Investigators say leadership at a home for aging veterans in Massachusetts where nearly 80 residents sickened with the coronavirus have died made “substantial errors and failures" that helped the disease run rampant
By
ALANNA DURKIN RICHER Associated Press
June 24, 2020, 5:02 PM
4 min read
The leadership of a home for aging veterans in Massachusetts where nearly 80 residents sickened with the coronavirus have died packed dementia patients into a crowded unit as the virus began spreading, one of several “utterly baffling” decisions that helped the virus run rampant, investigators said in a report released Wednesday.
The superintendent of the Holyoke Soldiers’ Home was not qualified to run a long-term care facility and “substantial errors and failures” he and his team made likely contributed to the high death toll there, investigators found. Among them was a decision prompted by staffing shortages to combine two locked dementia units, both of which already housed some residents with the virus.
“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. 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.
When a social worker raised concerns about the move, the chief nursing officer said “it didn’t matter because (the veterans) were all exposed anyway and there was not enough staff to cover both units,” the report said. One staffer who helped move the dementia patients told investigators she felt like she was “walking (the veterans) to their death.” A nurse said the packed dementia unit looked “like a battlefield tent where the cots are all next to each other.”
As the virus took hold, leadership shifted away from trying to prevent its spread, “to preparing for the deaths of scores of residents,” the report said. On the day the veterans were moved, more than a dozen additional body bags were sent to the combined dementia unit, investigators said. The next day, a refrigerated truck to hold bodies that wouldn't fit in the home's morgue arrived, the report said.
Since March 1, 76 veterans who contracted COVID-19 at the home have died, officials said. Another 84 veterans and more than 80 staff have also tested positive.
Republican Gov. Charlie Baker, who hired former federal prosecutor Mark Pearlstein to conduct the investigation, said 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," he said in an emailed statement.
The home’s superintendent, Bennett Walsh, has defended his response and accused state officials of falsely claiming they were not notified quickly enough about the spread of the virus. He was placed on administrative leave March 30 and the CEO of Western Massachusetts Hospital, Val Liptak, took over operations.
An email seeking comment was sent to Walsh’s attorney on Wednesday.
Investigators said officials with the Department of Veterans Services were aware of the superintendent's “shortcomings," but did not do enough about it. The chief of staff for Secretary of Veterans' Services Francisco Urena told investigators they thought Walsh was “in over his head" and did not spend enough time at the home. But Urena allowed Walsh to remain in his job.
Urena told reporters late Tuesday he was asked to resign ahead of the release of the report. He did not immediately respond to a message sent Wednesday by The Associated Press.
“I’m very sorry,” Urena told WCVB-TV. “I tried my best.”
Massachusetts Attorney General Maura Healey is also investigating to determine if legal action is warranted, she said. And the U.S. attorney’s office in Massachusetts and Department of Justice’s Civil Rights Division are looking into whether the home violated residents’ rights by failing to provide them proper medical care.
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Follow AP coverage of the pandemic at https://apnews.com/VirusOutbreak and https://apnews.com/UnderstandingtheOutbreak.
