Report raps Soldiers’ Home, state leadership over deadly coronavirus outbreak


  • An ambulance arrives at the Soldiers’ Home in Holyoke, March 31. GAZETTE FILE PHOTO

  • Massachusetts National Guard soldiers enter the Holyoke Soldiers' Home through the Outpatient Department entrance on Tuesday, March 31, 2020. GAZETTE FILE PHOTO

Staff Writer
Published: 6/24/2020 11:12:13 AM

HOLYOKE — A lawyer hired by Gov. Charlie Baker to investigate the COVID-19 outbreak at the Holyoke Soldiers’ Home that killed 76 veterans has found that leadership made “substantial errors” that likely contributed to the death toll at the facility.

The report also found that Superintendent Bennett Walsh “was not qualified to manage a long-term care facility,” and that high-ranking Baker administration officials failed to act decisively when informed of the developing crisis.

The investigation, led by former federal prosecutor Mark Pearlstein, found that Walsh and other administrators made critical decisions during the final two weeks of March that were “utterly baffling from an infection-control perspective.” In particular, the 174-page report slams the combining of two already crowded dementia units as the “worst decision,” resulting in conditions that staff described as “a nightmare,” “total pandemonium” and resembling “a war zone.”

The investigation also found errors at the state level. Under Walsh’s leadership, the Soldiers’ Home “substantially complied with reporting requirements established by state leaders,” the report states. Those requirements included notifying the state about positive COVID-19 tests and the deaths of those who tested positive, but not about those who died and were still awaiting test results.

“Our investigation also reveals failures relating to the appointment and oversight of Superintendent Walsh by the Massachusetts Department of Veterans’ Services,” the report reads. “While the Home’s leadership team bears principal responsibility for the events described in this report, Mr. Walsh’s ... 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.”

Baker hired Pearlstein on April 1 to conduct the investigation after news broke that more than a dozen veteran residents of the home had died as the outbreak spread. The Baker administration suspended Walsh and set up a “clinical command structure” at the facility led by Val Liptak, CEO of Western Massachusetts Hospital.

As the virus spread, workers described scenes of ”complete chaos.” They said they were not given adequate personal protective gear at the beginning of the outbreak, and that management did not properly isolate the first veteran to test positive for COVID-19. Staffing shortages that employees have been complaining about for years helped the virus spread quickly as staffers were forced to move from unit to unit to help out, they said.

To date, 76 veterans at the Soldiers’ Home have died after testing positive for COVID-19. In a statement, Baker said that the 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,” Baker said.

Combining dementia units a ‘catastrophe’

A significant focus of the report is the combination of the dementia units on March 27. Pearlstein’s team found that the decision was made by Chief Nursing Officer Vanessa Lauziere and approved by Walsh, who is a Baker appointee. The report also found that “at the very least, [Medical Director David] Clinton was aware (or should have been aware) of the move and did nothing to stop it,” despite Clinton’s contention that he wasn’t consulted.

“One social worker recalled raising concerns with the Chief Nursing Officer about the risk of COVID-19 spreading, and the Chief Nursing Officer responded that ‘it didn’t matter because [the veterans] were all exposed anyway and there was not enough staff to cover both units,’” the report reads.

The decision was a “catastrophe,” resulting in “the opposite of infection control,” the report concludes. Witnesses told Pearlstein’s team that veterans on the combined unit “did not receive sufficient nursing care, hydration, or pain relief medications during the weekend of March 28 and 29.”

One staff member, Carrie Forrant, described sitting with one dying veteran and holding his hand, while across from him another veteran lay “moaning and actively dying.” A third veteran, who was “alert and oriented,” was next to her, she explained.

“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,” Forrant told investigators. “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,” Forrant, a social worker, continued. “I don’t know how the staff over in that unit, how many of us will ever recover from those images.”

Walsh and Lauziere said that because of staffing shortages they had no choice but to consolidate the units, but that was incorrect, according to the report.

“Within hours of arriving on March 30, 2020, the Commonwealth’s emergency response team assessed the acuity of the patients and quickly sent many of them to hospitals and other acute-care facilities,” the report reads. “The same option was available to Mr. Walsh and his team.”

Additional missteps that the report attributes to Soldiers’ Home leadership included: a failure to immediately isolate veterans suspected of having COVID-19; delays in isolating patients who were showing symptoms and in closing common spaces; not stopping the floating of staff members from unit to unit; inconsistent policies and practices around the use of personal protective equipment; and record-keeping and documentation failures.

