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Hawaii County officials announced another death at the Yukio Okutsu State Veterans Home on Sunday, in what has become the state’s deadliest infection cluster of the pandemic.

Also on Sunday, U.S. Sen. Brian Schatz said it is “infuriating” that the private operator of the veterans home failed to implement basic infection control practices months after the COVID-19 pandemic began.

Hawaii County Civil Defense and hospital officials said Sunday there have been 24 deaths at the Okutsu facility of infected veterans or their spouses. “Nothing can be said to convey the sadness and emptiness of this,” said a written Civil Defense message Saturday announcing some of the deaths.

UPDATE: Hospital officials announced another death at the veterans home late Sunday evening, bringing the total number of residents who have died there to 24.

Schatz and Hawaii County Mayor Harry Kim have both said they are unhappy with the results of a Sept. 11 inspection of the veterans home by a team from the U.S. Department of Veterans Affairs. That report uncovered a variety of problems, including findings that residents sometimes wandered in the facility hallways and did not always wear masks when they were outside of their bedrooms.

“There was very little evidence of proactive preparation/planning for COVID,” the VA team stated in its report, which was released publicly by Avalon.

“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 workflow seemed to be lacking even approximately three weeks after (the) first positive case,” the VA report states.

Kim was briefed on the Sept. 11 inspection of Okutsu veterans home, and has called on the state to remove Avalon Health Care as the manager of the home.

Earlier this month Schatz , and a 19-member team from the Veterans Administration is at the facility now supporting operations there.

As for the VA report on the Sept. 11 inspection, Schatz said in a written statement Sunday that it makes clear “Avalon did not take the steps necessary to protect its residents and staff. We have known all along that nursing homes and their residents were particularly vulnerable to COVID-19, so it is infuriating to see that basic infection control practices were not in place months after the pandemic began.”

Avalon included its responses to the VA findings in the documents it released to the media, and said that “the Facility has been actively engaged in pandemic preparation since the identification of a global pandemic.”

Okutsu established a pandemic committee, educated staff on COVID-19 and infection control practices, screened staff and essential visitors to the facility, and staged drills for setting up an isolation unit, according to Avalon.

Avalon did facility-wide testing in June with no COVID-19 cases detected, set up weekly testing of high-risk dialysis patients and implemented random testing in August that identified the first infected staff member, who was asymptomatic.

“All of this testing was above any testing requirements of state or federal agencies in place at the time,” the company said in its response to the VA report.

Report Details Infection, Response

The disease most likely entered the facility via the staff member who was exposed in the community, and also through a resident who was exposed at an outside dialysis appointment, Avalon has said.

At the time the VA assessment team did its one-day inspection of the facility earlier this month there had been 10 deaths at Okutsu home.

The facility has been divided into a first-floor area for residents who are infected with the coronavirus, and a second-floor living area for residents who test negative or have recovered.

The VA inspectors noted residents were found wandering within the units or into hallways, and not all residents were consistent about wearing masks outside their rooms. Avalon replied that “This is a big challenge, especially after 6+ months of residents being asked to stay in their rooms.”

Okutsu staff have tried to re-direct wandering residents and have provided diversional activities, but “several residents have PTSD and behavioral diagnoses, which make it very difficult to re-direct and these residents are not always compliant with re-direction and mask use,” the company wrote in its reply.

The inspection report found hand sanitizing stations were not readily available throughout the facility, and Avalon noted in its response it has ordered 25 additional dispensers. Inspectors also reported staff were vague on how frequently high-touch surfaces must be cleaned, and noted that paper bulletins for staff in some cases prevented proper cleaning of surfaces.

Inspectors also found staff was wearing scrubs home when their shifts ended, but Avalon said it has now arranged for a scrub exchange with the Hilo Medical Center. The facility also got rid of chairs covered in fabric in the facility hallways after the inspectors noted they cannot be properly sanitized, according to Avalon.

The inspectors also noted that staff were moving from one wing to another within the first-floor COVID-19 unit without changing their gowns. Avalon reported it has since divided the first-floor COVID-19 unit into three separate units, each with dedicated staff. Staff change their garments when moving from one unit to another, according to the company.

The company also created distinct living units to separate residents who have not been infected with COVID-19 from residents who are recovered, although Avalon said those arrangements go beyond what is required by the Centers for Disease Control and Prevention.

The Yukio Okutsu State Veterans Home has had a history of problems, according to federal inspection reports.

The inspectors also observed that Okutsu did not have ultraviolet sanitation boxes for handheld items, and Avalon said in its reply it has ordered four of the devices although that equipment also exceeds CDC guidance.

The Okutsu administrator told inspectors there were no procedures for preventing housekeeping or maintenance staffs from moving from the COVID-19 unit to other areas of the facility,  according to the VA report, but Avalon disagreed with that finding.

The company said there has been a dedicated housekeeper in the COVID-19 unit since it was created, and maintenance staff are told to work in the COVID-19 unit at the end of their shifts so that they do not pass from there into other parts of the facility.

The VA inspectors urged Avalon to dedicate staff to specific areas at Okutsu so people are not moving around the facility any more than necessary, and to take steps to reduce the number of people entering the COVID-19 unit.

As part of that effort, the company said it is hiring two additional housekeepers, and has requested three more from the Hawaii Emergency Management Agency.

One social worker who was interviewed by the inspection team “expressed exhaustion” from working long hours to cover for other staffers who tested positive for coronavirus or had quit, but the VA team concluded that the Okutsu management did not seem to believe there is a staff shortage.

Avalon replied that it “continues to carefully review its staffing model and plan to ensure adequate staffing to meet residents’ needs. Avalon has deployed additional direct line staff and consulting staff to assist for the duration of the outbreak.”

Schatz said in his written statement Sunday that “Avalon must take immediate action to address the recommendations of this report to ensure the safety of the veterans and staff at the State Veterans Home.”

The Yukio Okutsu State Veterans Home has had a history of problems, according to federal inspection reports.