TWO OF THREE REPORTS RELEASED ON CLUSTER & DEATHS AT STATE VETERANS HOME
(Editor's Note: Now that the dying is half-over, the 'heroes' have arrived to firmly shut the barn door. We destroyed the economy to stop a disease which mostly kills seniors. But when the disease got into a nursing home, we didn't do anything until it was too late. Lesson: YOUR SACRIFICE IS DESIGNED TO MAKE YOU 'FEEL' URGENCY. And it worked.)
News Release from COVID-19 Information Center, September 21, 2020
(Honolulu) – Two reports detailing in-depth assessments of conditions and protocols at the Yukio Okutsu State Veterans Home (YOSVH) in Hilo, have been developed. The assessments were conducted separately by the U.S. Department of Veterans Affairs (VA) and the Hawai‘i Emergency Management Agency (HI-EMA). The VA and HI-EMA assessment reports are attached with this release.
The Dept. of Health’s (DOH) Office of Health Care Assurance (OHCA) is preparing a report on its inspection of infection control measures based on State and Centers for Medicare and Medicaid Services standards and requirements. The OHCA inspection report is still undergoing internal review and will be shared soon after YOSVH receives it. The home is operated by Avalon Health Group, under contract to the State of Hawai‘i.
Each of the two assessments highlights different observations, and in some cases places more emphasis on certain factors over others. 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 Corp. 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 3 weeks after first positive.”
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 YOSVH on Sept. 11. At that time the team reported ten (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 status |
Patient movement between units |
| Inconsistent mask usage by residents |
Wandering residents (dementia) |
| Intermixing of housekeeping/maintenance staff between units |
Staff gatherings at work and in the community |
| Little proactive preparation |
Lack of physical distancing measures for staff & patients |
| Numerous examples of potential infection from cross-contamination |
Concerns 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 units |
Outsource testing to free up staff |
| Encourage staff breaks outdoors |
Continue to halt new admissions |
| Consistent staff assignments to avoid cross-contamination |
Employ extremely low testing thresholds |
| Regular risk mitigation training |
Higher staff ratio for COVID-19 unit |
| Leadership presence on all shifts for compliance, accountability & risk identification |
Eliminate 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 YOSVH.
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PDF: VA Report & Avalon Response
PDF: HIEMA Report
CB: Report: ‘Culture’ At Hilo Veterans Home Contributed To Deadly Spread Of COVID-19
SA: HI-EMA report says Hilo veterans home staff played role in COVID-19 spread
SA Editorial: Strict oversight for Hilo nursing home
HTH: Reports find fault with Avalon Health Care Group
HPR: HI-EMA Says Culture Of Complacency Major Contributor To Veterans Home Outbreak