VA, HIEMA Reports Indicate Bad Practices, Procedures at Veterans Home

September 21, 2020, 3:26 PM HST (Updated September 21, 2020, 8:46 PM)
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The US Department of Veterans Affairs (VA) and the Hawai‘i Emergency Management Agency (HIEMA) conducted independent reports on the coronavirus cluster at the Yukio Okutsu Veterans Home in Hilo, where more than 100 cases have been confirmed between residents and staff combined. Twenty-five individuals, all residents, have died.

While both reports found fault with the protocols and practices at the home, run by Avalon Health Group, which received the administrative contract from the state, separate observations and emphases of concern were highlighted.

Namely, patients weren’t segregated based on COVID status, employee and resident movement wasn’t restricted allowing for cross-contamination, and social distancing policies, particularly the mandatory usage of face masks, was not effectively applied or enforced.

“I believe the nursing home culture at (the veterans home) was one that remained entrenched in pre-COVID norms of respecting individual resident rights over the health of the general population,” wrote Dr. K. Albert Yazawa, who conducted HIEMA’s assessment after the Hawai‘i Health Systems Corp. asked the agency to investigate the cluster.

The VA was also critical of the practices at the home.

“There was very little proactive preparation/planning for COVID. Many practices observed seemed as if they were a result of recent changes,” the VA published in its report. “Even though these are improvements, these are things that should have been in place from the pandemic onset and a major contributing factor towards the rapid spread. A basic understanding of segregation and workflow seemed to be lacking even approximately (three) weeks after (the) first positive.”

The state Department of Health’s Office of Health Care Assurance (OHCA), which is also conducting a report that has yet to be made public, said staff were trained on proper procedures and policies. OHCA added, however, that “it appears there was no follow-up to ensure appropriate behaviors or enforcement.

HIEMA confirmed there was a series of educational meetings to discuss how to handle the COVID pandemic between June 10 and June 15, 2020. Testing was conducted of all staff and residents during that same month, and all tests returned negative results.

The source of the outbreak has not been determined. Both the VA and HIEMA suggested patients could have been exposed in early August after traveling to Hilo for dialysis treatment.

Below are tables compiled by the state of Hawai‘i outlining the problems and guidance offered in each report.

Select Deficiencies  

Veterans Administration Assessment Hawai‘i Emergency Management Agency Assessment 
Residents not cohorted based on COVID statusPatient movement between units
Inconsistent mask usage by residentsWandering residents (dementia)
Intermixing of housekeeping/maintenance staff between unitsStaff gatherings at work and in the community
Little proactive preparationLack of physical distancing measures for staff & patients
Numerous examples of potential infection from cross-contaminationConcerns about continued staff positives after mass testing


Select Recommendations 

Veterans Administration Assessment Hawai‘i Emergency Management Agency Assessment 
Additional hand sanitizer unitsOutsource testing to free up staff
Encourage staff breaks outdoorsContinue to halt new admissions
Consistent staff assignments to avoid cross-contaminationEmploy extremely low testing thresholds
Regular risk mitigation trainingHigher staff ratio for COVID-19 unit
Leadership presence on all shifts for compliance, accountability & risk identificationEliminate staff complacency toward safe practices, internally and externally

Both the VA and HIEMA assessments also recommend the immediate discontinuation of nebulizer use. Nebulizers transform liquid medicine into an aerosol form that can be inhaled. 

The VA formed a 20-person “Tiger Team” to help implement recommendations, provide training and oversight, and to provide needed staffing support and respite.

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The OHCA inspection report is still undergoing internal review and will be shared after the veterans home receives it, according to a state press release. The VA and HIEMA reports can be viewed in full by clicking the following links:

VA Report

HIEMA Report

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