The Hawaii Department of Health on Thursday cited the private operator of a state veterans nursing home for deficiencies leading to a COVID-19 outbreak earlier this year in which 27 residents died.
The agency also ordered the administrator of the Yukio Okutsu State Veterans Home in Hilo to implement a list of corrective actions, but then on Friday rescinded both the order and the citation that listed deficiencies in complying with statutory health care regulations mainly related to infection control.
Janice Okubo, DOH spokeswoman, said the rescission was made at the request of the federal Centers for Medicare and Medicaid Services “to ensure that (the documents) are fully supported in the event of an appeal.”
Avalon Health Care, the nursing home’s Utah-based operator, responded to the DOH on Thursday to say it is not admitting fault but that it has taken several immediate actions.
Those actions include re-educating the facility’s infection preventionist, its director of nursing, about contact tracing and about self-isolation protocols for individuals who don’t pass the facility’s entry screening.
Avalon also said in its memo to DOH that the director of nursing or a designee will validate that contact tracing has been completed for anyone testing positive for COVID-19, and ensure that proper use of the entry screening process is validated every day for 14 days, after which validation would be weekly.
Allison Griffiths, an Avalon attorney and spokeswoman, declined to comment on the DOH actions because they were withdrawn.
“We’re on hold because this has been rescinded,” she said.
Okubo said DOH plans to issue a revised version of the report likely later next week.
The issued and then rescinded 28-page deficiency report was completed Wednesday and based on an unannounced inspection of the nursing home that began Sept. 9 and included personnel interviews, observations and a review of records.
There were 89 residents living at the care home before the COVID-19 outbreak. Since then, 71 residents and 35 employees contracted the virus.
The report concluded that the facility’s first COVID-19 case was a maintenance worker who was tested Aug. 20 and received a positive result two days later.
This unidentified worker, according to the report, belonged to a family connected with a 20-person community coronavirus outbreak that started Aug. 15, and was sent home Aug. 20 after a supervisor noticed the worker’s voice was hoarse.
A second maintenance worker also was sent home Aug. 20, four minutes behind his colleague, after receiving a call from a family member who said a friend tested positive and that they may have been exposed to COVID-19, the report said. That worker tested positive Sept. 5.
A third maintenance worker who routinely works with and eats lunch with the other two staffers wasn’t sent home Aug. 20, according to the report, and returned to work the following day with instructions from a supervisor to stay in the office and not go outside “unless the building is on fire.”
On Aug. 23, the third maintenance worker received a positive COVID-19 result from a test administered Aug. 20.
The report said the facility’s nursing director had this view of the third maintenance worker: “He was asymptomatic, so he can come to work.”
DOH’s investigator said in the report that a contact tracing list from the nursing home indicated that the third maintenance worker had complained of a stuffy nose and spent more than 15 minutes with his two colleagues and a housekeeper.
The report cited other shortcomings that included an inspector witnessing a doctor leaving the facility without removing all protective gear or hand cleaning, witnessing the same doctor entering the facility’s designated COVID-19 resident care unit without wearing a protective gown, and seeing a nurse leave the facility without hand cleaning.
“These deficient practices (led) to the COVID-19 outbreak in the facility and may have contributed to twenty- six COVID-19 related resident deaths,” said the report, which didn’t account for one death.
DOH’s now-rescinded order called for the nursing home to hire an infection control consultant or manager to work at the facility for at least six months.
The order also required the facility’s medical director, director of nursing or other qualified official to implement safe hand hygiene and glove use practices prescribed by federal health agencies in an online training program.
Staff at the nursing home also was directed to watch four specific videos on topics for keeping COVID-19 out of such facilities.
These and some other requirements in the order were supposed to be carried out within 15 days.
Though the citation was rescinded, it could have led to civil monetary penalties by the Centers for Medicare and Medicaid Services, along with denial of payment for new admissions if corrective action was not taken. The citation also allowed Avalon to contest the findings.
DOH’s report was issued about three weeks after two other government agency reviews.
One by the U.S. Department of Veterans Affairs noted things that included a lack of readily accessible hand sanitizers throughout the facility, staff uncertainty over exactly what surfaces were expected to be disinfected or how often, scrubs worn home by staff after work and wandering mask-less residents.
A review by the Hawaii Emergency Management Agency also was critical of nursing home practices related to infection control.
Avalon, which operates the state-owned nursing home under a contract, has previously contended that it diligently sought to implement guidelines from DOH, the Centers for Disease Control and Prevention, and the Centers for Medicare and Medicaid Services throughout the pandemic.
Late last month, Avalon and state officials agreed to let the Hawaii Health Systems Corp., a state agency operating several hospitals and care facilities, take over running the veterans home through a transition expected to take several months.