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Law firm investigates COVID-19 outbreaks in Missouri Veteran care, recommends changes


SPRINGFIELD, Mo. — An independent investigation into the Missouri Veteran Commission’s (MVC) response to the pandemic has been released. 

The more than 53-page report took data from the seven Veterans Homes in Missouri and found three main factors led to the COVID-19 outbreaks. 

The Veterans Homes in Missouri are in Cameron, Cape Girardeau, Mexico, Mount Vernon, St. James, St. Louis, and Warrensburg. 

  • Failure to recognize and appreciate the problem at the first sign of an outbreak: 
    • MVC did not reach out to external partners for help 
    • MVC was collecting data but lacked the ability to analyze it 
    • Homes did not move quickly enough to mitigate spread, isolate patients 
    • MVC failed to communicate concerns at “Fusion Cell” meetings, Missouri’s governmental agency for COVID-19 response 
    • The MVC Headquarters told Fusion Cell current COVID-19 numbers on Sept. 10, and Fusion Cell did not raise concerns or ask questions. 
  • Failure to plan for the outbreak: 
    • The report says, “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 guidance they did provide was confusing and often contradicted CDC and Veterans Affairs (VA) best practices. 
    • MVC previously had no policies or manual on infection prevention, something that is required by CDC and VA. 

  • Failure to properly respond to the outbreak 
    • Homes began routine COVID-19 testing in August, but continued to have staff and Veterans interact without PPE while awaiting test results. 
    • The report claims Homes did not assign staff to dedicated units – something that is difficult when facilities are short-staffed. 
    • MVC failed to address staffing shortages, but has since gotten assistance from the state and the VA. 
    • Staff were only wearing surgical masks prior to the September outbreak. 
    • Materials were not being cleaned properly – areas were clean but not disinfected. 

On Oct. 2, 2020, Governor Mike Parson instructed MVC Chairman Tim Noonan to “conduct a rapid, independent, external review of all seven Missouri Veterans Homes to assess their performance to date and identify what steps, if any, should be taken to improve their management of COVID-19.” 

“This was a structural and systemic issue,” said Noonan. “Failure to interpret the data, a lapse in reporting and communication, the absence of a contingency plan, and the following of PPE policies. No one of those things is the driver. “ 

Chairman Noonan said the Commission is mostly made up of volunteers; people who typically know their role but have no clear outline of how to handle the pandemic. 

“When we became completely overrun, we ran out of quarantine space,” said Noonan. “That was insight that we did not have that continuity plan in place 

When the number of cases started to rise, Noonan said the MVC failed to communicate the data in a way that would raise concerns enough for Missouri’s COVID-19 response team to offer help. 

“Could we have done better, absolutely, and again, a very very complex healthcare environment overwhelmed a very, very well-intended workforce,” said Noonan. 

Noonan says despite several deficiencies with the MVC’s COVID-19 response, the report mentioned several times that MVC and Veterans Home staff genuinely care for the Veterans and are working diligently in this stressful and rapidly changing situation to protect the men and woman who have kept them safe. 

The report says one family member was quoted saying, “They treated him like a hero.” 

“From the executive director, to a front line worker, everybody cares about the veterans. Everyone was doing the right thing. They were doing the best they could with the information they had and the training that was in place,” says Noonan. 

The law firm analyzing the data, Armstrong Teasdale, gave a list of recommendations to the MVC. Some of the items on the list are already being implemented, while others are in progress. 

The list can be read below: 

  • Develop a comprehensive COVID-19 outbreak plan – all staff should be trained on it 
  • Better communication with Fusion Cell 
  • Check Veteran’s vitals every 4 hours 
  • Staff – 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. 
  • Develop specific thresholds that would trigger further action. 
  • Streamline reporting to lighten the burden on staff 
  • Develop a plan outlining a delegation of duties among MVC Headquarter staff 
  • Develop immediate response checklists when patient or staff test positive 
  • Do not penalize staff that report systems or a need to quarantine 
  • Secure rapid tests, at least through April 2021. 
  • Work with the state to ensure Homes get priority to vaccine 
  • Veterans should live in private rooms to the extent possible 

The law firm also recommended the MVC better publicize the phone number families can call with concerns and to develop a plan to have family members visit. 

Copyright 2021 Nexstar Inc. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

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