BOSTON (WHDH) – The Baker-Polito Administration on Wednesday released the results of an independent report ordered by Gov. Charlie Baker into the COVID-19 outbreak at the Holyoke Soldiers’ Home, where at least 76 coronavirus-related deaths occurred after administrators made a series of “terrible errors.”
The 174-page report detailing the investigation and its findings, which Baker called “nothing short of gut-wrenching” and “hard to read,” can be viewed here.
“I called for an independent and thorough investigation into the tragic events that occurred at the Holyoke Soldiers’ Home to get to the bottom of what happened and take immediate action,” Baker said in a statement. “This report lays out in heartbreaking detail the terrible failures that unfolded at the facility, and the tragic outcomes that followed. 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.”
Despite existing public health recommendations on how to prevent the spread of the virus, investigators say they identified “substantial errors and failures by the Home’s leadership that likely contributed to the death toll during the outbreak.”
Investigators concluded the Home’s superintendent, Bennett Walsh, was unfit to preside over the facility, especially amid a pandemic that exacted an unimaginable toll of death and devastation throughout the United States.
“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,” the report stated.
The most substantial error made by the Home’s leadership team came on March 27, when they decided to move all veterans from one of the two locked dementia units (2-North) into the other locked dementia unit (1-North), where they would be crowded in with the veterans already living there, investigators said.
At the time, each unit was said to have had some veterans who were COVID-19 positive, some who were suspected of having the disease, and others who were 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 stated. “This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19.”
During the course of the investigation, 111 interviews were conducted with 100 staffers who witnessed the events, with nurses describing the move as “total pandemonium,” “when hell broke loose,” and a “nightmare.”
A recreational therapist who was instructed to help with the move reportedly said that she felt like she was “walking [the veterans] to their death” and that the veterans were “terrified.” A social worker added that they “felt it was like moving the concentration camp — we [were] moving these unknowing veterans off to die.”
After the consolidation was completed, one nurse is said to have described 1-North as being “like a battlefield tent where the cots are all next to each other.” Another staffer “thought my god, where is the respect and dignity for these men?”
An experienced healthcare administrator sent in three days later to address the crisis described the unit as resembling “a war zone,” with some veterans clothed, some unclothed, some without masks on, and some obviously in the process of dying from COVID-19, according to investigators.
Another social worker offered a heartwrenching account of the time they spent in the locked dementia unit, telling the following to investigators:
“I was sitting with a veteran holding his hand, rubbing his chest a little bit. Across from him is a veteran moaning and actively dying. Next to me is another veteran who is alert and oriented, even though he is on a locked dementia unit. There is not a curtain to shield him from the man across from him actively dying and moaning, or a curtain to divide me and the veteran I am with at the time, from this alert, oriented veteran from making small talk with the confused little fellow. He is alert and oriented, pleasantly confused, and talking about the Swedish meatballs at lunch and comparing them with the ones his wife used to make. I am trying to not have him concentrate on the veteran across from him who is actively dying or the one next to him who I am holding his hand while he is dying.
It was surreal…I don’t know how the staff over in that unit, how many of us will ever recover from those images. You want to talk about never wanting this to happen again.”
When COVID-19 struck the dementia units, investigators say it appears the Home’s leaders shifted focus from any attempt to prevent the spread of the virus to “preparing for the deaths of scores of residents.”
A number of witness accounts suggest that veterans on the combined unit did not receive sufficient nursing care, hydration, or pain-relief medications for days leading up to their death, the report indicated.
The report also stated that several days before and after the consolidation, the Home’s Chief Nursing Officer — Vanessa Lauziere — instructed social workers to call veterans’ family members in an effort to persuade them to change their end-of-life healthcare preferences, such that they would not be transferred to the hospital.
No one at the Home apart from Lauziere would admit to being involved in making the decision to consolidate the two units, according to investigators.
Medical Director Dr. David Clinton, who was present at the Home on the day of the consolidation, allegedly claimed that he “was not involved in, or consulted” in the decision and that he disagreed with it.
“We find this not to be credible, and at the very least, that Dr. Clinton was aware (or should have been aware) of the move and did nothing to stop it,” investigators said.
The investigation also revealed that the Home failed to promptly isolate suspected COVID-19 patients using designated rooms, and dragged their feet when it came to testing additional veterans for the virus when they were showing symptoms, in addition to having inconsistent practices with respect to personal protective equipment.
The Home’s recordkeeping and documentation practices were also said to be in a state of “disarray.”
“We did not know what patients were in the Home or where they were,” a response team member who helped take command of the Home told investigators.”
Secretary of Veterans Affairs Francisco Urena resigned Tuesday, Baker announced Wednesday during a news conference at the State House.
“Based on the results of the report, Secretary Urena was asked to step down, and he did,” Baker said.
Baker also said the state is working to remove Walsh — who was placed on leave on March 30 — from his superintendent position.
The Home has since recovered from the devastating outbreak, with no newly reported positive coronavirus cases as of Tuesday, but a great deal of work must still be done, according to Baker.
“There remains a long road ahead to repair the damage and deep wounds that have been inflicted by this crippling tragedy,” Baker said.
In a statement released by Walsh’s attorneys they wrote, “… we dispute many of the statements and conclusions in the report, to which we were never given the opportunity to rebut prior to publication. We are also disappointed that the report contains many baseless accusations that are immaterial to the issues under consideration. We are reviewing the report and will have more to say in the days ahead.”
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