What went wrong at Holyoke Soldiers’ Home
A series of decisions that resulted in a catastrophe
THE WORST DECISION made by the staff at the Holyoke Soldiers’ Home was to combine some 40 residents of two locked dementia care units – some with COVID-19 and most not – into a single room with a capacity of 25 people.
“The decision was a catastrophe,” said a 174-page report written by attorney Mark Pearlstein summarizing his investigation into the deaths of 76 veterans at the facility.
The decision on Friday, March 27 was made by Vanessa Lauziere, the chief nursing officer, and affirmed by then-Superintendent Bennett Walsh in a brief phone call.
While the decision was justified as necessary because so many staff members had called in sick that day, Pearlstein’s report said the action helped spread the disease, and many staffers knew what the consequences would be. Social worker Carrie Forrant said it felt like the veterans were being moved to a concentration camp. “We [were] moving those unknowing veterans off to die,” she told Pearlstein and his investigators.
Several days before and after the consolidation of the two dementia care units, the report said, Lauzier “instructed social workers to call veterans’ family members in an effort to persuade them to change their end-of-life healthcare preferences, such that they would not be transferred to the hospital.” On the afternoon of the consolidation, 13 additional body bags were delivered to the facility and a refrigerated truck, intended to supplement the limited capacity of the home’s morgue.
Mistakes have been made at long-term care facilities across the state during the rapid and confusing rise of COVID-19. Those mistakes, coupled with an elderly population particularly vulnerable to the disease, have resulted in 4,970 deaths, nearly 63 percent of the state’s total. But Pearlstein’s report and Gov. Charlie Baker both said some of the most deadly mistakes at the Holyoke Soldiers’ Home could have easily been avoided and violated both state and federal guidance.
“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 merging of the two dementia care units, for example, could have been averted if officials had shipped patients in need of immediate medical care to area hospitals, as an emergency response team did when they were finally called into the Holyoke Soldiers’ Home on March 30. The emergency response team found what was described as a “war zone,” with veterans crowded together, some unclothed and some “obviously in the process of dying from COVID-19.”
When Val Liptak, the interim administrator, arrived at the Soldiers’ Home, she “observed some staff with gowns but no masks; some with only masks; and some with only gloves on. Her initial assessment was that there was ‘no understanding of what the infection control guidelines were,’” according to the report.
Another key error was made when a patient with COVID-like symptoms was allowed to roam freely in the facility for weeks. Even after he was tested on March 17, the veteran remained on one of the dementia units, living in a room with three roommates, spending time in the common room, and wandering the unit. Only once his test came back positive four days later did staff at the home move his roommates out and attempt to isolate him.
Pearlstein’s report dismissed justifications for the lack of quick action – lack of staff and the feeling that it was too late anyway because most residents in the units had already been infected. “If in a long-term care facility with a capacity for 248 veterans, there were a staff shortage that made it impossible to comply with public health guidance and isolate one veteran, this would have been the time for Mr. Walsh and his team to sound the alarm and seek more staff,” the report said. “They did not do so until much later.”
On March 29, 2020, as the crisis unfolded, then Secretary of Veteran Services Francisco Urena sent a series of text messages to Walsh asking whether he had ensured that staff in the two infected units were not being “floated” to other units. Walsh replied: “We’ve done that for two weeks, attempt to keep same staff on same unit.” That statement, Perlstein noted, was false, as staff had been moved between units.
Thalia Rivers, a nursing assistant, cared for the first veteran with COVID-19 symptoms before he was tested. She brought a mask from home and was verbally reprimanded by Celeste Surreira, the assistant director of nursing, for wearing a mask while treating a veteran. Rivers tested positive herself on March 19 and missed five weeks of work while recovering.
Kwesi Ablordeppey, a certified nursing assistant, provided direct care to the veteran whose test later came back positive for COVID-19. He donned personal protective equipment on one overnight shift, something that later resulted in a disciplinary letter from Lauziere. She wrote in the letter that he put on “Personal Protection Equipment without permission or need,” calling his actions “disruptive, extremely inappropriate.” Ablordeppey thought the disciplinary action was in retaliation for his union activities.
There were also broader managerial issues that afflicted the Holyoke Soldiers’ Home. Staff turnover was high, in part because of a Baker administration early retirement incentive plan in 2015 that resulted in 46 employees leaving and partly because of an overbearing management style by Walsh, which contributed to frequent comings and goings.
Walsh, a decorated military veteran, had no experience in running a nursing home facility. State officials demanded that he hire John Crotty, a licensed nursing home administrator, as his top deputy when he took over. Crotty said Walsh described his role as the “inside man” while viewing his own role as the “outside man.” Crotty left the Soldiers’ Home in June 2017 due to differences and run-ins with Walsh, and he was never replaced.
The Legislature also created the position of executive director of veterans’ services, which was intended to be filled by someone with a clinical background who could provide oversight of the soldiers’ homes in both Holyoke and Chelsea. That position also was never filled.
Ironically, the one issue that has received the most coverage in the press – that Walsh tried to conceal how bad conditions were at the facility – was largely dismissed by Pearlstein’s report. While the report accuses Walsh of hiding certain problems and failing to call in reinforcements, it says Walsh generally abided by standard reporting procedures and kept higher-ups apprised of the COVID-19 situation.
Baker and his Health and Human Services Secretary Marylou Sudders both have said they didn’t learn of the serious nature of the problems at the Holyoke facility until Holyoke Mayor Alex Morse alerted them on Sunday, March 29. According to the report, Morse claimed eight people had died over the weekend, a point Sudders disputed, claiming her records indicated there had only been two deaths.What Sudders and others on her team apparently didn’t understand was that the administration’s rules required the reporting of positive COVID-19 tests and deaths from COVID-19, but did not require disclosure of deaths of people suspected of having a COVID-19 or those for whom a test had been ordered but not returned yet. Once that issue was cleared up and those types of deaths were added in, the number of fatalities rose to eight and Sudders and Baker called in reinforcements.
As of Wednesday, they said, no one at the Holyoke Soldiers’ Home is infected with COVID-19.