The staff at the Yukio Okutsu State Veterans Home had a nursing home “culture” that made them reluctant to move patients who objected, and also allowed residents of the nursing home with dementia to wander in the facility without attempting to restrict their movements, according to a new report on Hawaii’s most deadly COVID-19 infection outbreak.

The six-page report by Dr. K. Albert Yazawa of the Hawaii Emergency Management Agency concludes that “in this pandemic crisis these were major errors that contributed to the infectious spread” in the 95-bed facility in Hilo.

“I believe the nursing home culture at YOSVH was one that remained entrenched in pre-COVID norms of respecting individual resident rights over the health of the general population,” he wrote.

Yukio Okutsu Veterans Home in Hilo is the site of a large outbreak of COVID-19. Photo: Tim Wright

The Yukio Okutsu Veterans Home in Hilo is the site of the largest outbreak of COVID-19 in Hawaii.

Tim Wright/Civil Beat

The report, released by the state on Monday, also concludes that staff at the Okutsu home were not properly protected, and some probably became infected while working there.

“As for the staff, despite all good intentions, new infections were identified among staff with every facility-wide testing,” wrote Yazawa, who inspected the facility on Sept. 11. “With community positivity rates in the Hilo area far below 5%, it is unlikely this can be attributed to community acquired COVID.”

He said he believes that staff acquired COVID-19 at the veterans nursing home due to less than optimal day-to-day personal prevention practices “as well as a lack of good systemic practices which may have limited individual exposure, like better cohorting strategies, stricter PPE use in common areas like the central nursing area, or an alternate set-up made available for them that would limit contamination, and higher staffing ratios in the COVID unit.”

As of Monday, a total of 24 veterans and their spouses who lived at the home have died after testing positive for COVID-19.

The operator of the veteran’s home is Avalon Health Care, which says it has been following the guidance and directives of the U.S. Centers for Disease Control and Prevention, the federal Centers for Medicare and Medicaid Services, and the state Department of Health on COVID-19 and infection control and prevention.

Allison Griffiths, spokeswoman and vice president for legal affairs for Avalon Health Care Management Inc., said in a written statement Monday that “we are very disappointed with how politically charged this situation has gotten.”

“The lack of collaboration and support by the Department of Health and other state agencies is unprecedented,” Griffiths wrote. “Avalon operates in 6 states. This is the only state where we have seen this type of blatant politicization of a crisis situation and a complete lack of support, collaboration, or assistance following an outbreak in a health care facility.”

“In every other state in which we operate, the state Department of Health has offered support, guidance, collaboration, PPE, testing, etc. to our facilities as the common goal among all involved is the health and safety of the residents and the community.

“We are also heartbroken by the hostility and lack of aloha towards our staff – who are all local folks who live in Hilo – and who have put themselves in harm’s way to care for our veterans whom they love like family,” she wrote. “They are health care heroes – as are all health care workers – who are fighting on the front lines of this historic public health crisis.”

The disease most likely entered the facility via a staff member who was exposed in the community, and also through a resident who was exposed at an outside dialysis appointment, according to the state report, which is consistent with what Avalon and state officials have said.

The HI-EMA report says four patients had dialysis appointments at Liberty Dialysis on Aug. 28, and all four eventually tested positive for COVID-19. Liberty had its first staff member test positive on about Aug. 5, according to Yazawa, who noted concerns over a lack of “transparency” among Liberty and the skilled nursing facilities in East Hawaii.

Yazawa did not elaborate on that issue in his report, and Okutsu staff told Yazawa the matter had been resolved.

Mayor Harry Kim makes a point to joint WAM Finance Committees.

Hawaii County Mayor Harry Kim has called on the state to remove Avalon Health Care as the operator of the Yukio Okutsu State Veterans Home.

Cory Lum/Civil Beat

However, Yazawa said in the conclusion of his report that there were “multiple potential sources of infections brought into the facility by staff who appear to be connected to known community outbreaks (and) unknown asymptomatic but infectious carriers (staff),” as well as community exposure at the dialysis center.

“Knowing exactly which staff may have had community exposure (i.e. 2nd jobs, care home operator, home health, etc.) would have been useful to preempt suspected exposures,” according to Yazawa’s report.

Within the facility, Yazawa reported that “more than one demented person known (to be) wandering residents remained wandering on Ohana 1,” which was the first-floor area of the veterans home where residents who tested positive for COVID-19 were housed.

Some of those wandering residents lived next to dialysis patients, “and probably also facilitated spread in Ohana 1,” according to the report.

On the issue of testing, Yazawa wrote that “testing was conducted numerous times routinely, but residents/staff could have been tested sooner on an as needed basis rather than wait for the next round of scheduled testing.” Doing so earlier might have caught infections sooner, he wrote.

Staff at the facility had been doing all of their own testing of patients and staff, and Yazawa recommended that Premier Medical Group be allowed to take over testing to free up staff for patient care.

Yazawa also noted there was a delay in creating an isolation area for residents who had not tested positive but likely were exposed, such as the roommates of residents who did test positive.

Creating such an isolation unit immediately after the first seven patients with COVID-19 were identified on Aug. 25 “may have helped to stop the spread,” according to the report.

Hawaii County Mayor Harry Kim, who was briefed on the Sept. 11 inspection of the veterans home after Yazawa inspected the facility, has called on the state to remove Avalon Health Care as the manager of the home.

Avalon on Friday publicly released a report on the same inspection that was produced by the U.S. Department of Veterans Affairs, along with Avalon’s rebuttal to a number of the VA findings.

“There was very little evidence of proactive preparation/planning for COVID,” the VA team stated in its report.

That report also uncovered a variety of problems, including findings that residents sometimes wandered in the facility hallways and did not always wear masks when they were outside of their bedrooms.

A third report by the state Department of Health’s Office of Health Care Assurance has not yet been released to the public, but a news release from the Hawaii COVID-19 Joint Information Center quoted from the OHCA report.

The OHCA report noted that “staff received education on COVID-19 Infection and Control during a meeting on June 10 to June 15, 2020,” but the instructions may not have been carried out.

“Staff were in-serviced on facility policies and procedures, but it appears there was no follow-up to ensure appropriate behaviors or enforcement,” according to the forthcoming OHCA report.

Read the HI-EMA report here.

Read the VA report and Avalon’s responses here.

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