An independent study of the deadly COVID-19 outbreak at Missouri Veterans Homes finds that “the MVC Headquarters and Home staff genuinely care for the Veterans, three major lapses contributed to the COVID-19 outbreak in the Homes this fall: (1) failure to recognize and appreciate the problem at the first sign of an outbreak; (2) failure to plan for the outbreak; and (3) failure to properly respond to the outbreak. The investigation also exposed the unintended negative consequences of isolation due to the restrictive measures intended to protect Veterans.”
Governor Mike Parson called for an outside investigation after a sudden increase in cases and deaths at state-run veterans homes.
This summary of a scathing report from corporate law firm Armstrong Teasdale acknowledged that the Missouri Veteran’s Commission took proactive and effective steps in March to protecting its seven homes from the virus, community spread surged, and “Unfortunately, MVC Headquarters was lulled into a false sense of security and failed to capitalize on its early successes.”
The report finds three critical areas where the commission fell short:
A. Failure to Recognize the Outbreak
MVC Headquarters failed to recognize and appreciate the impact of even one positive case of COVID-19, despite a number of experts, like the Missouri State Epidemiologist and the Missouri Medicaid Director, defining a COVID-19 outbreak in a residential setting as a single positive case. This meant that MVC leadership did not change tactics to aggressively contain the first positive
cases, nor did they reach out to external partners for assistance. Instead, they treated the initial cases as something that could be overcome using the same directives, policies, and internal resources that had been employed prior to the positive case.
This lack of understanding was not due to a lack of information. Homes staff provided data to Headquarters via reports, calls, and meetings on an ongoing, nearly real-time basis. MVC
Headquarters simply lacked the ability to engage in meaningful analysis of this data. They should have recognized the presence of a COVID-19 outbreak in the Cape Girardeau Home by September 2, 2020 (when the Home reported a jump from one positive Veteran to three positive Veterans within a 72 hour period, and a jump from five positive staff members to seven positive staff members within a two week period), but even as cases increased, MVC Headquarters failed to appreciate the need to move quickly to isolate positive patients. This also impacted their
communication with external stakeholders, in that MVC Headquarters did not identify specific issues or concerns related to the outbreak. For example, in weekly briefings to DPS, the MVC
provided little data about the outbreak, other than its impact on staffing vacancies—missing a critical opportunity early on to engage outside agencies and resources.
B. Failure to Plan for an Extensive Outbreak
While the novelty of COVID-19 makes long-term strategic planning difficult, MVC Headquarters demonstrated an absence of leadership in failing to appropriately plan for a severe and
prolonged COVID-19 outbreak. Headquarters should have known by the beginning of summer 2020—well before the fall outbreak—that COVID-19 spreads covertly through asymptomatic
carriers and is difficult to control in a residential setting like a nursing home. But despite several months to prepare for a predicted fall surge in COVID-19 cases, MVC Headquarters did not
develop any comprehensive outbreak plan. As a result, they did not have an opportunity to vet the plan with outside agencies or other long-term care facilities, or test the plan to identify areas of
needed improvement. The lack of a comprehensive outbreak plan led to confusion and inefficiencies, and it almost certainly contributed to the inability to contain the spread of COVID-19
once it was introduced into the Homes.
As early as February 2020, MVC Headquarters could have relied on publicly-available guidelines, templates, and checklists published by the CDC. They also could have looked to open
source material regarding outbreaks that had already occurred in congregate care settings in other parts of the country, including in Missouri. The investigation revealed that around March and April, MVC Headquarters studied and learned from an outbreak in Kirkland, Washington, but they did not study any additional outbreaks, even as occurrences multiplied across the country. No one at MVC Headquarters took the initiative to gather this information and develop a comprehensive plan. MVC Headquarters did provide some guidance to the Homes in the form of directives, but these directives were reactionary, haphazard, and often conflicted with each other. The directives addressed only discrete aspects of care and COVID-19 management and in some instances were inconsistent with CDC and VA guidelines or infection control best practices. They were also issued frequently, with little insight as to how staff might learn of or implement them. Staff found it difficult to keep up with the constant updates and changes, and most did not have access to any compilation of the directives they were supposed to be following. The lack of policies and
frequently-changing directives made it difficult to educate, let alone train staff in how they should provide hands-on care and services in the Homes.
