Illinois Failed To Address Legionnaires’ Outbreak

On Monday, March 25 the Illinois Auditor General released the state report related to the deadly Legionnaires’ disease outbreak at an Illinois veterans’ home located in Quincy that began on August 21, 2015. The infectious disease crisis carried along for several years and impacted 66 residents and 8 others who tested positive for legionella and resulted in 13 resident deaths which likely could have been prevented. The report contradicted the state’s former administration’s solutions to the outbreak and showed recommendations led by federal authorities to remedy the crisis were not actually followed.

Our legal team has highlighted these key themes found within the state audit report:

• According to documentation provided by the Illinois Department of Veterans Affairs, there were no legionella policies in place and there had been no training on legionella prior to the 2015 outbreak at the Quincy Veterans home.
• Until August 27th, 2015, there was limited notification or specific procedures provided to the nursing staff at the Quincy Veterans’ Home that were necessary to protect residents or employees. This was six days following confirmation of the second case.
• Although Quincy Veterans Home officials stated skilled care residents were monitored every four hours and independent care residents were monitored twice daily beginning on August 22nd, 2015, there was no documentation to support that a directive was provided to the nursing staff or whether it was followed.
• In December of 2015, the CDC recommended a point-of-use filter installation on all fixtures fed from the potable ho-water system. Filters were not installed on all fixtures other than the showers until after the February 2018 outbreak in April 2018.
• According to the CDC, many of the optimal conditions for legionella growth were found at the Quincy Veterans’ Home including the presence of bio film, scale, and sediment.
• As of June 30, 2018, The State has expended 9.6 million dollars for legionella remediation at the Quincy Veterans Home since the initial outbreak in August 2015.
• According to IDVA officials, as of December 2018, there have been no cases of legionella after the four confirmed cases in February 2018.

According to the Centers for Disease Control (CDC), 80 percent of all cases of Legionnaires’ are contracted at a long-term care facility and hospitals are responsible for as many as 18 percent of all cases. While advanced age is a risk factor for the disease, it also must be known that the water systems within nursing home facilities are not overseen with as much care as other facilities such as hotels or apartment complexes. Proper maintenance of water supplies along with quick recognition of symptoms and treatment associated with diseases like Legionnaires’ are essential to preventing nursing home resident illnesses and deaths.