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‘Watching people die’: Pa. vets’ nursing home failed residents during COVID-19 outbreak

Southeastern Veterans' Center (DMVA/Released)

The Southeastern Veterans’ Center (SEVC), a state-run nursing home in Chester County where dozens of residents have died of COVID-19, failed to protect elderly residents from the coronavirus outbreak and continued to place them in “immediate jeopardy” by flouting infection-control guidelines, according to state and federal health inspectors.

The scathing inspection report, based on an early June inspection but only posted recently on the state Department of Health website, said SEVC officials did not consistently screen the temperatures of staff entering the building each day or enforce social distancing; allowed employees to work in both COVID-positive and COVID-negative units in the same day; and maintained a work culture in which staffers were afraid to speak out about problems for fear of termination.

“We will be fired for talking to you,” a licensed practical nurse told an inspector. “Watching people die was awful. We were told to wrap the residents in a body bag and meet the undertaker at the elevator.”

For weeks, the 238-bed facility, run by the Department of Military and Veterans Affairs (DMVA), kept many relatives and residents in the dark about how widely the virus had spread. The Inquirer reported on April 17 that at least 10 residents had already died, citing an internal report.

The coronavirus death toll continued to rise rapidly, with as many as four residents dying in a single day. By late May, after 37 residents had died of the virus, the head of the facility, Commandant Rohan Blackwood, and his director of nursing were suspended. The state’s five other veterans nursing homes, including the one in Philadelphia, had fewer than five deaths among them, state data showed.

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At the time, The Inquirer also reported on widespread concerns about mismanagement of the nursing home, which employees attributed largely to Blackwood and his administrators. Besides a flawed strategy to contain the coronavirus, the employees’ allegations included the altering of medical records, wage theft and retaliation, and chronic understaffing, which studies have found can worsen infectious outbreaks.

“The commandant and director of nursing did not effectively manage the facility to make certain that proper infection control procedures were followed,” the new health inspection report states.

Specifically, inspectors said the veterans center “failed to consistently maintain an infection prevention and control program, which placed residents in immediate jeopardy. The facility staff failed to ensure proper screening of staff entering the building, failed to implement tracing and investigation of positive COVID-19 residents/staff, cleaning and disinfecting of multiuse equipment, staff failed to use proper PPE, proper hand-hygiene, and store/handle linens in the proper manner to prevent the potential for cross contamination.…”

The report also said the nursing home did not have a policy for separating residents who tested positive and negative, a problem first made public by The Inquirer, based on complaints from those with family living at the nursing home, in East Vincent Township.

According to the report, “The commandant and the [director of nursing] failed to fulfill their essential job duties to ensure that the federal and state guidelines and regulations were followed.”

Blackwood did not respond to requests for comment Tuesday. DMVA spokesperson Joan Zlogar Nissley said the nursing home disagrees with the inspection and has submitted a request for informal dispute resolution.

“When areas of concern are identified, we take immediate action to address and rectify them, with a continued focus on the safety and care of residents,” Nissley said in a statement, adding that DMVA has hired a temporary management team to assist the staff.

Fran McDermott, whose 91-year-old mother, Josephine McKeon, has lived at the home for several years, said her mother weathered a traumatic spring in which both of her roommates became sick and died as residents and staff members went without masks.

It was not clear whether they died from COVID-19, though McDermott said her mother reported that both were put on oxygen and were showing symptoms of the infection. At first, staff would not test McKeon, McDermott said. After the National Guard was deployed to the facility, her mother tested positive for the virus, though she remained asymptomatic.

On Tuesday, McDermott said her mother had recovered and has since tested negative several times.

”She was one of the lucky ones,” McDermott said.

Since the nursing home has been under new leadership, McDermott said, the staff has kept her well informed about her mother’s health.

An outside law firm hired by Gov. Tom Wolf’s Office of General Counsel is conducting an investigation of the COVID-19 outbreak at SEVC, according to a spokesperson for the Department of Military and Veterans Affairs.

State Sen. Katie Muth, a Democrat whose district includes SEVC, said Tuesday that she wasn’t completely satisfied with the latest report or the state’s response to the ongoing issues at the home.

“The report mentions the failures by the commandant and the director of nursing, but those aren’t the only problematic people who allowed this to happen,” she said. “I’m fearful that because this is a state-run facility, a true assessment of what’s happened already and what’s continuing to happen won’t take place.”

Muth was one of the first elected officials to publicly raise concerns about SEVC after being contacted by staff members. She said those employees, including nurses, were still complaining about shortages of PPE as recently as this past weekend.

She said she had begun drafting a letter to the Senate Veterans Affairs and Emergency Preparedness Committee to formal requesting a hearing on the nursing home.

“I think there are still a few more avenues I can exhaust,” she said. “The silence of the DMVA leadership and the governor’s office is damning.”

Ian Horowitz, whose father lived at the veterans center and died of complications of the coronavirus in May, said Tuesday that he wants to see higher-ranking DMVA officials held accountable, in addition to Blackwood. He believes his father became infected from his roommate.

“There are too many red flags flying around this administration, and it’s frustrating,” Horowitz said.

Chester County Coroner Christina VanDePol said Tuesday that 42 residents of the home died of COVID-19. No new deaths from the pandemic have been reported there in several weeks.

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© 2020 The Philadelphia Inquirer