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Illinois Veterans’ Home timeline raises even more questions

Thursday, Dec 14, 2017

* Last night, I went through the WBEZ story about the 2015 Legionnaires’ disease outbreak at the Illinois Veterans’ Home in Quincy with the idea of putting together a timeline to make it easier to understand. But I quickly found that I needed even more information outside of the story.

What I’ve come up with is admittedly incomplete, but it still gives you an idea of what’s out there in the public domain. Dates with hyperlinks contain information outside of the WBEZ story. Those without links are from the WBEZ story, which, if you missed it, you can read by clicking here

July 24: Earliest known case of Legionnaires’ disease at the Illinois Veterans’ Home in Quincy, according to a report issued later by the Centers for Disease Control (CDC).

August 21: Illinois Department of Veterans Affairs Director Erica Jeffries later claims that on this date, her department “shut down the water, we removed aerators from all the showers, we shut down our fountains, we started issuing bottled water” because of the outbreak.

August 21: Illinois Veterans’ Home resident Melvin Tucker develops a fever. He is given Tylenol.

August 23: Illinois Department of Public Health notifies CDC of “five laboratory-confirmed cases of Legionnaires’ disease among residents and staff.”

August 24: Adams County Health Department Director of Clinical and Environmental Services Shay Drummond claims this is the date when “environmental control and mediation” actually starts

August 24: In an email, a state Veterans’ Affairs spokesman alerted the governor’s press staff about the Legionnaires’ test results, saying, “We have a situation at the Quincy home.” The spokesman went on to say he did not intend to publicize details of the test results that day unless “directed or in the case of wide media interest.”

Aug. 26: There are now 28 Legionnaires’ disease onsets, the CDC reports later.

August 26: Three days after CDC was first notified of the Legionnaires’ disease outbreak, and 2-4 days after remediation efforts began, Gerald Kuhn, 90, is given Tylenol for a fever that reaches 104 degrees. Kuhn asks to go to the hospital and tests positive there for Legionella.

August 26: Last day Dolores French is seen alive. Her military veteran husband lives in another section of the complex.

August 27: “The Illinois Department of Veterans’ Affairs (IDVA) and the Illinois Department of Public Health (IDPH) today announced eight confirmed cases of Legionnaires’ disease in residents at the Illinois Veterans’ Home - Quincy. There have been no known deaths related to this outbreak.”

August 27: After six days with a fever, Melvin Tucker is still not on any kind of antibiotic and hasn’t yet been tested for Legionnaires’, despite the CDC being notified four days earlier of an outbreak and the state announcing eight confirmed cases that same day.

August 28: “Two residents of an Illinois veterans home have died of Legionnaires’ disease, the Illinois Department of Public Health said Friday…. [both] had underlying medical conditions. Both were among 23 residents of the facility who had earlier been diagnosed with the disease.”

August 29: Dolores French is found dead and her body was decomposed. Her only underlying medical condition was deafness.

August 30: IDPH formally requests Epidemiologic Assistance (Epi-Aid) from the CDC.

August 31: Melvin Tucker and Gerald Kuhn die, bringing the death total to four.

August 31: Three CDC Epidemic Intelligence Service Officers and one environmental health specialist arrive at the veterans’ home.

September 1: “The Illinois Department of Veterans’ Affairs (IDVA) and the Illinois Department of Public Health (IDPH) today announced the deaths of a total of seven residents at the Illinois Veterans’ Home-Quincy. The seven residents, all of whom had underlying medical conditions, were among the 39 individuals who had been diagnosed with Legionnaires’ disease to date.” [Dolores French’s only underlying medical condition was deafness.]

September 9: Adams County health officials report 2 more deaths.

September 14: Another resident dies, bringing the death toll to 12 out of 54 who have by now contracted the disease.

The most important takeaway for me when doing this post is that they knew they had a disease problem, yet aged men who were displaying symptoms were given Tylenol and neither tested or given antibiotics. Look, hindsight is 20/20. I get it. But this is just appalling.

