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Investigation commissioned by Gov. Mike Parson issues damning report

Posted on Thursday, January 21, 2021 at 9:01 pm

Response to COVID-19 outbreak in Missouri veterans’ homes deemed “inadequate”

By Barry Dalton

“They treated him like a hero.”

“I couldn’t ask for a better place for him to be.”

“I’m thankful my brother is where he is through this time.”

“I can’t express how grateful I am that these people are there taking care of him when I can’t.”

These were some of the heartwarming quotes included in the 415-page independent, external investigation report into the Missouri Veterans Commission’s response to COVID-19. But the report also reached some very blunt findings about the MVC’s response, leading to the resignation of MVC Chairman Timothy Noonan.

The investigation, ordered by Gov. Mike Parson and conducted by Armstrong Teasdale, indicated that more than 140 COVID-19 deaths had been reported at the state’s seven veteran nursing homes, but this number could have been smaller with a better response.

The MVC manages 1,238 beds with more than 500 employees across its seven veterans’ homes, which are located in Cameron, Cape Girardeau, Mexico, Mount Vernon, St. James, St. Louis and Warrensburg. The MVC’s response to the outbreak was “inadequate,” the report stated. In particular, the homes had significant issues related to testing, cross-contamination and staffing.

Neither MVC nor the homes’ administrative leadership were prepared for the rapid spread of the virus, the report said, and at least one isolation area filled with 50 patients in one week. This required frequent relocation of veterans among the scarce quarantine and isolation beds, and sometimes led to the hectic co-mingling of COVID-19 positive veterans with otherwise uninfected veterans.

At the end of February, faced with evidence of the life-threatening risk COVID-19 posed to veterans requiring long-term care, the MVC was lauded for preparing its homes for the impending pandemic. Thanks to these early efforts, MVC homes went nearly six months without a significant outbreak, while other public and private long-term care facilities were experiencing multiple outbreaks.

Unfortunately, MVC was “lulled into a false sense of security and failed to capitalize on its early successes,” the report concluded.

In September, the homes “experienced a prolonged and rapidly escalating outbreak of COVID-19.” When early indicators of trouble within the homes became known during the last week of August into the first week of September—despite advances in the available data concerning how the virus spreads through asymptomatic carriers, advances in testing and better personal protective equipment (PPE)—MVC found itself unprepared.

While the investigation revealed that the MVC and home staff genuinely care for the veterans, three major lapses contributed to the COVID-19 outbreak: Failure to recognize and appreciate the problem at the first sign of an outbreak; failure to plan for the outbreak; and failure to properly respond.

MVC should have known by the beginning of the summer—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, the report noted.

Directives from MVC “were reactionary, haphazard and often conflicted with each other,” and in some instances “were inconsistent with CDC and VA guidelines or infection control best practices.”

Home staff found it difficult to keep up with the constant updates and changes, and most did not have access to any compilation of the directives they were supposed to be following. This lack of preparation was compounded because the MVC did not have a current manual for infection prevention policy and procedure, which is required by VA and CDC guidelines.

In August 2020, the homes implemented routine nasopharyngeal PCR testing of all veterans and staff twice a week. However, these tests take anywhere from 24 to 48 hours to process. Neither staff nor veterans were quarantined pending the results.

Residents “moved freely among the homes, dined together, interacted with each other and remained lodged with their roommates. Asymptomatic staff continued to work, engage with veterans and take breaks with other staff members pending test results.”

The investigation also exposed the unintended negative consequences of isolation due to the restrictive measures intended to protect veterans.

Among the report’s recommendations is that homes ensure better publication of a telephone number that family members may call if they have concerns or issues with the homes, as well as more timely responses to these family members. A limited number of designated family members should be allowed to visit their loved ones, the report recommended, if they follow the COVID-19 protocols, screening and testing.

The report also found fault with the organizational structure of MVC considering that it falls under the umbrella of the Department of Public Safety but operates independently except for a board of unpaid commissioners with “limited oversight.”

MVC claims to have already implemented many of the recommendations in the report. The full report is available at