Report details problems with ventilation, staff and hand sanitizer at LaSalle vets home


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(The Center Square) – A report from the U.S. Department of Veterans Affairs detailed problems at a LaSalle Veterans’ Home including ventilation problems, ineffective hand sanitizer and a Halloween party staff reportedly attended.

Just 90 minutes before Tuesday afternoon’s virtual Illinois Senate Veterans’ Affairs Committee hearing on the outbreak earlier this month at the LaSalle Veterans’ Home, the Illinois Department of Veterans’ Affairs said it would be implementing recommendations from the report.

“There were multiple questions and potential concerns with the ventilation in the facility,” officials wrote in a report after a visit to the LaSalle home on Nov. 13. “Negative pressure—informed that rooms on the NW unit had been recently converted to negative pressure. Staff explained that patients who were positive were moved to these rooms first when the outbreak began.”

“Room doors were left open with positive patients inside,” the reports said. “Staff explained this was due to fall-risk if not directly observed.”

There were also issues with staff behavior.

“It was reported that a number of employees who eventually tested COVID positive were in attendance at a common Halloween party,” the report said.

The report gave a timeline of how fast COVID-19 spread, showing on Nov. 6 a hospitalized resident tested positive. Routine surveillance found two positive staff members and 22 residents. A campus-wide test found eight positive staff and 48 positive residents.

Three residents who tested positive died on Nov. 8. Four more deaths were reported Nov. 10. By Nov. 12 there were 73 positive residents, seven deceased among the 121 residents. Of around 200 staff 84 were positive.

There have been at least 24 deaths at the home, according to the latest numbers on the IDPH website.

The report also recommended certain dress procedures for staff changing into scrubs. It said staff breaks “should be staggered and should not involve multiple people smoking together either outside or inside personal vehicles.”

“Observed three staff members in the facility’s kitchen with masks around their chins, eating, and all <6 feet from each other,” the report said. “Observed staff wearing gloves touch patients and multiple surfaces without changing or performing hand hygiene.”

“The key for containment of this outbreak will be concentrating on slowing the spread amongst the staff,” the report said.

Investigators also discovered foam hand sanitizer that’s not effective against COVID-19 socked and mounted through the facility, including in resident rooms.

“This could have significant impact on the transmission of COVID-19 within the facility,” the report said.

There were also procedures in place to screen entrants to the home.

“At the staff entry, however, a different form was used which did not list all the screening questions/symptoms,” the report said. “Although it was explained that there is a dedicated staff member to perform temperature monitoring, there was no one stationed there at the time of the visit.”

Slow test turnaround was another concern.

“This seems to be a challenge with tests sent out to Chicago IDPH lab, which was necessary at the beginning of the outbreak due to the Springfield lab being temporarily closed,” the report said. “Recognition of an outbreak is difficult when test results trickle in, as the correlation between time and location is hard to demonstrate without all the information available. IDPH representative suggested that the Springfield lab should place a priority on the LaSalle samples during the outbreak.”

The Pritzker administration said it’s ordering independent investigations and implementing new COVID-19 guidelines in Illinois veterans’ homes.

“The recent outbreak of COVID-19 and subsequent loss of lives at the LaSalle Veterans’ Home is a tragedy,” IDVA Director Linda Chapa LaVia said. “My heart goes out to the families and loved ones of those who have become ill and those who have passed on. The IDVA is committed to a transparent review of the circumstances surrounding the outbreak and has adopted all recommendations from the IDPH, CDC, CMS and U.S. VA moving forward.”


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