Several employees at the Jerry L. Pettis Memorial V.A. Medical Center in Loma Linda, CA, have filed a federal whistleblower complaint against hospital officials alleging that they are covering up a Legionella bacteria outbreak, the Orange County Register (OCR) recently reported. The complaint says that officials put patients, hospital visitors, and staff at risk for catching Legionnaires’ disease.

A five-page, redacted complaint was submitted to the U.S. Office of Special Counsel Robert Wilkes, acting Secretary of Veterans Affairs. The complaint, which was obtained by the Southern California News Group, claims “gross mismanagement, abuse of authority, gross waste of funds, and substantial and specific danger to public health and safety.”

“We have an administration not following Veterans Administration directives to protect the welfare of employees, patients, and visitors from exposure to Legionella,” said Dr. Linda Hyder Ferry, chief of preventive medicine at Pettis Medical Center and among more than a dozen whistleblowers (physicians and nurses).

Ferry told the OCR that federal officials visited the hospital and collected hundreds of pages of patients’ records after the whistleblowers filed their complaint.

Officials deny problems exist

Wade J. Habshey, a spokesperson for Pettis Medical Center, dismissed there was a Legionella issue at the facility.

“(The) V.A. takes Legionella prevention very seriously,” Habshey said in an email to the OCR. “V.A. directives on Legionella are among the most stringent in the country. The V.A. Legionella prevention program addresses the education of staff on how to prevent Legionella, reduction of conditions for Legionella growth, (and) monitoring and remediation if found.”

Water quality is monitored quarterly at the Pettis Medical Center, according to Habshey, and the facility has a prevention team to deal with any Legionella problems.

“We have been very successful and have a zero history of hospital-acquired Legionella cases,” he said.

Administration failed to communicate

The complaint alleges that the hospital’s administration knew of the Legionella issue in 2017 but failed to notify the medical staff, failed to correct the problem, and denied that bacteria existed at the facility.

“There are many employees and patients who could have been exposed from August-September to November from the sporadic growth of Legionella in the water system,” the complaint reads.

The whistleblowers specifically cite Melissa Lloyd, the hospital’s associate director for patient care services, for her lack of communication with the medical staff, after she learned of a positive Legionella test. “None of the physicians were informed of the presence of Legionella,” states the complaint.

The whistleblowers also state that Pettis Medical Center officials have not been forthcoming with the California Department of Public Health. “Public health investigators were told by Loma Linda V.A. officials that there was no Legionella exposure to report, there was no verified index case, and that the water testing was negative,” according to the complaint.

State health officials said they had no reports of a Legionella outbreak. One whistleblower – who asked to remain anonymous out of fear of retribution – said they are unconvinced and concerned Legionella is widespread.

“We don’t know how many patients may have died from Legionnaires’ pneumonia,” the whistleblower said. “If they don’t tell doctors (about the existence of Legionella), we don’t do testing.”

Legionella: A V.A. problem

There have been many instances of Legionella contamination or disease cases plaguing V.A. hospitals across the country the past few years. Some examples:

  • February 2018: Four residents at the Illinois Veterans Home in Quincy were confirmed with Legionnaires’ disease, marking the fourth consecutive year the facility has battled an outbreak. There have been 68 people infected and 13 deaths since the first outbreak in 2015.
  • January 2018: A resident of the Fresno, CA, Veterans Home tested positive for Legionnaires’ disease. It’s unknown whether the illness was caught at the facility.
  • January 2017: Testing discovered the existence of Legionella at the V.A. Pittsburgh Healthcare campus. There were no reports of hospital-acquired Legionnaires’ disease after the discovery. The same facility was not as lucky during a Legionnaires’ outbreak in 2011-12, when 22 patients were infected and six of them died.
  • August 2016: Two residents contracted Legionnaires’ while living at the Ussery Roan Veterans Home in Amarillo, TX.
  • November 2015: Water samples at the Minneapolis, MN, Veterans Medical Center tested positive for Legionella, although no illnesses were reported.
  • August 2015: The V.A. Hospital in Phoenix, AZ, relocated 20 patients after routine testing indicated “unacceptable levels” of Legionella in the water system of one building. None of the patients contracted Legionnaires’ disease.
  • October 2014: Legionella were discovered in nine positive tests at the Prescott, AZ, V.A. hospital. It was caught before any illnesses were reported.
  • August 2014: Six buildings on the campuses of New Jersey V.A. Hospitals in East Orange and Lyons were found to be contaminated with Legionella.
  • February 2014: Hospital-acquired Legionnaires’ disease claimed the life of a patient at Bay Pines V.A. Medical Center in Bay Pines, FL. In September 2014, testing returned positive results for Legionella in nine of 19 sites in Building 1. Follow-up testing in December showed the bacteria was even more prevalent, with 11 of 20 sites testing positive.
  • June 2013: An 80-year-old veteran died from Legionnaires’ disease contracted at the Castle Point veterans campus of the Hudson Valley, NY, Health Care System.

What is Legionnaires’?

Legionnaires’ disease – also called legionellosis and Legionella pneumonia – is a severe type of pneumonia (lung infection). According to the Centers for Disease Control and Prevention (CDC), an estimated 25,000 cases of pneumonia due to Legionella bacteria (Legionella pneumophila) occur annually in the United States. Only 5,000 of those cases are reported, however, because of the disease’s nonspecific signs and symptoms.

Ten percent of people who become infected with Legionnaires’ disease will die from the infection.

Legionella bacteria are contracted by inhaling microscopic water droplets, usually in the form of mist or vapor. The bacteria, which grow best in warm water, are most commonly found in human-made environments.

Where do Legionella live?
Outbreaks have been linked to a number of sources:

  • large water systems, such as those in hospitals, nursing homes, and hotels
  • large plumbing systems
  • equipment used in physical therapy
  • cooling towers of air conditioning systems.
  • showers and faucets
  • hot-water tanks and heaters
  • hot tubs and whirlpools
  • swimming pools
  • mist machines and hand-held sprayers
  • decorative fountains.