After 12 residents of an Illinois veterans home died and dozens more became ill in the 2015 outbreak of Legionnaires’ disease, their families filed negligence lawsuits against the state. Those suits were recently settled when the state’s attorney general and the families agreed to an almost $6.4 million payout.
A March 27, 2020, state audit report supported the claims made by a year-long news media investigation that the state had mishandled the crisis. That investigation also resulted in some changes to state law and resulted in an ongoing criminal probe.
In December 2015, the Centers for Disease Control and Prevention (CDC) advised placing water filters on every water spigot in the facility. However, the audit found that filters were placed only on shower and bathtub heads before 2018.
The audit also criticized the Illinois Department of Public Health (IDPH) and Department of Veteran’s Affairs (VA) for a delay in responding to the outbreak and failing to notify the facility’s nursing staff and the public about the deadly outbreak.
The report made four recommendations to IDPH and the VA that involved making sufficient and timely communication to nursing staff and caregivers when an outbreak of Legionnaires’ is suspected and to ensure that all CDC recommendations are followed. The auditor wrote in the report, “IDPH officials did not know the seriousness of the problems.”
Compliance Perspective
Failure to recognize and take immediate action to prevent the spread of an infectious bacteria like Legionella that may cause a deadly disease like Legionnaires’ and failure to implement CDC recommendations fully may result in placing residents in immediate jeopardy, families filing negligence and wrongful death lawsuits, and provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points
- Review policies and procedures regarding the facility’s Infection Control Plan and any CDC recommendations for preventing or responding to an outbreak like Legionella or some other infectious organism.
- Train all staff about the facility’s Infection Control Plan and their individual responsibilities, such as for an outbreak of an infectious bacteria like Legionella, and how to implement all protocols for infection control and CDC recommendations.
- Periodically audit to ensure that the facility’s Infection Control Plan is in effect and that staff have implemented fully any recommendations issued by the CDC.
FOR MORE INFORMATION ON THIS TOPIC: LEGIONELLA AND FACILITY WATER SYSTEM SAFETY
