A report released by the Missouri Veterans Commission found staff at a local home failed to properly quarantine confirmed COVID-19 patients from still-healthy residents.
The report also found the Cameron Veterans Home failed to plan for sufficient isolation, failed to appropriately quarantine residents who temporarily left the home, failed to effectively communicate policy changes, failed to implement appropriate testing procedures and failed to follow appropriate guidelines for reusing personal protective equipment.
“So there was this issue that was happening, and folks were not following up on it for awhile,” Elad Gross, a civil rights attorney, said. “And then as a result of that people died.”
As of Dec. 17, 39 people had died from COVID-19 at Cameron’s Veterans Home.
Gross threatened to sue the MVC if its now former chairman, Tim Noonan, didn’t release the full report. Noonan resigned shortly after the report’s release. Missouri’s attorney general also told Noonan he should release the report.
The report, provided by Armstrong Teasdale, details each home’s response to COVID-19, including the Cameron home.
The first veteran to contract COVID-19 at the Cameron home happened sometime between Sept. 29 and Oct. 1, after the veteran returned to the home from a hospital visit.
At that time, the report says veterans were no longer able to leave their section of the home, but it appears they could still leave their rooms.
According to the report, a veteran who tests positive for COVID-19 is transferred to isolation. Veterans who have contact with a COVID-19 positive are placed into quarantine, but not necessarily isolated from other residents.
When positive COVID-19 cases overwhelmed a section of the home, known as “Apple Grove,” staff had cordoned off for isolation, the situation escalated.
Staff recommended residents who hadn’t contracted the virus to leave Apple Grove, but some refused. The report doesn’t indicate staff attempted to force the residents to leave.
In one outbreak, a staff member told investigators that two COVID-19 patients from the memory care unit weren’t transferred immediately following their positive tests and were instead transferred to isolation the next day.
That next day, three more patients tested positive. Four more residents of that unit would later contract the virus.
A manager told the initial staffer that it “wasn’t her call” to immediately transfer the original memory care patients, according to the report.
While indoor visitors have been prohibited at the home since March, one family member was found, “roaming the home without a chaperone.”
Staff members at the home are tested twice per week, on Mondays and Thursdays, even if they aren’t scheduled to work that day.
The report dinged the home because staff don’t follow, or don’t have room to follow, social distancing guidelines while they wait for the result of their rapid test.
Nursing staff are checking residents’ temperatures and oxygen levels at least once per shift. The home does have a policy for administering COVID-19 tests to residents if needed.
Home officials told investigators that the home does have sufficient PPE, but the report said staff have to reuse respirators, which goes against Centers for Disease Control and Prevention guidelines.
About 10 to 15 veterans refuse to wear masks inside the home, according to the report.
Staffing also has been an issue at the home since the first case in October. The Cameron home has nine open nursing positions, and more than 20 certified nursing assistant jobs are unfilled.
“(An employee) confirmed that some care providers have established with veterans that it is taking an emotional toll on employees,” the report states.