Massachusetts lawmakers released a lengthy and damaging report Monday night into what unfolded at the Holyoke Soldiers' Home.
A special committee on Beacon Hill has been investigating what took place at the facility where 77 veterans died from COVID-19 as the virus ravaged the home at the early height of the pandemic in the spring of 2020.
In the nearly-200-page report, lawmakers say a number of factors played into the desperate situation, including unsound medical decisions, poor clinical judgments, absence of leadership and the abdication of responsibility by top personnel.
The worst decision, according to the report, was combining the patients from two dementia wards, which included both COVID-positive and COVID-negative veterans.
In fact, the report concludes, there were many decisions and actions taken that were the opposite of what should have been done.
When a response team from the state showed up at the home when problems got out of hand, a team member said one of the units looked like a "war zone," with veterans crammed on top of each other.
The report finds the home's superintendent, Bennett Walsh, lacked medical and technical expertise, playing a significant role in the devastating sequence of events. It also faults the absence of a clear chain of command and a breakdown in communication involving Walsh, Massachusetts Secretary of Veterans' Services Francisco Urena, Gov. Charlie Baker and Secretary of Health and Human Services Marylou Sudders.
The report indicates there were problems at the home that were years in the making, specifically with staffing shortages and a toxic environment under Walsh.
The report questions how he even got the job in the first place.
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Lawmakers on the committee say all of it added up to a "perfect storm" for the COVID outbreak to become a "preventable tragedy."
The report makes several recommendations about what needs to change, including regular inspections of the facility.