Reports find fault with Avalon Health Care Group

  • Kelsey Walling/Tribune-Herald

    Raenette and Tim Marino advocate for the protection of veterans outside the Yukio Okutsu State Veterans Home last Thursday in Hilo. That was the anniversary of Raenette’s father’s injury during the Korean War. The Marinos usually celebrate the day as Raenette’s father lived through his injury.

Critical reports stemming from recent assessments at Yukio Okutsu State Veterans Home have identified a number of factors that might have aided in the spread of COVID-19 throughout the facility.

Assessments were conducted separately by the U.S. Department of Veterans Affairs, Hawaii Emergency Management Agency and the state Department of Health Office of Health Care Assurance as the Hilo facility grapples with an coronavirus outbreak that has so far infected 70 residents, 32 employees and claimed the lives of 24 residents.


The HI-EMA assessment, requested by the Hawaii Health Systems Corp., was conducted by Dr. K. Albert Yazawa. HHSC owns the facility, which is operated by Avalon Health Care Group under contract to the state.

That assessment identified movement of patients between units, wandering residents and staff gatherings at work and in the community, among other issues.

“Multiple potential sources of infections brought into the facility by staff who appear to be connected to known community outbreaks, unknown asymptomatic but infectious carriers (staff), and community outbreak exposure at a dialysis center,” Yazawa wrote. “Complacency by staff initially also played a part as evidenced by breakroom use and loose mask usage by some staff. Knowing exactly which staff may have had community exposure … would have been useful to preempt suspected exposures.”

And although testing was conducted numerous times, residents and staff could have been tested sooner, he wrote.

“I believe the nursing home culture at YOSVH was one that remained entrenched in pre-COVID norms of respecting individual resident rights over the health of the general population,” Yazawa concluded. “This was evidenced by not cohorting residents due to resident refusal to move rooms, not stopping all nebulizer treatments due to resident refusal and allowing dementia patients to wander without an attempt to restrict their movements. In this pandemic crisis, these were major errors that contribute to infectious spread. …”

The HI-EMA report comes days after the VA released a report of its own.

“There was very little evidence of proactive preparation/planning for COVID,” the VA report stated. “Many practices observed seemed as if they were a result of recent changes. Even though these are improvements, these are things that should have been in place from the pandemic onset and a major contributing factor towards the rapid spread. A basic understanding of segregation and work flow seemed to be lacking even approximately three weeks after (the) first positive case.”

The VA’s single-day on-site assessment took place Sept. 11, with a team lead by Dorene Sommers, associate director of patient care services and nurse executive at Erie Veterans Affairs Medical Center in Pennsylvania.

In a summary attached to the VA report, Avalon Health Care said the company and facility have consistently followed the frequently changing rules and guidance from the U.S. Centers for Disease Control, U.S. Centers for Medicaid and Medicare Services, and state Department of Health.

After receiving the VA assessment on Sept. 13, facility leadership began to prioritize and implement the recommendations.

“Many of the recommendations contained in the assessment are above and beyond CDC, CMS and state COVID-19 rules and guidance and are not common practice in long-term care facilities, even during a COVID-19 outbreak,” the Avalon summary states. “Likewise, some of the recommendations are hospital level (and above) interventions that a very, very small number of nursing homes nationwide would have implemented — or had the capability to implement.”

The facility, however, had more than 60% of the recommendations in place at the time of the VA visit, Avalon said.

“We were surprised by the many findings they made related to practices that were currently in place,” Avalon spokeswoman Allison Griffiths said Monday. “It seems that they had a standard template they were following, and, perhaps because they were only there for about four hours, did not confirm whether certain practices were already in place.”

Griffiths said Avalon also was surprised at the claims that there was little evidence of proactive COVID-19 planning, and the VA’s contention that improvements were the results of recent changes.

An unannounced, “COVID-focused infection control survey” conducted by the Office of Health Care Assurance on June 23 found no deficiencies, Griffiths said.

She added that the VA team didn’t request to see the facility’s pandemic plan or review any policy or training records, and “this was their first time at the facility, so how would they know what was in place last month or three months ago?”

According to Griffiths, the VA team is at the facility each day, working side-by-side with staff, but she was unsure how long the team plans to remain.

Among other observations, the VA assessment found that:

• Hand sanitizers were not readily accessible in all areas.

Avalon said hand sanitizers are and have been available throughout the facility since March, with more added in April. An additional 25 dispensers have been ordered.

• There was uncertainty as to which high-touch surfaces were to be disinfected and how often.

Avalon, however, said the facility has implemented “repeated cleaning” of high-touch surfaces throughout the facility since March and increased the frequency at the start of the outbreak.

• Scrubs were worn home after working an entire shift.

The facility has implemented a scrub exchange program with Hilo Medical Center.

• Staff moved from wing to wing wearing the same personal protective equipment.

Avalon said the wings were in the downstairs COVID unit and since all three wings were COVID-positive, they were in accordance with CDC guidelines. The COVID unit has been separated into three sub-units with dedicated staffing in compliance with VA recommendations.

The VA report also noted that some residents were wandering through the unit or floor into other hallways, and that some residents weren’t consistently wearing masks outside of bedrooms.

Griffiths said in an email to the Tribune-Herald late Friday that getting residents to comply with wearing masks or personal protective equipment is a “significant challenge.”

“Several residents have PTSD or behaviors, and they do not understand wearing masks or cannot tolerate them,” she said. “Staff has been constantly reminding the to wear masks when not in their rooms, but this is a huge challenge. Nursing facilities cannot require residents to always stay in their rooms as that would be an impermissible physical restraint. Nursing home residents have been asked to stay in their rooms and have not had visitors since March, so you can understand their desires to move freely about the facility, which is their home.”


According to the state, the Office of Health Care Assurance’s inspection report is still undergoing an internal review and will be shared after the veterans home receives it.

Email Stephanie Salmons at

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