Audit: Slow Legionnaires' response at Illinois veterans home


SPRINGFIELD, Ill. (AP) — A state audit released Monday contradicted former Gov. Bruce Rauner’s claim that his administration had done everything federal experts recommended to remedy a deadly 2015 Legionnaires’ disease crisis at an Illinois veterans’ home.

Auditor General Frank Mautino reported that the Centers for Disease Control and Prevention had recommended in December 2015 that filters be put on every water spigot. Despite Rauner’s claim, the audit found that only shower and bathtub heads were outfitted with filters before 2018.

The audit sharply criticized the Departments of Public Health and Veterans’ Affairs for delays in taking action and notifying nursing staff and the public in August 2015 of the outbreak at the Quincy facility, which ultimately led to the deaths of 13 elderly residents.

“Based on our review of communications between IDPH and the Quincy veterans’ home, auditors determined that there was limited communication …,” Mautino wrote. “IDPH officials often did not know the seriousness of the problems.”

Legionnaires’ is a flu-like malady caused by inhaling water vapor infected with Legionella bacteria. Particularly susceptible are the elderly or those with compromised immune systems. The audit determined the average age of those who died was 88, with several in hospice care.

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The crisis at Quincy became a main point of criticism of Rauner in his last year in office after families of residents filed lawsuits against the state. The audit found that 66 residents and eight employees of the 130-year-old home contracted Legionnaires’, including the 13 deaths.

Through June 2018, the state spent $9.6 million to fix the problem, including a $5 million water plant reimbursed by the federal government. Ultimately, Rauner decided the whole campus should be rebuilt . He was defeated for re-election in November by Democrat J.B. Pritzker.

“The new administration is committed to working to ensure the Quincy veterans’ home sets the standard for what quality care looks like for our veterans,” Veterans’ Affairs acting director Linda Chapa LaVia said in a statement. “The health and safety of our state’s heroes is our top priority and we will take all available action to keep our veterans safe as we move forward.” 

Rauner repeatedly claimed that the administration had done everything federal experts suggested. But the audit determined that while the CDC recommended filters for all water fixtures in December 2015, only shower and tub heads were outfitted with them before April 2018.

Mautino noted that after the confirmation on Aug. 21, 2015, of a second case of Legionnaires’ — a red flag that an outbreak was imminent — Public Health officials didn’t visit the campus until three days later and nursing staff were not given sufficient instructions on protecting other residents for six days.

The audit pinpointed the cause of the initial outbreak to water which sat unused in a disabled boiler for a month in July 2015. When the boiler began operating again, it was not drained. The water in it was heated to 120 degrees before it was released into the water system. But Legionella bacteria can survive in water up to 140 degrees.

Mautino made four recommendations for the Veterans’ Affairs and Public Health departments, including sufficient and timely instructions to nursing staff and caregivers after a Legionnaires’ outbreak is confirmed to protect other residents from water vapor exposure.

He said the Veterans’ Affairs should develop strict monitoring procedures for residents during outbreaks. Quincy staff said they increased monitoring but had no records to show for the stepped-up activity. Both agencies should improve communication and additionally, ensure that all CDC recommendations are followed.

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

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Auditor General’s report:


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