Audit: Slow Legionnaires' Response to Illinois Veterans

A state audit released on Monday contradicted former governor Bruce Rauner's badertion that his administration had done everything the federal experts had recommended to address the 2015 deadly crisis caused by Legionnaires' disease at the home of a veteran of Illinois.

Auditor General Frank Mautino said the Centers for Disease Control and Prevention recommended in December 2015 that filters be installed on every water tap. Despite Rauner's badertions, the audit revealed that only the shower and bath heads were equipped with filters before 2018.

The audit strongly criticized the Ministries of Public Health and Veterans Affairs for the delays in their actions and to inform the nurses and the public in August 2015 of the epidemic at the facility. of Quincy, which eventually resulted in the death of 13 elderly residents.

"Based on our review of communications between IDPH and the homes of Quincy veterans, the auditors determined that communications were limited …", wrote Mautino. "The leaders of the IDPH were often unaware of the seriousness of the problems."

Legionnaires are a flu-like illness caused by the inhalation of water vapor infected with Legionella bacteria. Older people or those with compromised immune systems are particularly susceptible. The audit found that the average age of those who died was 88, and many of them were hospitalized.

The Quincy crisis became Rauner's main criticism over his last year in power after resident families sued the state. The audit revealed that 66 residents and 8 employees of the 130-year-old house had contracted legionnaires, including 13 deaths.

As of June 2018, the state had spent $ 9.6 million to solve the problem, including a $ 5 million water treatment plant reimbursed by the federal government. In the end, Rauner decided to rebuild the entire campus. He was beaten for reelection in November by Democrat J.B. Pritzker.

"The new administration is committed to ensuring that the home of the Quincy Veterans sets the standard for the quality of veterans' care," said Acting Director of Veterans Affairs Linda Chapa LaVia. "The health and safety of our state's heroes are our top priority and we will take every measure possible to ensure the safety of our veterans in the future."

Rauner repeatedly stated that the administration had done everything the federal experts had suggested. However, the audit determined that although the CDC had recommended the use of filters for all fixtures in December 2015, only the showerheads and bathtubs had been equipped before April 2018 .

Mautino noted that after confirmation, on August 21, 2015, of a second case of legionnaires – an alarm signal stating that an epidemic was imminent – public health officials Visited the campus only three days later and the nursing staff was not adequately briefed on the protection of other residents for six days.

The audit determined the cause of the initial outbreak of water that was not used in an end-of-life boiler for one month in July 2015. When the boiler was returned to service, it was not not drained. The water that was there was heated to 120 degrees before being released into the water supply system. But Legionella bacteria can survive in the water up to 140 degrees.

Mautino made four recommendations to the Veterans Affairs and Public Health Departments, including sufficient and timely instructions to nurses and caregivers following the confirmation of the Legionnaires outbreak to protect other residents. from exposure to water vapor.

He added that the Department of Veterans Affairs should put in place strict monitoring procedures for residents during outbreaks. Quincy staff stated that he had increased monitoring, but that he had no records to report for increased activity. Both agencies should improve communication and ensure that all CDC recommendations are followed.

In the responses included in the audit, the agencies generally agreed with the recommendations.

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Online

Report of the Auditor General: http://tinyurl.com/y3v6fbwf