A detailed investigation into the massive coronavirus outbreak at Holyoke Soldiers’ Home was released Tuesday, which Massachusetts Gov. Charlie Baker said showed an "abject failure" of leadership.
Baker had commissioned former federal prosecutor Mark Pearlstein to investigate the causes of a coronavirus outbreak in the that lead to the deaths of at least 76 veterans and the infection of an additional 84 veterans and over 80 staff members.
Here are five takeaways from the 174-page report:
The 'Worst Decision': Cramming Two Units Together
Staff combined two locked dementia units containing veterans with a mix of COVID-19 statuses on March 27. The decision was a "catastrophe," according to the report, with staff describing the move as “total pandemonium,” “when hell broke loose” and “a nightmare.”
Witnesses, including a command-response leader brought in three days later to stabilize the situation, report that this “hot” unit had veterans “crammed in on top of each other,” some of whom “were clearly dying.”
Pearlstein characterized this as the "worst decision made during the Soldiers’ Home’s response to COVID-19."
Coronavirus Patients Weren't Quickly Tested and Isolated
The investigation found that the facility failed to promptly test veterans suspected of COVID-19 and isolate them. Particularly "egregious," the report said, is the failure to isolate some veterans after staff had already moved others to create negative-pressure isolation rooms, which minimize the spread of infectious disease by controlling airflow, and later emptied a hospice unit meant to be used as an isolation space.
Senior staff considered entire units "contaminated" after veterans were not isolated while test results were pending.
Staff Kept Rotating Between Units
The leadership of the Holyoke Soldiers’ Home failed to prevent the rotation of staff members from unit to unit, the investigation found, which presented a "substantial and obvious transmission risk." Some of those staff members later tested positive for COVID-19.
On March 29, Secretary of Veterans' Affairs Francisco Urena asked Superintendent Bennett Walsh whether he had ensured that staff in the two infected units were not being rotated to other units. Walsh lied, saying, "We've done that for two weeks," when in fact staff had been rotated during that time, including to units housing infected veterans, according to the report.
Superintendent Walsh Found Unqualified
Walsh was not licensed as a health care administrator and did not have any experience in managing a health care facility. The Holyoke Soldiers' Home isn't required to have a licensed administrator like other long-term care facilities, because it's state run.
Walsh’s family has strong political connections in western Massachusetts, witnesses said, and after leaving the military he pivoted his career search from security operations to superintendent of the facility when a state legislator reached out and suggested that he apply for the position.
The investigation found that some staff members -- including his deputy, who was licensed to run nursing homes -- felt that Walsh didn't allow others to question him in public. That deputy left in June 2019, when he "resigned in frustration with Mr. Walsh, leaving "a gaping leadership deficit" that remained until Walsh was put on leave March 30 and an interim administrator brought in.
'Complete Mayhem' in Tracking Veterans
When investigators with the response team that took over the facility on March 30 began looking at who was house there, they found the records disorganized and incorrect; “complete mayhem,” as one investigator put it, according to the report.
Some patients weren't being assessed and doctors were hesitant to examine residents because they were reluctant to examine them due to the risk of contracting the virus.
For his part, Walsh omitted information or gave inaccurate information when communicating with the departments of Veterans’ Services and Public Health.
Read the full report: