There is value in looking back, but the most important thing will always be what happens when we move forward.
That’s the spin we’d like people to put on Monday’s release from Auditor General Frank Mautino concerning the deadly Legionnaires’ disease crisis in 2015 at the Illinois Veterans Home in Quincy.
According to The Associated Press, the audit had harsh words for the Illinois Departments of Public Health and Veterans’ Affairs for delays in taking action and notifying nursing staff and the public of the outbreak, which ultimately led to the deaths of 13 elderly residents and sickened dozens more.
Last March, Chicago’s WBEZ obtained emails between state and local public health officials and the state agency that oversees the home showing attempts to spin news coverage to mislead the public as to the severity of the problem. A news release confirming eight Legionnaires’ cases at the home was issued six days after the matter was clearly epidemic.
Mautino noted a second case of Legionnaires’ was confirmed Aug. 21, 2015. Despite that red flag indicating an outbreak was imminent, Public Health officials didn’t visit for three days and nursing staff didn’t get sufficient instructions on protecting other residents for nearly a week.
The new audit makes it even more clear how those in power failed to care for veterans in the state’s care, as we now know the Centers for Disease Control and Prevention recommended in December 2015 that filters be put on every single water spigot, but despite former Gov. Bruce Rauner’s claim his administration had done everything federal experts recommended to remedy the problem, the audit found only shower and bathtub heads were outfitted with filters before 2018.
By June the state had already spent nearly $10 million to try to fix the problem. That total does include a new $5 million water plant paid for with federal government reimbursement, but it doesn’t count the cost of legal defense against the families suing the state for negligence, who make the very logical argument that deaths at the home were preventable.
The audit itself only bolsters those claims, given it linked the initial outbreak to water that sat unused in a disabled boiler for a month in July 2015, then was only heated to 120 degrees before being released into the system instead of the 140 needed to kill Legionnaires’ bacteria.
It’s important to understand how this situation happened and who is responsible. Plenty of public blame has targeted Rauner, which is fair given his former role, but he’s not in a position to do more harm. None of that blame will bring back the dead or heal the sick, though, so the top priority now is taking the right steps to prevent a similar disaster at this or any state-owned facility.
Mautino made four recommendations for the IDVA and IDPH, including sufficient and timely instructions to nursing staff and caregivers after a Legionnaires’ outbreak is confirmed to protect other residents from water vapor exposure. This should be common sense, but it should’ve been common sense in 2015 as well.
IDVA also should develop strict monitoring procedures for residents during outbreaks, Mautino added. Quincy staff said they increased monitoring but had no records to prove that claim. Both agencies should improve communication and ensure all CDC recommendations are followed.
Those are good suggestions indeed, and we hope they’re dutifully followed.
Further, we hope anyone elected or appointed to have serious influence on state institutions and agencies learns from this experience the serious consequences of failing to act in appropriate response to a real threat affecting health and safety.
Don’t let people die on your watch seems to be a low bar to clear, but far too often our chosen officials stumble and fall short.
We cannot allow that to be acceptable conduct.