Illinois’ top state auditor on Monday criticized former Illinois Gov. Bruce Rauner’s administration for mishandling a fatal 2015 Legionnaires’ disease outbreak at the state-run veterans’ home, saying top state officials did not initially comprehend the severity of the crisis.
The stinging state audit delivered by Auditor General Frank Mautino contended that two state agencies -- the Department of Veterans’ Affairs and Department of Public Health -- did not adequately notify residents, their families, staff members and the public about the epidemic in its earliest stages.
That poor notification exposed frail residents to a deadly waterborne form of pneumonia that has been tied to 14 deaths and dozens of illnesses during a series of repeated outbreaks between 2015 and 2018.
“There was a lot of instances where the department should have made decisions as opposed to waiting for someone else to act,” Mautino said. “There were a number of things that the audit shows that need to change that shouldn’t have happened in the first place.”
The report pointed to the mistaken July 2015 release of up to 1,600 gallons of bacteria-laden water into the home’s water system. That water had been contained in an out-of-service hot-water heater that was offline for about 30 days, and its release is a “likely cause of the initial outbreak,” the audit stated.
The audit raised questions about whether the facility stepped up its monitoring of residents once multiple Legionnaires’ cases were confirmed in August 2015. Mautino said there was no documentation to support an apparent precautionary directive that every skilled-care resident be monitored every four hours and independent care residents be monitored twice daily after the initial outbreak.
In fact, in a review of medical records for 45 residents who were sickened by Legionnaires’ after the Aug. 21 start of the epidemic, the audit found none received increased monitoring prior to the onset of their symptoms.
Mautino also hit the state veterans’ affairs department for not adhering to 2015 recommendations by the federal Centers for Disease Control and Prevention that special filters be attached to all fixtures fed by the home’s hot-water system. That didn’t happen until April 2018, the audit said.
Additionally, more than a week after multiple Legionnaires’ cases were confirmed, former state Public Health Director Nirav Shah concluded that he did not “think it’s necessary right now” to call in the federal Centers for Disease Control and Prevention to assist in the 2015 outbreak, according to the audit.
At that point, Aug. 28, 2015, three people had died from Legionnaires’, and 29 residents and staff had tested positive for Legionella. By the end of the next day, Shah reversed course and recommended that the CDC be brought in to assist the state, the report said.
Since 2015, 66 residents and eight staff members were sickened in rolling Legionnaires’ outbreaks at the facility, with 13 deaths directly attributable to the pneumonia-like illness tied to Legionnaires’. Another resident died in 2018, several months after being sickened by Legionnaires’.
The audit also hit the state Department of Veterans’ Affairs for being caught flat-footed by the 2015 Legionnaires’ outbreak.
“According to documentation provided by [the veterans’ affairs agency], 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,” the audit stated.
The long-awaited audit came after a series of WBEZ reports that began in late 2017 and focused on how the state waited six days from when it knew it had multiple confirmed Legionnaires’ cases at the Illinois Veterans’ Home before notifying the public about the epidemic.
The findings in Monday’s audit bolstered a yearlong WBEZ investigation, which also found Rauner’s office repeatedly overruling its own top experts in order to control and constrict what information was made public about successive deadly Legionnaires' outbreaks.
After the initial reporting, the Illinois legislature got involved, with the state Senate voting 48-0 in February 2018 to authorize an audit into how the state Department of Veterans’ Affairs managed Legionnaires’ outbreaks at the home in 2015, 2016 and 2017.
The sponsor of the resolution seeking the audit, state Sen. Tom Cullerton, D-Villa Park, said Mautino’s audit demonstrates that Rauner’s administration misled those in and out of the veterans’ home about the outbreaks and what was being done to address them.
“It validates for sure everything that was said and assumed,” Cullerton said. “But it also shows that the governor and his team were lying to everybody. They were lying to the people of Illinois. They were lying to the legislators. They were lying to the families. They were lying to the people who worked for them.”
Mautino’s audit did not address whether any of the missteps rose to the level of criminal conduct.
Former Illinois Attorney General Lisa Madigan announced in October that her office had opened a criminal investigation into the Rauner administration’s handling of the outbreaks. A spokeswoman for current Attorney General Kwame Raoul said that criminal investigation remains open.
No one has been charged with wrongdoing.
“The Rauner administration knew there was a crisis at the Quincy veterans home days before staff was made aware. The lack of notice ultimately caused more deaths to the already frail residents of the home,” said state Sen. Cristina Castro, D-Elgin. “I hope the investigation by the attorney general’s office holds accountable those responsible for this heinous act.”
Efforts by WBEZ to reach Rauner himself were not successful Monday, and past aides deferred to him for comment.
Some of the families of those who died expressed frustration at Mautino’s findings.
“My father was #13 to die at [the] hands of [the] state at #Quincyveteranshome so the constant reminders of ineptitude and gross negligence [are] upsetting and disheartening,” said Michael Dehn in a tweet after the audit’s release.
He is the son of Roy Dehn, who contracted Legionnaires and died in October 2017.
The Dehn family is one of 12 now suing the state for negligence in connection with their loved ones’ deaths from Legionnaires’ at the home. State lawmakers authorized payments of up to $2 million for each of those families, but they are waiting on Gov. JB Pritzker’s administration and Raoul to settle with them.
“I think the civil suits are extremely justified after this,” Cullerton said of the audit. This probably doesn’t help the state’s case.”
Dave McKinney and Tony Arnold cover state politics and government for WBEZ. Follow them @davemckinney and @tonyjarnold.