Gov. Bruce Rauner’s own administration formally rebuked the state agency overseeing the Quincy veterans’ home for how it told staffers about the fatal Legionnaires’ disease outbreak after workers there got sick in 2015.
The workplace safety reprimand issued by the state Department of Labor, first obtained by WBEZ, focused on a pair of emails Illinois Veterans Home administrators blasted out to state workers that seemed to downplay the threat of the disease.
The agency reproached the Illinois Department of Veterans’ Affairs, which oversees the home, saying it “failed to effectively notify all employees” about the outbreak just as it was taking hold.
That Feb. 8, 2016 finding undercuts the insistent public claims by outgoing Veterans’ Affairs Director Erica Jeffries that her department was “very clear” in its Legionnaires’ warnings to staff in Quincy.
But the Aug. 22, 2015 mass email to Quincy workers — which Jeffries has pointed to as proof the home’s workforce was informed early about the outbreak — downplayed the severity of the epidemic and failed to alert staff that two Legionnaires’ cases had already been confirmed by that time.
The email, sent by an infectious disease nursing supervisor to nearly 140 staff members, emphasized with all capital letters that there had been “an UNCONFIRMED diagnosis” of Legionnaires’. The correspondence admonished workers not to talk about the case with residents because “the last thing we need is for the residents to get worried and upset.”
It also came with this assurance, which was underlined, put in bold for emphasis, and repeated in a follow-up email three days later: “I want to reassure all staff that if we truly felt there was an issue with Legionella, we would not put the residents or staff at risk.”
In fact, 19 hours before that first message went out to Quincy workers, top state health officials already knew that a 90-year-old man and an 89-year-old woman had tested positive for Legionnaires’ disease, according to another email circulated to Public Health Director Nirav Shah and the former administrator of the Illinois Veterans Home. Shah would later acknowledge that by Aug. 21, 2015 — the day before the first note went out to Quincy’s front-line staff — the state knew it was dealing with “the beginning of an epidemic.”
By the time that staff email went out on Aug. 22, three workers who were later confirmed to have gotten Legionnaires’ had begun displaying symptoms, state records show. All told, eight veterans’ home staffers have been infected during repeated Legionnaires’ outbreaks since in 2015.
The public union representing some Quincy workers, AFSCME, has argued for years that the veterans’ home didn’t do enough to warn its workers about the Legionnaires’ threat. Rauner’s administration has disputed AFSCME’s claims but it has not previously disclosed the internal reproach from the Department of Labor.
The new revelations come at a delicate juncture for Rauner as he attempts to persuade state lawmakers by the end of May to approve a $245 million replacement for the 132-year-old veterans’ home that once housed former Union soldiers from the Civil War.
Questions about how forthcoming the state was to the home’s workforce — some of whom lacked state email accounts — arise after state health authorities justified withholding word of the 2015 Legionnaires’ outbreak from the public for six days after its onset.
During the period the public was kept in the dark, residents were displaying symptoms — and in some cases, dying – as a result of a form of pneumonia that typically responds to antibiotics if treated quickly. Legionnaires’ has been tied to 13 resident deaths at the Quincy home, and 11 victims’ families are now suing the state for neglect.
The new disclosures by WBEZ about how the crisis first got reported to some — but not all — staff members are drawing criticism from one of the nation’s top infectious disease experts.
“That’s not how you manage an outbreak. That’s not how you communicate a public health emergency to your staff members, who are going to be instrumental in understanding this outbreak and controlling this outbreak,” said Dr. Amesh Adalja, senior scholar at the Center for Health Security in the Johns Hopkins Bloomberg School of Public Health in Baltimore.
“Whether that rises to the level of legal and criminal issues is something that I would defer to an attorney to answer,” Adalja said. “But I do think it clearly is a breach of professionalism and a breach of ethical standards that you would hold medical professionals to, that you would hold administrators of veterans’ homes to.”
Jeffries, who will resign May 18 after criticism over her handling of the crisis, insisted that employees at the Quincy home were kept abreast of the outbreak through emails from administrators, mandatory “town hall” and smaller group meetings, and informational material posted at all nursing stations.
“We communicated effectively to our staff and to our residents and certainly to the family members of each resident that was exhibiting signs and symptoms of pneumonia,” she said in a statement.
‘This is a sensitive case’
The Department of Labor’s involvement in the 2015 outbreak came as a result of two complaints from sickened staffers to the federal Occupational Safety and Health Administration, which regulates workplace safety. On Sept. 4, 2015, that agency transferred the complaints to state Labor Department because the workplace in question was at a state facility — setting up a scenario in which the Rauner administration essentially would be investigating itself.
Within an hour of getting the case, state records show, state Department of Labor official handed it off to an investigator with these words in an email: “Keep me posted. This is a sensitive case, and we are working jointly with the Feds on this.”
Roughly two weeks later, the Labor Department investigator set up interviews with the sickened employees.
