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Problems at a Massachusetts veterans home -- where 76 deaths were linked to a coronavirus outbreak -- began when patients from two dementia units were combined into one, a 174-page state report says.
“This decision was catastrophic,” the report on the Holyoke Soldier’s Home says, according to FOX station WFXT-TV in Boston. “Staff described the move as ‘total pandemonium,’ ‘when hell broke loose,’ and ‘a nightmare.’’’
“This [is] the most insane thing I ever saw in my entire life,” one staff member said, according to the report, the release of which was followed by the firing of the home's superintendent.
CUOMO BRUSHES OFF CRITICISM OVER NURSING HOME DEATHS AS 'SHINY OBJECT'
The merger of the two units represented “the opposite of infection control,” according to the report, creating conditions that were “close to an optimal environment for the spread of COVID-19.”
It was the start of a crisis that, in addition to the 76 deaths, also led to infections for 84 other veterans and 80 staff members over 11 weeks, the Boston Globe reported.
“The subject matter and details of this report are nothing short of gut-wrenching. In fact, this report is hard to read,” Massachusetts Gov. Charlie Baker, a Republican, said Wednesday.
“The subject matter and details of this report are nothing short of gut-wrenching. In fact, this report is hard to read.”
Flags and wreaths honor veterans on the grounds of the Soldiers' Home in Holyoke, Mass., Tuesday, April 28, 2020. (Associated Press)
The events at the veterans home in Holyoke -- a city of about 40,000 residents, about 90 miles west of Boston -- are “difficult to even think or speak about,” Baker added, calling the situation, “truly horrific and tragic," according to the Globe.
Susan Kenney, whose 78-year-old father died in April after contracting the virus at the home, told The Associated Press she was horrified as she read the report.
“Action needs to be taken,” said Kenney, the daughter of Air Force veteran Charlie Lowell. “We want this to never happen again.”
Baker said information about reform plans would be coming Thursday, the Globe reported.
WHITMER FEELS HEAT FROM DETROIT PAPER OVER CORONAVIRUS: SHE 'MUST ANSWER FOR NURSING HOME POLICY'
A second major error at the home occurred when the staff failed to isolate suspected coronavirus patients in rooms that were set aside for isolations, despite being advised to do so, the report says, according to WFXT.
The veterans home’s superintendent, Bennett Walsh, was notified as early as March 12 that any patients displaying coronavirus symptoms should be isolated, the report says. Officials were also told March 13 that all common areas should be closed to help prevent spread of the virus – but the Holyoke Soldiers’ Home kept the common areas open through March 16, one day before the first veteran there was tested for the virus, WFXT reported.
The state report also accuses Walsh and two other officials – Chief Nursing Officer Vanessa Lauziere and Medical Director Dr. David Clinton – of excluding others, including the home’s infection control nurse, from participating in key decisions, WFXT reported.
It also portrays Walsh as ill-prepared and inept in his job, overly concerned with politics, and having tendencies to bully many members of the staff, MassLive.com reported.
Walsh, a Marine Corps combat veteran, was suspended with pay March 30 but was fired Wednesday after the state report was made public, according to the news outlet.
An attorney for Walsh pushed back on how his client was portrayed in the state’s report, according to the news outlet.
“We dispute many of the statements and conclusions in the report, to which we were never given the opportunity to rebut prior to publication,” attorney William Bennett said. “We are also disappointed that the report 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.”
"The report contains many baseless accusations that are immaterial to the issues under consideration."
Bennett is also Walsh’s uncle and a former district attorney in Hampden County, the MassLive.com report said.
The attorney said he may file a lawsuit against Gov. Baker’s administration over the firing.
MassLive.com obtained a copy of Walsh’s termination letter, which was signed by Baker and by state Health and Human Services Secretary Marylou Sudders.
CLICK HERE FOR COMPLETE CORONAVIRUS COVERAGE
“The findings of the report cite critical failures by you and your leadership team during the preparation for, and response to COVID-19,” the letter says. “The report further states that the decisions made by you and your leadership team were inconsistent with the Home’s mission to treat its veterans with honor and dignity. There is no confidence in your ability to perform your responsibilities as Superintendent of the Holyoke Soldiers’ Home.”
Meanwhile, state Secertary of Veterans Services Francisco Urena, who allowed Walsh to remain in his job, told reporters Tuesday that he was asked to resign ahead of the report's release.
"I'm very sorry," Urena told The Associated Press. "I tried my best."
The Associated Press contributed to this story.
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