This lack of preparation was compounded by the fact that the MVC did not have a current, comprehensive manual for infection prevention policy and procedure generally. An infection prevention policy and procedure manual is required by VA and CDC guidelines. This manual would have included an outbreak management plan or emergency management plan for infections generally, and it would have provided the Homes baseline guidance regarding isolation, quarantine, and universal precautions. While the MVC developed a general pandemic plan in March, there was no evidence that this plan was updated, reviewed, used, or tailored for use during the COVID-19 pandemic. The MVC should have prepared and printed a comprehensive COVID-19 plan and made multiple copies accessible to staff in each Home.
C. Failure to Respond to the Outbreak
Without an appreciation for the problem or a comprehensive plan in place, the MVC’s response to the outbreak was inadequate. In particular, the Homes had significant issues related to
testing, cross-contamination, and staffing. The timing of test results facilitated the spread of COVID-19. In August 2020, the Homes implemented routine nasopharyngeal PCR testing of all Veterans and staff twice a week. PCR tests take anywhere from 24 to 48 hours to process. This is significant because approximately sixty percent of individuals who are COVID-19 positive are either pre-or asymptomatic at the time they are tested. This meant that while awaiting test results, infectious staff and Veterans interacted with one another, some without any personal protective equipment (“PPE”). Asymptomatic Veterans and some symptomatic Veterans were not quarantined pending the results and moved freely among the Homes, dined together, interacted with each other, and remained lodged with their roommates.
In addition to testing issues, improper quarantine and isolation procedures contributed to the spread and cross-contamination of COVID-19 within the Homes. Initially, most of the isolation
and quarantine spaces only had between one and four beds, and little consideration had been given to how expansion would occur if or when necessary. Neither MVC Headquarters nor the Homes’ administrative leadership were prepared for the rapid spread of the virus, and at least one isolation scarce quarantine and isolation beds, and sometimes led to the hectic co-mingling of COVID-19 positive Veterans with otherwise uninfected Veterans. A delay in closing common spaces also contributed to cross-contamination and the spread of COVID-19 within the Homes. In the early days of the outbreak, Veterans were allowed to move freely about the Homes. Many did so without wearing masks, even while exhibiting COVID-19 symptoms.
In many Homes, staff movement has contributed to cross-contamination. At the onset of the outbreak, staff typically were not assigned to work on a dedicated unit, but rotated across all
units. In two Homes, surges of cases were tied to COVID-19 positive staff who had moved throughout the entire facility. While the Homes are now trying to dedicate staff to one particular
unit, staffing shortages have climbed, it is particularly difficult to assign dietary and environmental services staff to a dedicated unit, and many staff continue to serve multiple roles in the Homes.
These staffing shortages could have been prevented, or at least mitigated. Prior to the outbreak, MVC Headquarters failed to make a contingency plan to address potential staffing shortages, and it waited to coordinate with the VA until the Homes were in the midst of the current staffing crisis. Currently, the VA and personnel from The Missouri Disaster Medical Assistance Team (“DMAT”)
are providing additional staffing as needed.
However, staff morale is low, and many are overwhelmed by the emotional toll of caring for COVID-19 affected Veterans, the negative media attention, and the added demands of COVID-19
protocols—especially when many of them live in Missouri communities where mask mandates and social distancing are not enforced. The Homes need to provide education about practicing COVID19 prevention measures when staff are in their own homes and communities, as well as develop consistent policies regarding when staff who have been exposed to COVID-19 may return to work.
Staff should feel empowered to collaborate with Headquarters in the development of policies and procedures.
The investigation also identified inconsistencies in the use of PPE and in the initial screening process, which may have contributed to cross-contamination.
Finally, although the frequency of cleaning the Homes increased after the outbreak, disinfectant products were not being used according to the manufacturer’s recommendations.
Specifically, staff was only letting the products sit for 1 minute, when the products must sit for 10 minutes to be effective against viruses, including COVID-19. Thus, while the Homes were clean,
they were not disinfected.