Leaders at the Missouri Veterans Commission failed to adequately prepare for and respond to COVID-19 outbreaks at the state’s seven veterans’ homes that resulted in the deaths of more than 100 resident veterans, according to a report issued Dec. 2 by a law firm hired by the state in October to investigate the matter.
Just one Missouri veterans’ home resident had died of COVID-19 prior to September. The death toll had since risen to 109 as of Nov. 18.
“Headquarters should have known by the beginning of summer 2020 – well before the fall outbreak – that COVID-19 spreads covertly through asymptomatic carriers and is difficult to control in a residential setting like a nursing home,” according to an investigative report produced by St. Louis law firm Armstrong-Teasdale. “But despite several months to prepare for a predicted fall surge in COVID-19 cases, MVC Headquarters did not develop any comprehensive outbreak plan.
As a result, the report found, MVC officials did not have an opportunity to vet the plan with outside agencies or other long-term care facilities, or test the plan to identify areas of needed improvement.
“The lack of a comprehensive outbreak plan led to confusion and inefficiencies, and it almost certainly contributed to the inability to contain the spread of COVID-19 once it was introduced into the homes,” the report found.
The report said that although staff provided data about COVID-19 cases to the Missouri Veterans Commission, “MVC Headquarters simply lacked the ability to engage in meaningful analysis of this data,” adding that the commission should have recognized an outbreak at the Cape Girardeau home by Sept. 2, as cases multiplied.
“Even as cases increased, MVC Headquarters failed to appreciate the need to move quickly to isolate positive patients,” the report said.
The report recommends a list of corrective recommendations, including improved coordination between MVC headquarters and veterans’ home staff to develop comprehensive plans for preventing and containing future outbreaks.