The Baker administration has said it was in the dark about the situation within the home as the contagion spread. Walsh, however, has disputed those claims. Walsh’s attorney, former Hampden district attorney William Bennett, released documents last month that show Walsh providing officials at the state Department of Veterans’ Affairs and the Executive Office of Health and Human Services with regular updates.

Those emails show Walsh communicating with Veterans Secretary Francisco Urena after March 21, when the first Soldiers’ Home resident received a positive COVID-19 test. Urena resigned Tuesday evening ahead of the release of the report.

Efforts to reach Urena, Walsh and Bennett were unsuccessful Tuesday.

Failed state oversight

The Department of Veterans Services “failed in its responsibility to oversee the Soldiers’ Home,” the report said, noting that Urena approved Walsh’s appointment despite the fact that Walsh had no health care administration experience.

During Walsh’s tenure, Urena and his chief of staff were concerned about Walsh’s performance and attempts to control information coming out of the Soldiers’ Home, and they thought he was “in over his head,” according to the report. The document says there was “massive” staff turnover under Walsh, who once attempted to hire a deputy administrator who boasted on her resumé of having of being a “union buster.” Walsh had to see an anger management coach after complaints from others, the report said.

“Despite all this, Secretary Urena did not take sufficient action to address Mr. Walsh’s deficits, and allowed the Deputy Superintendent role to remain open for nine months — including the period of the COVID-19 outbreak,” the investigation found.

The report says that limited state reporting requirements were what contributed to confusion on March 29, when Holyoke Mayor Alex Morse correctly told Human Services Secretary Marylou Sudders eight people had already died, but she responded that only two had died.

“Mayor Morse’s aggressive and persistent efforts to investigate reports from social media concerning problems at the Soldiers’ Home — and his decision to elevate these reports to Lieutenant Governor Polito — were critical,” the report said. “Had he not done so, it would likely have taken several additional days before a command team responded to the Soldiers’ Home to address the COVID-19 crisis.”

Morse said in an interview that he hopes the investigation will lead to improved access to care for seniors and veterans, and improved governance for the Soldiers’ Home.

Pearlstein’s report includes the recommendation that future superintendents of the facility should “be licensed nursing home administrators with substantial healthcare experience, and that the facility should comply with the Department of Public Health’s licensing and inspection regime.”

Staffing, technology and physical plant improvements are also recommended in the report. They include: complying with a mandate passed in 2016 that DVS employ a health care leader to oversee the state’s two soldiers’ homes; ensuring that at least two trustees have relevant clinical or health care administration experience; implementing a permanent staffing schedule and an electronic medical records system; improving labor relations, education and training; and hiring an occupational health nurse.

Members of two unions representing workers at the Soldiers’ Home — SEIU Local 888 and the Massachusetts Nurses Association, or MNA — were many of the 100 witnesses interviewed for the investigation. In a statement, the MNA said that it has long called for improved staffing and that as the outbreak began nurses called for safe isolation protocols and protective equipment.

“This report exposes what happens when leaders detached from the reality of patient care ignore the concerns of frontline nurses and healthcare workers,” the MNA said.

Former deputy superintendent John Paradis, an outspoken voice during the outbreak, said he agreed with the report’s call for better staffing and for the Soldiers’ Home to fall under the DPH’s licensure and inspection requirements. But he said the facility’s board of trustees needs a bigger overhaul than what is recommended in the report.

“It’s a political animal right now”, he said. “It doesn’t represent the veterans, it represents the governor.”

Paradis and others, including former superintendent Paul Barabani, have called for the state to put up matching funds for a $116 million renovation and expansion that has already been approved for 65% federal funding. In a statement, U.S. Rep. Richard Neal, D-Springfield, also called for improvements to the facility.

“Now, more than ever, it is time to refurbish the facility and it must be treated with the same equity as its counterpart in Chelsea,” Neal said. “I stand ready to volunteer any resources that the federal government can provide as the state moves forward to examine next steps.”

Pearlstein’s team is not the only one investigating the Soldiers’ Home. Federal prosecutors, state lawmakers and the state inspector general are all conducting probes. So too is state Attorney General Maura Healey, who said the Pearlstein’s report “lays bare systemic failures of oversight by the Baker Administration in adequately preparing, staffing, and responding to this crisis to protect our veterans.”

“These veterans served our country and risked their lives to protect us, and our state wholly failed to protect them,” Healey said in a statement. “Our ongoing investigation will determine whether these missteps and errors warrant legal action.”

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