According to the investigator’s notes, one staffer fell ill on Aug. 14, 2015 and missed about a week of work. The woman’s doctor diagnosed her with pneumonia, prescribed antibiotics, and admitted her to the hospital. But she only learned of the outbreak after returning to work and tested positive for Legionnaires’ four days later.
In another case, a nursing assistant with a 103-degree fever was admitted to the hospital, where she tested positive for Legionnaires’. The woman told the state investigator the facility never alerted her to the outbreak and that she first learned of it through news reports.
By Sept. 21, 2015, the Labor Department considered citing the home for possibly violating a state law that requires all public employers to provide employees with “a workplace which [is] free from recognized hazards that cause or are likely to cause death or serious physical harm,” state records show.
A heavily redacted Labor Department document from that date titled “Violation Worksheet” outlined the potential violation as “serious.” It noted the two staffwide emails that Jeffries would later cite but indicated they came “well after the confirmed outbreak and second reported illness.”
“The employer failed to immediately notify employees of the outbreak nor instructed [sic] them as to proper precautions to avoid or eliminate exposure,” the document stated.
It’s unclear what happened to the potential violation against Jeffries’ agency. No citation ever was issued, and emails produced by the state Labor Department to WBEZ don’t reveal any internal deliberations over how to conclude what had been described earlier as a “sensitive” investigation.
In a statement, Department of Labor spokesman Ben Noble said former state Labor Director Hugo Chaviano approved issuing the written reprimand but said there was no citation because no workplace safety standards had been violated.
By Feb. 8, 2016, the Labor Department closed its investigation with the letter to Jeffries from the division manager of Illinois OSHA. The supervisor noted the presence of a “safety concern that while not violating any OSHA standards, should be addressed.”
The letter then detailed the agency’s findings.
“The employer failed to effectively notify all employees of the outbreak or instructed [sic] them as to proper precautions to avoid or eliminate exposure in a timely manner. It was discovered that although a mass email was sent to employees informing them of the outbreak, not all employees had email, and subsequently were not able to be informed until sometime after the first email was sent,” the letter noted.
The Department of Labor has received no follow-up complaints, Noble said, despite subsequent outbreaks in 2016 and 2017, with another spate of illnesses early this year.
The fight with labor: ‘My blood is boiling’
In February, a labor leader at the home testified in a legislative hearing about what she described as the facility’s “delayed communication” with staff during the 2015 outbreak.
Nettie Smith, president of AFSCME Local 1787 and a licensed practical nurse at the home since 1993, told lawmakers she learned of the outbreak through a Facebook post. She also recounted how a co-worker got sick, was misdiagnosed and hospitalized — all before learning on her own that she had contracted the illness.
Smith’s testimony triggered an unusually aggressive response from Jeffries. Last month, Jeffries sent a more than 200-page rebuttal to the joint House-Senate committee that started probing the outbreaks in response to the launch of a WBEZ investigation.
Jeffries’ packet included worker email receipts from the two staffwide emails and sign-in sheets from an Aug. 26, 2015 staff meeting on Legionnaires’. She also described testimony from Smith and another AFSCME official, Anne Irving, as “inaccurate and misleading” and dissected a transcript of their remarks on an almost sentence-by-sentence basis.
But notably missing from Jeffries’ critique was any documentation of the state Labor Department finding, which the committee’s Democratic co-chairs learned about only after being shown the document by WBEZ this week.
The omission prompted state Sen. Tom Cullerton, a Villa Park Democrat, to accuse the outgoing director of “lying to the committee.”
“This is the Rauner administration Department of Labor saying that the director of Veterans’ Affairs screwed up and they did this wrong, and they had their employees in danger and they did not do what they were supposed to do,” he said. “Then, that same person comes to the committee and tells us ‘we did everything,’ knowing that email was there a year ago.
“This right here is a failure,” Cullerton said.
In a statement, a Jeffries spokesman reiterated the director’s belief that her agency did nothing wrong.
The Veterans’ Affairs Department “has been transparent concerning its response to the outbreak in 2015 and has provided thousands of documents to both members of the media and the General Assembly,” Jeffries spokesman Dave MacDonna said. “We are focused on providing the best care for our veterans and look forward to building a new, state-of-the-art facility at Quincy.”
But a top labor official believes the Rauner administration has been anything but transparent throughout the ordeal.
Irving, AFSCME’s director of public policy, said the union had to rely on the local health department in Quincy and the federal Centers for DIsease Control & Prevention for information during the initial outbreak, noting the state was “largely unresponsive” during that period.
She’s also indignant Jeffries would discredit the union and be selective with facts in the lengthy rebuttal given to the committee, particularly considering that six staffers at the home got sick in 2015 with an illness some knew nothing about.
“My blood is boiling they would spend the time putting together a document like this when it was clearly false,” Irving said. “I’m just furious.”