Besides that, there are a ton of unanswered questions here. Why did state officials wait so long to notify the CDC, the governor’s office and the public, including the residents and their families ? When did the cleanup really start? Why did they wait so long to request a CDC Epi-Aid (click here for an explanation of what that is)? Why did they emphasize the claim that all of those who died had underlying medical conditions?

And here’s something else to ponder: On August 12, 2015, the Tribune reported that an inmate at Stateville Correctional Center in Joliet was diagnosed with Legionnaires’ disease. How does IDOC stop an outbreak among prisoners at the same time that IDVA is badly bungling the care of military veterans?

- Posted by Rich Miller        

  1. - Anonymous - Thursday, Dec 14, 17 @ 7:59 am:

    I’d like to know why, after more than 2 years, no one seems to have a dollar amount to replace the water system other than someone’s shoot from the hip $500 million.

    Did none of these superstars throughout this administration even consider soliciting estimates? Not a priority while they’re throwing tens of millions at IT vendors?

  2. - Perrid - Thursday, Dec 14, 17 @ 8:24 am:

    I agree they got caught with their pants down it seems, no one seemed to know what to do or was unwilling to make the decision. Did the nurse/staff who gave them Tylenol know about the outbreak? Were they briefed on what the symptoms were? Why not? The answer to the last one is probably that the head honchos were putting their head in the sand and hoping the problem went away.

  3. - illini - Thursday, Dec 14, 17 @ 8:32 am:

    Given the timing and very questionable actions - or the lack of the same - regarding an apparent anemic response to this serious issue raises other questions.

    I follow the St. Louis media and know that Missouri is finding serious issues in the operation of its 7 VA homes. Physical abuse, personal and medicinal neglect, and other issues are apparently common and have been long term.

    Not saying that we should look at Missouri as an example of good governance, but their Governor has taken forceful actions - heads have rolled, major personnel changes have been made and new policies instituted. But then Gov. Greitens is a veteran himself.

    So what is the bigger picture here about the level and standard of care our veterans receive? Does anyone care or is anyone willing to take charge and some responsibility?

  4. - Anonymous - Thursday, Dec 14, 17 @ 8:34 am:

    Nice job with the timeline. I’ll just cut to the chase. Can we get him on this?

  5. - Rutro - Thursday, Dec 14, 17 @ 8:45 am:

    I already addressed this, I’m not in charge.

  6. - Soccermom - Thursday, Dec 14, 17 @ 8:50 am:

    Rauner has made it clear that he does not take the deaths of the elderly or disabled seriously.

    Read this, and explain why anyone thought he would do differently as Governor — and explain why no one pointed out that one of the Governor’s major responsibilities is making sure that sick, old, and disabled people are kept safe?

  7. - whatever - Thursday, Dec 14, 17 @ 8:52 am:

    This line from the end of that story might explain how Rauner won despite his clear record of letting old, sick and disabled people die needlessly on his watch:

    “Quinn’s campaign did not immediately respond to requests for comment.”

  8. - cdog - Thursday, Dec 14, 17 @ 8:55 am:

    Besides the executive level issues here, the operational issues appear criminal.

    Delores French was dead “for a significant amount of time,” and her body was “badly decomposed.”

    Who lied on the phone to her family? Who was working their shifts, or was “on the floor,” during those hours not doing their job? Do they still work at IVHQuincy?

    Which prosecution would make the best example to any creeps still getting away with not doing their job, or the right thing? Federal, State, or County?

  9. - Flippy - Thursday, Dec 14, 17 @ 8:59 am:

    This is bad. B-A-D bad. The Governor has zero interest in governing and taking the lead. Only complain, deflect and deny. And now these folks have lost their lives. Ugh.

  10. - cdog - Thursday, Dec 14, 17 @ 9:00 am:

    This is another example of negligence at the operational level, from the Wbez story, about Delores’ husband Richard.

    “Steve French said the troubles didn’t end there: In checking Richard French out of the home, staff erroneously marked him as deceased, meaning he faced a cutoff in Social Security benefits as he was moving into another nursing home.”

