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.