Hawai'i Public Radio | HI-EMA Says Culture Of Complacency Major Contributor To Veterans Home Outbreak

September 22, 2020
In The News
A culture of complacency among staff at the Yukio Okutsu State Veterans Home in Hilo was a major contributor to the rapid spread of COVID-19 throughout the facility. That’s according to a new report on the outbreak, which has claimed the lives of 25 veterans as of today and infected another 79 residents and staff.

The latest report on the Yukio Okutsu State Veterans Home reveals a nursing home culture where staff was reluctant to force residents to do anything they didn’t want to.

When residents were being relocated within the facility according to their COVID status, some residents refused to move, and staff didn’t force them. When residents with dementia were seen wandering the halls, staff made no attempts to restrict their movements.

These were major errors that contributed to the infectious spread, according to the six-page report released yesterday by the Hawaiʻi Emergency Management Agency (HI-EMA).

The report was compiled by HI-EMA’s long-term care specialist and geriatrician Colonel Albert Yazawa.

He found multiple potential sources of infections at the Hilo facility. This includes the previously reported asymptomatic staffer and the resident exposed at an outside dialysis center.

But there was apparently a staff connection to known community outbreaks.

Yazawa says knowing exactly which staff may have had community exposure could have helped prevent prolonged exposures.

So far 34 staff have tested positive for COVID-19, and Yazawa says there have been new infections among staff during the past five facility-wide tests.

He says it’s unlikely staff acquired COVID-19 in the community but rather because of a lack of personal prevention practices like wearing a mask.

The HI-EMA report is the second to point to serious shortcomings in infection control and other issues at the veterans home that contributed to the outbreak.

A U.S. Department of Veterans Affairs assessment team report released Friday found little evidence that there was proactive planning and preparation for COVID-19 at the veterans home.

Avalon Health Care Group, which operates the veterans home and two others in Hawaii, has maintained that it followed the guidelines of the U.S. Centers for Disease Control and Prevention, the Centers for Medicaid and Medicare Services, and the state and county. 

It said 60 percent of the recommendations made in the VA report were in place before the team visited the facility on Sept 11.

Avalon has been sharply criticized by U.S. Sen. Brian Schatz, who sounded the alarm earlier this month about the need for urgency in dealing with the veterans home outbreak. He said the VA report showed the company did not take steps to protect its residents and staff. Schatz said it was "infuriating" to see that basic infection controls were not in place months after the pandemic began.

U.S. Rep. Tulsi Gabbard, whose district includes Hilo, weighed in yesterday, saying in a statement: "The culture of complacency that allowed this incredible loss of life and suffering must end. Those responsible for this must be held accountable. I will continue to support all efforts to conduct oversight and follow-through to ensure immediate action is taken to keep our veterans and their caregivers safe. Sadly, for many of the residents and their families, it’s too late.” 

A 19-member VA team is now at the veterans home to help implement infection controls and other practices to prevent further spread of the virus.

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