Did residents at Boulder City veterans home die because of COVID-19 testing lapse?

A complaint filed against the Southern Nevada State Veterans Home in Boulder City alleges that a failure to regularly test employees for COVID-19 may have led to the deaths of three patients in late 2022.

The complaint was filed by the granddaughter of Grant Lau, who was infected with COVID-19 when he died of pneumonia on Nov. 10, according to the document filed with the Nevada Bureau of Health Care Quality and Compliance.

In the complaint, Leah Lau wrote that she had learned that two other patients in the home had died within a two-week period of her grandfather’s death. She said she also learned that infection control staff were aware that staff and residents were not being tested regularly for the virus that causes COVID-19.

Leah Lau wrote that Fred Wagar, former director of the Nevada Department of Veterans Services, said in a meeting that “we caused the death of the three residents by not testing our staff, per policy,” according to the complaint.

Lau’s complaint asks the state to investigate her claim. “Since this occurred, there has been no transparency, instead being a cover-up by the leadership there of the tragic consequences of their appalling negligence.”

Records show testing inconsistencies

Following up on a tip about Lau’s complaint, the Boulder City Review filed an extensive request under the Nevada Public Records Act for any available documents referencing COVID-19 testing of employees at the veterans home.

While the head-count numbers have not been provided yet, reports generated by the home’s infection control staff show the number of employee tests being performed varied wildly over the period examined.

In December 2020, more than 400 employee tests were reported in a single week. In December 2022, only 281 tests were performed in the entire month. In some weeks during the second half of 2022, as few as 50 tests were reported to have been taken, according to documents.

And there are several instances of comments made in emails about employees — including the administrator then overseeing the veterans home — not complying with the testing requirements.

It was not until December 2022, after the outbreak that led to the deaths of Lau and two others and at about the same time that the home was scheduled for an extensive federal inspection called a survey by the Centers for Medicare and Medicaid Services, that discussion appears in email records about the need to set up a written policy so that employees who skipped testing could be disciplined.

While there was written policy about the need for all employees to test twice each week, there was no written policy describing disciplinary actions that could be taken for those who did not comply with the testing policy.

Agency denies allegation

The BCR spoke with two people who say they heard Wagar make the accusation blaming staff for the 2022 deaths, which reportedly came during a weekly leadership meeting held over Zoom on or around Dec. 1, 2022. Only one of those people would go on the record: Poppy Helgren, the home’s director of nursing at that time. However, both attendees reported that Wagar said, “We killed three patients” and blamed the then-current COVID outbreak on lax employee testing.

NDVS Communications Director Terri Hendry has denied wrongdoing or the the statement attributed to Wagar.

“We can emphatically state that at no time was the resistance of mandatory Covid-19 testing by staff responsible for Covid-19 related deaths at the home,” Hendry said. “You will find a review of the documents supports our claim. We can find no information that supports your implied supposition that such a statement was made.”

Hendry went on to state, “Soon after his appointment to serve as director, Director Wagar realized some inconsistencies in following Covid-19 policies, rules, and regulations. He immediately stressed to leadership at the home that all Covid-19 regulations would be followed. Director Wagar is extremely pleased with the current leadership at the home and the compliance of the entire staff ensuring the safety of all staff and residents.”

Less than a month later, on Jan. 19 of this year, Wagar was reportedly dismissed. Despite multiple attempts to get comments about Wagar’s separation via the office of Gov. Joe Lombardo, no information has been forthcoming about what Hendry referred to as a “change in leadership” in an email to staff.

Another publication reported that the governor’s outgoing chief of staff said that it was a “personnel decision” with no explanation. The Reno Gazette-Journal has reported that the separation was a dismissal. Multiple emails to the governor’s press office have gone unanswered and unacknowledged as of press time.

Lau said her grandfather lived in the home for about eight years. According to the death certificate she provided, he died as a result of pneumonia, which was the result of COVID infection. She said her grandfather served in the Army from 1950-1953, and that she filed her complaint after overhearing staff at the home talking about Wagar reportedly blaming staff directly for several deaths, including that of her grandfather.

She reported that the family is actively seeking representation in order to file legal action against the home and the Department of Veterans Services.

Contact reporter Bill Evans at wevans@bouldercityreview.com or at 702-586-9401.