fall, well after employees had been put on notice about the danger the pandemic posed to the home’s elderly residents, a government investigation has found.

A staff member exposed at home was denied a test and told to just wear a mask while finishing a shift caring for residents. The employee tested positive for the virus the next day.

Testing was inconsistent even after the virus started to spread within the Veterans Affairs complex in Danville, near the Indiana border. Isolation of people who’d been exposed — even those who tested positive — was haphazard.

“Direct care staff described chaos and a lack of awareness of what to do,” the inspector general of the U.S. Department of Veterans Affairs says in a report on the findings.

The outbreak lasted for five weeks in October and November 2020. During those two months, 92 staff members and 239 patients tested positive at the facility, which includes a nursing home, hospital and outpatient clinic.

Marine Corps veteran Mike Manning, 73, was one of those who died, but his daughter said VA officials didn’t cite the virus on his death certificate until she complained.

Caitlin Darling said she believes the staff who cared for her father did their best but that management might have left them ill-equipped to deal with the outbreak.

“I don’t know how many guys they ended up losing in my dad’s ward,” she said, “but I think last time I asked about it, it was eight out of 18, 10 out of 18.”

COVID-19 tore through long-term care facilities, accounting for a third of coronavirus deaths during the first year of the pandemic.

The inspector general’s report on the VA Illiana Health Care System in Danville is the first to publicly detail extensive breakdowns at a facility operated by the Department of Veterans Affairs. The agency operates 134 nursing homes serving about 9,000 veterans a day in 46 states, the District of Columbia and Puerto Rico.

An examination by the federal Government Accountability Office in June found there were 3,944 cases and 327 deaths among residents of VA nursing homes from March 2020 through mid-February. The case rate among residents was 17%, and the death rate was 1%.

Those numbers are a fraction of the toll in nursing homes nationwide. In a study published by the JAMA Network, researchers estimatedthere were 592,629 cases and 118,335 deaths last year. The death rate among long-term care residents as of March was 8%, according to the COVID Tracking Project.

The highest cumulative case rates from March 2020 to mid-February at VA nursing homes ranged from 38% of residents at the VA nursing home in Los Angeles to 59% at the facility in Montrose, New York.

The facility in Danville had the fifth-highest death rate — from zero to 6% in a month. The true rate is probably higher. After the GAO counted seven deaths during the outbreak, the inspector general found four other deaths related to COVID.

The watchdog launched an investigation after getting complaints in October 2020. Investigators concluded a lack of planning and urgency contributed to failures in testing, training and other infection-control measures. The facility didn’t provide enough respiratory protection and training for nursing staff and defied a national directive by continuing group therapy sessions, investigators found.

A resident with confirmed COVID-19 was left overnight with a roommate, investigators found. The roommate wandered the halls and into communal areas before testing positive for the coronavirus.

VA officials in Washington said they “deeply regret” what happened.

U.S. Department of Veterans Affairs

Staci Williams, acting director of the Danville VA facility since August, said, “The cases in our Community Living Center” — the nursing home — “impacted our entire staff and reinforced our commitment to learning and improving from the experience.”

The Danville VA facility has primary care and mental health clinics and an acute care medical center with 38 hospital and psychiatric inpatient beds. The facility’s nursing home has more than 100 beds across several units.

When the virus hit, administrators developed a 46-item plan covering everything from staff and visitor screening to personal protective equipment. The facility set up a command center with specialists in infection, quality control and emergency management. The director held town halls with staff. They planned to take coronavirus patients from the community if needed.

But the inspector general found several critical breakdowns.

By late June, after the rural area around Danville escaped the waves of infections reported in urban areas, the director of the VA facility reduced the frequency of town hall meetings and curtailed operations at the command center.

Staff members in nursing home units weren’t included in the facility’s respiratory protection program, so they weren’t all fit-tested and issued N95 masks or trained in using other respirators.

Though staffers had planned what to do with patients from outside the facility, the inspector general found, “an internal outbreak was not part of the considerations.”

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The facility was ill-prepared Oct. 12, 2020, when a nursing home staffer developed a cough and learned a family member tested positive.

Managers told investigators an associate director told them the employee should work the remaining six hours of a shift. The associate director denied being consulted. The staff member wasn’t tested and was told to put on a mask and keep working.

“This failure resulted in an employee, who later tested positive for COVID-19, providing direct patient care,” the inspector general found.

Under national VA guidance, after an employee tests positive, all staff and residents should be tested as soon as possible. The inspector general found two-thirds of staff in one Danville nursing home ward, nicknamed “Victory,” and 22% of staff in another, nicknamed “Unity,” were tested on their next shift.

“Three Victory and two Unity staff worked multiple shifts between October13-19, 2020, before testing occurred and ultimately tested positive,” the inspector general reported.

Investigators found that staff treated two residents with aerosol-generating equipment such as nebulizers without precautions to contain the droplets. The two residents tested positive.

Group therapy sessions continued. In the days after the initial staff member’s diagnosis, five residents were diagnosed with COVID-19 shortly after attending group sessions. Before the outbreak, staff said, residents did not wear masks to the sessions, though the facilitator did. A nursing home manager and recreation therapists told investigators they didn’t know about the directive to cancel group activities.

Mike Manning had been at the Danville VA nursing home since January 2020, his daughter said. Diagnosed with Parkinson’s disease and dementia, he had deteriorated in a matter of months.

“He was not happy,” Darling said. “Part of what kept him there and made him stop fighting me was COVID happened. And I said, ‘Dad, you need to stay there, where you’re gonna be safe.’ ”

In late September, as part of pandemic safety protocols, Manning was quarantined in a room on the Victory ward for 14 days after having a medical test outside the facility, his daughter said. When he got out, he tested negative and was “out and about” on the ward and engaged in his favorite pastime, painting. Within weeks, he was infected and had double-lung pneumonia.

“I was a little astounded,” his daughter said.

She said nursing staff told her a couple of other people on the ward had tested positive.

The inspector general’s report, which doesn’t identify veterans by name, detailed incidents in which veterans who tested positive were allowed to remain on their wards.

Shortly after 9 p.m. Oct. 20, a lab notified a doctor that two residents had COVID. One had a roommate known to wander the halls, and a nurse voiced concerns about leaving the infected veteran in the same room. A doctor decided not to move anyone that night since the roommate already had been exposed.

The infected residents were scheduled to be transferred to a quarantined COVID9 unit the next morning. That didn’t happen until that evening — 20 hours after the lab results came in.

Staff said that, during the ensuing hours, there was confusion about who was supposed to care for infected residents and which isolation protocols to follow.

The exposed roommate paced the ward, “including communal areas where other residents were congregated.”

It was about this time, between Oct.20 and 22, that facility leaders met to discuss what to do about the outbreak. A plan was finalized Oct. 22 — seven months into the pandemic.

The outbreak continued until Nov. 17, when the last infected resident died.

Manning’s daughter said she was allowed to visit him a few days before he died.

“When I went to pick up his stuff, the charge nurse, the other nurses that came out to bring his stuff out, were all sobbing — I mean, they are so heartbroken,” Darling said.

She donated a piece of his artwork to the facility, a painting of Abraham Lincoln, whose words became the motto of the VA: “to care for him who shall have borne the battle and for his widow, and his orphan.”

She dismisses VA officials’ comments now as meaningless.

“I don’t want their condolences,” Darling said. “I want my dad.”

Read more at USA Today.