The leadership at the Soldier’s Home in Holyoke, Massachusetts made some decisions that were “utterly baffling from an infection-control perspective,” according to a probe that was ordered by Governor Charlie Baker and led by former Federal prosecutor Mark Pearlstein. The poor planning and decision-making led to 76 deaths earlier this year. Another 84 veterans and 80 hospital workers tested positive.

“The details of this report are nothing short of gut-wrenching. In fact, this report is hard to read,” Baker said adding that the events at the Holyoke Soldier’s Home were “horrific and tragic.”

“Veterans who deserve the best from state government got exactly the opposite, and there is no excuse or plausible explanation for that.” Baker added that there was a failure in leadership and a “complete lack of compassion for these vulnerable heroes.”

“Some of the critical decisions made by Mr. Walsh and his leadership team during the final two weeks of March 2020 were utterly baffling from an infection-control perspective,” the report said.

The scathing report found multiple other errors that included: 

  • Delays in testing veterans for the virus despite the display of symptoms 
  • Delays in closing common spaces 
  • Failure to keep the staff from rotating among units 
  • Inconsistent use of protective equipment
  • “Complete mayhem” with the recordkeeping system

Among the findings from the probe was that on March 27 the staff decided to consolidate 40 veterans from two locked dementia units into one space designed to hold 25. Both of the units housed veterans who had contacted the virus.

While both units had confirmed cases of COVID-19, there were other patients in the units who were asymptomatic. Rather than separate them from the already infected patients, they combined both units in a tightly packed area that was far too small and further led to the coronavirus spreading quickly.

One social worker attempted to raise concerns about that. Yet, the chief nursing officer replied, “it didn’t matter because [the patients] were all exposed anyway and there was not enough staff to cover both units,” the report added. 

One hospital staffer who helped move the dementia patients into the tight confines of the overcrowded room told investigators she felt like she was “walking [the veterans] to their death.” Another nurse commented that the packed dementia unit looked “like a battlefield tent where the cots are all next to each other.”

The first veteran patient tested positive for coronavirus on March 17. Although he had been showing symptoms for weeks, Holyoke’s staff “did nothing to isolate” him until his test came back positive. In the meantime, they had allowed him to remain with three roommates, wander the unit, and spend time in a common room, investigators said.

Bennett Walsh, the superintendent of the Holyoke Soldiers’ Home, was determined “not qualified to manage” the long-term care facility. He was placed on paid administrative leave at the end of March and the CEO of Western Massachusetts Hospital, Val Liptak, took over operations.

Attorneys for Walsh disputed the report saying that they were “disappointed that [it] 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. We are also reviewing legal options as it appears that the action by Secretary Sudders and Governor Baker violates the order of the Superior Court and denies Mr. Walsh the opportunity for a fair and public hearing.”

Pearlstein’s investigation also found that the Department of Veterans’ Services failed to effectively oversee the home during Walsh’s tenure.

The Secretary of Massachusetts Department of Veterans’ Services, Francisco Urena, told NewsCenter 5 television that he has been asked to resign as the state’s secretary of Veterans’ Services. 

Massachusetts Attorney General, Maura Healey, is conducting an investigation to determine if legal action is warranted. Additionally, the U.S. attorney’s office in Massachusetts and the Department of Justice’s Civil Rights Division are looking into whether the Soldier’s Home violated residents’ rights by failing to provide the proper medical care to the veterans.