    There was/are some bad pennies in that place.

  11. - Anon221 - Thursday, Dec 14, 17 @ 9:00 am:

    From August 24- In an email, a state Veterans’ Affairs spokesman alerted the governor’s press staff about the Legionnaires’ test results, saying, “We have a situation at the Quincy home.” The spokesman went on to say he did not intend to publicize details of the test results that day unless “directed or in the case of wide media interest.”

    This,IMO, will be one of the main smoking guns of this case. The spokesman was asking for direction. What direction was given by the Rauner Administration, when, and by whom? Did IDOC make the same request with their outbreak? If so, what direction was given to them, when, and by whom?

    Based on some Googling, Rauner was busy signing all kinds of bills into law that day. On the 22nd, he did this…

  12. - Quill - Thursday, Dec 14, 17 @ 9:03 am:

    One of the core problems here is that in institutional settings, whether they are nursing homes or prisons or other types of congregate settings greater than four people, there is a tendency towards decreased personal accountability. No one would allow this to happen to their close family member, so why it is allowed to happen at work to the people you serve? There is a problem with lack of engagement in personal responsibility in institutional settings. Frankly the rules/policies can make people disengage from owning a problem. This sort of issue is totally common in nursing facilities, and a great reason why people don’t want to live in them.

  13. - Arsenal - Thursday, Dec 14, 17 @ 9:15 am:

    One aspect of this reflects something I see in my day job: we don’t have nearly enough people qualified to do this kind of nursing/care work. There are policies we can implement to fix that.

  14. - Anonymous - Thursday, Dec 14, 17 @ 9:16 am:

    Anyone reach out to Z or Goldberg to find out how they let this happen? Did they see it as a worthwhile problem to address?

  15. - FCCSM - Thursday, Dec 14, 17 @ 9:16 am:

    Our state facilities have serious infrastructure problems. The VA home is crumbling. Our prisons are crumbling. Many of the buildings owned by the State have been woefully neglected for years. I realize we’ve had years of budget crises, but failing to address these problems only exacerbates them. What the State will pay in lawsuits for these deaths is likely equivalent to what the State could have spent to fix the problem - and in that case, no one would be dead on Rauner’s watch.

    Why wasn’t Rauner, Jefferies or someone screaming from the top of their lungs about this? You can’t deflect blame to Madigan, or claim it’s a national issue, when you knew how to fix it and didn’t.

  16. - Swift - Thursday, Dec 14, 17 @ 9:23 am:

    Rich, Legionella is fairly common in the environment, however it is often only harmful with those who have some other illness, or are otherwise infirm. I suspect that the purpose of the reference to underlying conditions was intended to alleviate fears in healthy individuals of contracting the pneumonia as a result of exposure. I also suspect that is why IDOC didn’t suffer as badly, most of their inmates at Stateville aren’t elderly individuals or otherwise ill with other conditions.

  17. - Henry Francis - Thursday, Dec 14, 17 @ 9:25 am:

    This is truly appalling. But not that surprising when the executive branch is led by someone who has made clear he has no interest in running state government.

    I’m sure he will claim that he has a lot on his plate and he is angry that this wasn’t brought to his immediate attention. But we all know he has never missed taking his photographer and tweeter to greet the return of the honor flights. Priorities.

  18. - Anon - Thursday, Dec 14, 17 @ 9:27 am:

    Another story of Illinois getting from Government what it pays for from politicians that have repeatedly made clear that they will only support budget cuts and a Governor that has repeatedly shown he has no interest in actually providing the services he was elected to administrate.

  19. - kitty - Thursday, Dec 14, 17 @ 9:31 am:

    As a Veteran and one who had a father and uncles who were WWII and or Korean War vets, I find the lack of transparency and apparent conflicting accounts of what happened very troubling. Rauner’s soulmate in Wisconsin, Scott Walker, presides over what are arguably the most dysfunctional state operated Veteran homes in the US. See

  20. - Sugar Corn - Thursday, Dec 14, 17 @ 9:36 am:

    Durbin is right. The remaining residents should be moved.

    Rauner should go there and drink the water himself if he wants them to stay.

    What a crying shame.

  21. - Ann - Thursday, Dec 14, 17 @ 9:47 am:

    Thanks for continuing to follow up on this story. My husband came way too close to dying of Legionnaires a decade back. Two things we learned at the time: 1) It’s tough to diagnose. It’s pneumonia. Lots of things cause pneumonia. We were in a small town and the nearest lab that could test for Legionella was at Mayo’s. It took four long long days for the result to come in and in the meantime he was getting all sorts of treatments that probably made things worse. 2 )It’s really cheap to treat. The right generic antibiotics (tetracycline or erythromycin) work well if it’s not too late. So once a outbreak is identified there’s no possible excuse not to have all hands on deck assuming that new pneumonias might be Legionnaires and treating appropriately.

  22. - My New Handle - Thursday, Dec 14, 17 @ 9:53 am:

    George Ryan has been tagged with the fatalities of a family, so does the neglect leading to the deaths of vets get stuck to Rauner? It certainly should.

  23. - Langhorne - Thursday, Dec 14, 17 @ 9:53 am:

    There should be a thorough criminal investigation, in addition to a medical investigation. The timeline brings things into focus.

    Overlap this timeline with the BTIA IPI revolving door events. Were they too preoccupied w that to pay attention to this?

  24. - Langhorne - Thursday, Dec 14, 17 @ 9:55 am:

    Oops, missed the 2015 date, not this summer.

  25. - We'll See - Thursday, Dec 14, 17 @ 9:55 am:

    - Swift @ 9:23 -
    “… Legionella is fairly common in the environment.”
    You’re so right, it’s more common than most realize and can be found in supermarket spray units for fruits and vegetables; hotel and home whirlpools; home shower heads, etc.

    Most people exposed to Legionella never have a adverse outcome but those with underlying health conditions are more at risk of contracting Legionnaires.

  26. - Rich Miller - Thursday, Dec 14, 17 @ 9:57 am:

    === but those with underlying health conditions are more at risk of contracting Legionnaires. ===

    Exactly right. And that’s why IDVA should’ve been Johnnie on the Spot about this. For crying out loud, if they can’t care for those veterans then we need to find people who can.

  27. - cdog - Thursday, Dec 14, 17 @ 10:03 am:

    “need to find people who can”

    Yes, yes, yes. And as someone who was a union officer, many moons ago, there is nothing worse than being expected to defend a crappy person, who should be fired, from appropriate discipline.

    It takes courage to do the right thing at all levels.

  28. - Thinking - Thursday, Dec 14, 17 @ 10:17 am:

    Was there Capitol Development Board involvement on getting this tragic situation fixed? Thought I read something on that but can’t recall details of it.

  29. - Professor - Thursday, Dec 14, 17 @ 10:22 am:

    Aug 24,a Veterans Affairs spokesman notifies a ‘press’ person in the governor’s office: “we have a problem.” This is not a PR problem or is that the way it was perceived? This is a real emergency. Top level people should be talking and responding, immediately. What incompetence! And people subsequently died.

  30. - Annonin' - Thursday, Dec 14, 17 @ 10:25 am:

    It is interesting to see interest in this story. Long delayed by all concerned.
    It also deflects attention from the devastating Tribbie review of home health care regulation.
    Neither tops the other. Both point to a failure by GovJunk and his various shifts of SuperStars, Best in the Nation, Top Notch advisers should have handled. Of course both problems started before he stumbled into office. But one might expect more from the “shake it up”

  31. - Sigh - Thursday, Dec 14, 17 @ 10:39 am:

    A simple Google search find….

    December 4, 2015 CDC Memo to Nirav Shah (IDPH Director)Page 22:

    “This outbreak occurred in a setting with no formal water management plan, no Legionella specific prevention plan, limited previous Legionella testing both clinically and environmentally, and limited monitoring of water treatment parameters making conclusions regarding the Legionella risk prior to the outbreak investigation period impossible. However, our investigation did reveal multiple potential exposures that may have resulted in the large outbreak experienced at the Illinois Veterans Home in Quincy, Illinois. Widespread colonization of the highly pathogenic outbreak Legionella strain identified throughout the facility’s potable water and cooling tower, an at-risk population, and one or a combination of plausible scenarios consistent with either a contaminated aerosolized plume or contaminated potable water bolus dissemination likely explains the explosiveness of the outbreak.”

  32. - Swift - Thursday, Dec 14, 17 @ 11:07 am:

    Rich, I don’t disagree, and as Sigh points out, the CDC harshly states there was no plan in place at the time of the outbreak. Maybe that is something we need legislation for, legionella plans for long term care facilities, state operated or otherwise. Unfortunately, as we have seen from the current administration and the contenders (except for Kennedy, thankfully) it’s become a blame the other side game instead of coming up with smart solutions. We have irate politicians chiming in for a news cycle and then the issue, and chance for possible change, is lost. I, for one, don’t want the Quincy outbreak to go the way of the bump stock ban or state licensure for police officers and the numerous other issues politicians don’t want to use political capital on after the “hotness” of the issue has gone away.

  33. - Honeybear - Thursday, Dec 14, 17 @ 11:19 am:

    Having worked a lot in facilities when I was in hospice the decomposed body jumps out at me.
    Check staffing levels
    In my mind there is no reason for not discovering that a person
    Has died outside of 4 hours or roughly the time between meals
    Even if it was independent living
    Regular check ins at least very least daily
    Says to me not enough staff
    Check ins went by the wayside
    To direct prioritized care
    Because they
    Didn’t have enough
    Right here folks
    Right here
    Is what you get when you cut
    Agency budgets
    Program budgets
    Wages and benefits for caregivers
    When a governor
    Denegrates his workforce
    Attacks them mercilessly.

    I’d wager a huge amount
    That staffing was way down
    Maybe I’m wrong
    I don’t know
    But we need to know.

  34. - @misterjayem - Thursday, Dec 14, 17 @ 11:39 am:

    “Why did they emphasize the claim that all of those who died had underlying medical conditions?”

    That emphasis on blame is what happens when you prioritize public relations crisis over the public health crisis.

    – MrJM

  35. - We'll See - Thursday, Dec 14, 17 @ 11:48 am:

    - Honeybear @ 11:19 -

    The women found dead was in her own apartment, separate from the living arrangements of her husband. Quincy allows spouses of veterans to live there as well.

    I’m guessing that because she was in an independent living arrangement, staff were not assigned to check on her.

  36. - Johnny Tractor - Thursday, Dec 14, 17 @ 12:01 pm:

    Can someone run and win on a good government platform? Is it appealing enough to voters to say that what you’ll bring to the Governor’s office is good, basic management skills - propose budgets; use the powers of the office to manage expenditures at levels consistent with/below appropriated levels; operate the departments at a consistently good, functional level? Or do you have to brand yourself as a visionary first and oh, yeah, you’ll cut waste, fraud and abuse? Can boring get elected?

  37. - Sigh - Thursday, Dec 14, 17 @ 12:03 pm:

    Swift- check out the other post about the FOIAs.

    In 2016 Rauner admits to a reporter during a visit to the home that they are on top of this situation. I believe these families are suing. Even if you remove the politicians from this story or their efforts to get answers, the media will continue to cover the story because if the families.

    On a personal note, I know what it is like to receive a call regarding a loved one in a nursing home. If it takes irate politicians chiming in in this situation, the so be it because the residents of this facility deserve better care and those that passed away as a result of this situation deserve justice.

  38. - Skeptic - Thursday, Dec 14, 17 @ 12:18 pm:

    Johnny Tractor: I suspect that as soon as there is a hint of “a tax increase to pay for it” (even if it is good government) the candidate is dead in the water.

  39. - Rusty Jones - Thursday, Dec 14, 17 @ 12:31 pm:

    At the end of the day, this appears to be a result of the budget impasse and the inability of the state to maintain the facility properly.

    The alleged information suppression by the Governor’s office, just makes a bad situation worse.

  40. - Cubs in '16 - Thursday, Dec 14, 17 @ 12:44 pm:

    ===The women found dead was in her own apartment, separate from the living arrangements of her husband. Quincy allows spouses of veterans to live there as well.

    I’m guessing that because she was in an independent living arrangement, staff were not assigned to check on her.===

    While that’s probably true the article says she spent roughly 8 hours a day with her husband. Her sudden absence should’ve raised at least a few eyebrows and prompted someone to check on her well being.

  41. - We'll See - Thursday, Dec 14, 17 @ 1:02 pm:

    - Cubs in ‘16 @ 12:44 pm _
    I agree that her absence should have raised concern and wellness check should have been completed.

  42. - Sonny - Thursday, Dec 14, 17 @ 1:59 pm:

    Are we going with cover up or just complete incompetence?

  43. - Gettysburgaddress - Thursday, Dec 14, 17 @ 2:46 pm:

    What did Governor Rauner know and when did he know it?

  44. - Sugar Corn - Thursday, Dec 14, 17 @ 3:00 pm:

    This response from Jil Tracy is weird - can you imagine if a Dem Governor was “in charge”? What a joke:

    “State Sen. Jil Tracy, R-Quincy, and Rep. Randy Frese, R-Paloma, had a private meeting with Rauner later, and the Veterans Home was among their top issues.

    “We need to keep this home open, and we need to fix any problems,” Tracy said.

    Tracy said the state has acted appropriately, spending more than $5 million on a water purification system, new water heaters and individual filters on fixtures such as shower heads.

    “WBEZ is acting as if nothing has been done,” which is not accurate, Tracy said.”


  45. - wordslinger - Thursday, Dec 14, 17 @ 3:27 pm:

    If I’m reading this correctly, it took a month (July 24-Aug. 24) between the first known case of Legionaire’s Disease and the time any executive branch actions were taken.

    That needs some explanation.

  46. - Cubs in '16 - Thursday, Dec 14, 17 @ 3:47 pm:

    ===Are we going with cover up or just complete incompetence?===


  47. - anonlurker - Thursday, Dec 14, 17 @ 4:04 pm:

    Word @ 3:27
    Agreed that explanation is needed. I read the reports including Sigh’s link at 10:39. Seems that July 24 was the onset of the illness that was later determined to be Legionnaires. I saw nothing about the exact date of when they actually tested that person. The 10:39 link indicates under “Factors that Contributed to the Outbreak” that timely testing was an issue. So possible that he was not tested until some time after the initial July 24 illness.

  48. - Gettysburgaddress - Thursday, Dec 14, 17 @ 4:49 pm:

    What did Governor Rauner know and when did he know it? Governor Rauner last year “We’re really on top of the situation.”

  49. - anonlurker - Thursday, Dec 14, 17 @ 5:12 pm:

    Gettys @4:49 Thanks.

  50. - cc - Thursday, Dec 14, 17 @ 11:46 pm:

    More and more there seems to be a common state of mind by many that are feeling that veterans and retired local, state, federal government employees that have earned and contributed to retirement funds should be allowed to have those funds and are increasingly made to feel that they have outstayed their welcome.
    To paraphrase…are there no prisons nor workhouses? “If they would rather die,they had better do it and decrease the surplus population.” Charles Dickens.
    Happy Holidays.
    And, I personally don’t know any of those folks that do not pay any taxes nor spend half their remaining lives trying to hide their income as some others are wont to do.

  51. - Rabid - Friday, Dec 15, 17 @ 5:57 am:

    Raunergate hearings for his reelection achievement exposay

  52. - Rabid - Friday, Dec 15, 17 @ 6:37 am:

    Underlying; lies under the Rauner administration

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