An independent investigation into the deadly coronavirus outbreak at the Holyoke Soldiers' Home released Wednesday said the facility's leadership team made "substantial errors" in responding to the outbreak that resulted in the deaths of at least 76 veterans and the infection of an additional 84 veterans and over 80 staff members.
Massachusetts Gov. Charlie Baker hired former federal prosecutor Mark Pearlstein to carry out an independent investigation into the coronavirus outbreak in the nursing facility in Holyoke in April.
"This report lays out in heartbreaking detail the terrible failures that unfolded at the facility, and the tragic outcomes that followed," Baker said. "Our emergency response to the COVID-19 outbreak stabilized conditions for residents and staff, and we now have an accurate picture of what went wrong and will take immediate action to deliver the level of care that our veterans deserve."
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He called the situation "horrific and tragic," and said the "abject failure" of leadership at the home led to errors in judgement "before the pandemic, in anticipation of the pandemic and once the pandemic landed."
Baker said he plans to announce a series of reforms and legislative proposals on Thursday aimed at addressing the concerns raised in the report.
"There remains a long road ahead to repair the damage and deep wounds that have been inflicted by this crippling tragedy," he said. "Today is only the first step."
The most substantial error by the Soldiers' Home's leadership, Pearlstein said, was a decision on March 27 to move all veterans from one of the two locked dementia units into the other locked dementia unit, where they were crowded in with veterans already living there. At the time, the unit had some veterans who were positive for COVID-19, some who were suspected of having it and others displaying no symptoms.
"Rather than isolating those with the disease from those who were asymptomatic -- a basic tenet of infection control -- the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25," the report said. "This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19."
The report said interviews with staff were "searing." One nurse described the move as "total pandemonium." A recreational therapist who was instructed to help with the move said she felt like she was "walking [the veterans] to their death" and that the veterans were "terrified." After the consolidation was completed, one nurse described the unit as being "like a battlefield tent where the cots are all next to each other." An experienced healthcare administrator sent in three days later to address the crisis said the unit resembled "a war zone," with some veterans clothed, others unclothed, and some obviously in the process of dying from COVID-19.
Families of patients were livid after reading the report.
"It was such a toxic environment," said Eileen Driscoll, whose father, 91-year-old Alfred Healy, died in April from COVID-19.
Healy, a veteran of the Korean War, was a resident at the home.
"These veterans were victims, and there's not enough negative words to describe what's illustrated in this report," Driscoll said. "These veterans suffered, and they didn't have to suffer. They were just not cared for."
Colleen Croteau's dad, Donald Bushey, also lived at the home, and he died from COVID-19 in March.
"They were putting them in, healthy veterans, in with guys who tested positive of at least presenting symptoms," Croteau said.
"My father was positive and he still was in a room with his roommate," Driscoll added.
The investigation also found that the Soldiers' Home failed to promptly isolate patients suspected of having COVID-19, delayed testing veterans showing symptoms, delayed closing common spaces to reduce the spread of the virus and failed to stop rotating staff members from unit to unit,
The report said even if the leadership of the Soldier's' Home had done everything right some residents might have contracted and even died from the coronavirus. But Pearlstein said the "substantial errors" that were made "likely contributed to the scope of the outbreak, and its horrific toll." He also found that the Soldier's Home fell short of its mission to provide "care with honor and dignity."
"The Soldiers' Home in Holyoke has a proud history of serving people who have given so much for this country," Pearlstein wrote in the conclusion to his report. "The tragic events described in this report cry out for reform, and it has already begun. We hope that the process of rebuilding the Home's legacy will receive full support from the Commonwealth's political leaders, so that veterans will once again be assured of receiving the high-quality care they so richly deserve."
The handling of the COVID-19 outbreak resulted in Bennett Walsh, superintendent of the facility, being placed on paid administrative leave on March 30. Baker said Wednesday that the state is moving to end Walsh's employment.
Pearlstein's report said some of the decisions made by Walsh and his clinical and administrative teams during the final two weeks of March were "utterly baffling from an infection-control perspective" and likely contributed to the death toll.
Pearlstein said his investigation also revealed failures relating to the oversight of Walsh by the state Department of Veterans' Services.
Secretary of Veterans’ Services Francisco Urena resigned Tuesday in anticipation of the release of the report.
"While the Home's leadership team bears principal responsibility for the events described in this report, Mr. Walsh was not qualified to manage a long-term care facility, and his shortcomings were well known to the Department of Veterans' Services -- yet the agency failed to effectively oversee the Home during his tenure despite a statutory responsibility to do so," Pearlstein wrote in his report.
Baker said Wednesday that Cheryl Poppe, superintendent of the Chelsea Soldiers' Home, has been named acting secretary of veterans' services.