Office of Inspector General report faults lack of training, also reaffirms cover-up of Legionella outbreak in 2017 and 2018

Department of Veterans Affairs officials failed to provide housekeeping staff at the VA Medical Center in Loma Linda with adequate training, possibly contributing to an increase in potentially deadly infections at the facility, according to a new federal report.

The VA Office of Inspector General’s 55-page report released Tuesday also reaffirms a separate 2018 federal investigation that found Jerry L. Pettis Memorial VA executives concealed the existence of Legionella bacteria in the hospital’s water system from clinical staff for months.

It wasn’t until the VA was contacted by the Southern California News Group about a whistleblowers’ complaint filed by two doctors and six nurses that officials told staff about the Legionella.

Stephanie Rapp-Tully, a Washington attorney for the whistleblowers, said her clients are pleased with the report’s findings. “We want to thank Office of Inspector General for its hard work investigating these matters,” she said.

The Pettis Medical Center has 162 acute-care beds and a 108-bed community living center. It is part of the VA Loma Linda Healthcare System that has more than 2,400 employees and 1,300 volunteers who serve more than 76,000 veterans.

Corrective actions

Efforts are underway to implement corrective actions recommended by the Office of Inspector General, according to Kristen Hall, spokeswoman for the VA Loma Linda Healthcare System.

“Responsiveness to environment-of-care concerns is a shared responsibility between leadership, service chiefs and staff,” she said. “Daily huddles between leadership and staff have resulted in a more rapid response to environment-of-care needs.”

The report’s findings are troubling, said Rep. Pete Aguilar, D-Redlands, who along with Rep.Mark Takano, D-Riverside, requested the inspection at the medical center, which in 2018 earned a one-star VA rating, the lowest possible performance score.

“Our veterans deserve the best possible care in clean and safe medical facilities, and it’s outrageous that they weren’t receiving that at the VA Loma Linda Healthcare System,” he said. “The oversight conducted by the Office of the Inspector General is a step in the right direction, but we must continue our work to ensure Inland Empire veterans and those who care for them are never subjected to these types of conditions again.”

The whistleblower complaint filed with the U.S. Office of Special Counsel prompted an unannounced federal inspection at the Pettis Medical Center in March 2018, followed by a second visit two months later.

Hospital deemed unclean

In addition to the Legionella issue, the inspection largely focused on the overall cleanliness of treatment, nutrition and waiting areas as well as patient rooms.

Inspectors found that the medical center was not clean, its furnishings were in need of repair, and its Environmental Management Services Department did not have standard operating procedures for cleaning and sanitizing the facility.

“EMS leaders did not evaluate the level of competency of EMS housekeeping staff to ensure they had the knowledge and skills to properly perform their duties,” the report says. “When Office of Inspector General staff asked the (medical center’s) nurse executive why the EMS housekeeping competencies had not been validated, the nurse executive stated, “I just did not do it.”

That lack of training may have contributed, over a two-year period, to an increase in Clostridium difficile, a bacterium that can cause diarrhea and life-threatening inflammation of the colon, inspectors found.

The report says 32 cases of C. diff infections were confirmed at the Pettis Medical Center in 2016 and 36 cases in 2017.

Inspectors also determined 534 medical center staff members did not consistently complete required blood-borne pathogens training from May 2016 to March 2018.

Addressing another whistleblower complaint, inspectors could not determine whether patients and staff were exposed to biohazard residue from water leaks in March and April 2018 at the facility’s dental clinic. However, inspectors substantiated that staff members were not routinely cleaning the clinic.

Legionella cover-up substantiated

The report also states that while medical center officials followed Legionella testing protocol and undertook remediation, they did not communicate positive test results to clinical staff, putting patients at risk.

“Positive Legionella tests in the water system … may affect clinical staff’s course of action to include increased Legionella testing and clinical surveillance for susceptible patients,” the report says.

Legionnaires is a severe form of pneumonia that can be contracted by inhaling microscopic water droplets in mist or vapor.

Legionella bacteria thrive in fresh water, but can multiply in indoor water systems such as hot tubs and air conditioners, according to the Centers for Disease Control and Prevention.

Legionella is not spread through person-to-person contact. Symptoms can include diarrhea, high fever, cough, chest pain and shortness of breath. Those at higher risk for infection are people 50 and older and those who have smoked or currently smoke, have chronic lung disease or a weakened immune system. Left untreated, Legionnaires’ disease can be fatal.

Inspection in 2018

The Office of the Medical Inspector launched a separate investigation into the whistleblowers’ complaint and made a visit to the hospital from July 9-13, 2018, and interviewed more than 50 employees.

Federal investigators reviewed data from Pettis Medical Center for 2017 and 2018 and found 33 positive results for Legionella.

Specifically, 64 individual tests were conducted in wards, intensive-care units, operating rooms and other inpatient rooms. Nine tested positive for Legionella, with one room testing positive twice in September and once in October 2017. All positive tests were on the hot water outlet in the sink, the report says.

Hospital officials informed the nurse manager of the Legionella, patients were relocated to different rooms and the sink was removed.

However, other nurses and the hospital’s doctors were kept in the dark for months about Legionella bacteria lurking in the water system.

In 2018, the VA gave the hospital a one-star rating, the lowest possible performance score for its medical facilities.