Feds say VA covered up Legionella at Loma Linda hospital, putting patients, staff at risk

Veterans Administration officials failed to notify physicians in 2017 about Legionella bacteria found at the VA Medical Center in Loma Linda, posing a public health danger and possibly causing at least one doctor to contract potentially fatal Legionnaires’ disease, according to a federal report obtained by the Southern California News Group.

The 26-page VA report substantiates a whistleblower complaint filed in February 2018 with the U.S. Office of Special Counsel by two doctors and six nurses at the Jerry L. Pettis Memorial VA who alleged hospital officials concealed the Legionella discovery for months.

“We found violations of Veterans Affairs and Veterans Health Administration policy, and note that a substantial and specific danger to public health and safety existed at Loma Linda,” says the November 2018 report from the U.S. Department of Veterans Affairs.

Rep. Pete Aguilar, D-Redlands, said Monday the VA’s findings — which have not been publicly released — are disturbing.

“Inland Empire veterans deserve access to the highest-quality care in clean and safe facilities, which is why I was outraged by reports that the Loma Linda VA failed to inform staff about the spread of Legionella at their facility,” he said in a statement. “While the Office of Special Counsel continues to investigate these reports, I look forward to working with my colleagues in Congress to conduct the necessary oversight to ensure our veterans and those who provide them care can feel safe inside VA facilities.”

The VA did not substantiate several other whistleblower allegations about the medical center, including a nursing shortage and unsanitary conditions.

Report not final yet

Stephanie Rapp-Tully, a Washington attorney for the whistleblowers, declined to discuss the report’s findings.

“The report is a draft that is covered by executive privilege because it is not final,” she said. “Thus, we cannot comment.”

The VA takes Legionella prevention very seriously and its directives for the bacteria are among the most stringent in the country, said Wade J. Habshey, a spokesman for the Pettis Memorial VA Medical Center.

“We conduct quarterly water safety testing, and if any trace of Legionella is identified in water during routine preventative surveillance, that water source is immediately placed out of service, infection control staff are notified, mitigation is completed, and the area is retested along with the entire water loop,” he said. “The area is not reopened until it has tested negative.”

The report acknowledges that, despite evidence in 2017 of Legionella in the Pettis Medical Center’s water system, VA officials didn’t develop an effective strategy to deal with the problem until contacted in June 2018 by the Southern California News Group.

The Pettis Medical Center has 162 acute-care beds and a 108-bed community living center. It is part of the VA Loma Linda Healthcare System that has more than 2,400 employees and 1,300 volunteers who serve more than 76,000 veterans.

Federal team investigated complaint

The Office of the Medical Inspector assembled a team to investigate the whistleblowers’ complaint and made a visit to the hospital from July 9-13, 2018, and interviewed more than 50 employees.

Legionnaires is a severe form of pneumonia that can be contracted by inhaling microscopic water droplets in mist or vapor. Legionella bacteria thrive in fresh water, but can multiply in indoor water systems such as hot tubs and air conditioners, according to the Centers for Disease Control and Prevention.

Legionella is not spread through person-to-person contact. Symptoms can include diarrhea, high fever, cough, chest pain and shortness of breath. Those at higher risk for infection are people 50 and older and those who have smoked or currently smoke, have chronic lung disease or a weakened immune system. Left untreated, Legionnaires’ disease can be fatal.

According to the report, federal investigators reviewed data from Pettis Medical Center for 2017 and 2018 and found 33 positive results for Legionella, the report says.

Specifically, 64 individual tests were conducted in wards,  intensive-care units, operating rooms and other inpatient patient rooms. Nine tested positive for Legionella, with one room testing positive twice in September and once in October 2017. All positive tests were on the hot water outlet in the sink, the report says.

Hospital officials informed the nurse manager of the Legionella, patients were relocated to different rooms and the sink was removed.

However, other nurses and the hospital’s doctors were kept in the dark for months about Legionella bacteria lurking in the water system.

Communication splintered

Federal investigators also reviewed Pettis Medical Center’s Water Safety Committee meeting minutes for October, November and December 2017 and March 2018.

During the December meeting, the hospital’s associate director for patient care services, who was not identified, stated that she “normally does not send out emails regarding Legionella information, but would leave it to leadership to decide,” the report says.

The hospital’s Facilities Management Service chief expressed concern during the meeting about two separate “silos” that existed in communicating Legionella issues to staff: one from the Facilities Management Services Department and the other from the infectious disease and nursing departments, according to investigators.

“The FMS chief also stated that the communication had not been tightened up enough and suggested a future discussion on how to improve communication flow,” the report says.

Delay in informing staff

Investigators found evidence hospital officials worked to mitigate the Legionella, but staff was not informed until June 2018, when SCNG contacted the VA about the whistleblowers’ complaint.

The report also states the Office of Inspector General is investigating an allegation from the whistleblowers that at least one physician at the hospital contracted Legionnaires’ disease.

Legionella cases are required to be reported to the San Bernardino County Department of Public Health within a week of discovery. Failure to report can result in disciplinary action by the California Board of Medical Quality Assurance.

Information was not immediately available from the health department regarding whether the VA reported any Legionella cases at Pettis. Thirty Legionella cases and three deaths were reported in San Bernardino County in 2017. Figures for 2018 have not yet been compiled.

The blistering Legionella findings by the VA punctuate several difficulties and controversies plaguing Pettis Medical Center.

In 2018, the VA gave the hospital a one-star rating, the lowest possible performance score for its medical facilities.

And last month, the Southern California News Group revealed that 57-year-old Edwin Winslow Bennett, convicted of the 1989 gangland-style execution of a business rival, is employed as a project manager for the VA Loma Linda Healthcare System’s Ambulatory Care Center in Redlands.

That revelation has prompted Aguilar to demand answers from the VA regarding Bennett’s hiring.

“This fact raises a number of concerns and issues regarding Loma Linda VA’s hiring process and background check system,” he wrote in a letter to Karandeep Singh Sraon, director of the VA Loma Linda Healthcare System.