Soldiers’ Home Report Cites Poor Decisions, Lack of Leadership

HOLYOKE — A long-awaited independent report investigating the COVID-19 outbreak at the Holyoke Soldiers’ Home, released Wednesday, identifies a number of poor decisions made by suspended Superintendent Bennett Walsh that ultimately led to what the author of the report called “the opposite of infection control.”

The report also levels criticism at the Department of Veterans’ Services for putting Walsh in that position when he had no experience managing a long-term-care facility, and for lack of oversight.

“While the home’s leadership team bears principal responsibility for the events described in this report, Mr. Walsh was not qualified to manage a long-term-care facility, and his shortcomings were well known to the Department of Veterans’ Services — yet the agency failed to effectively oversee the home during his tenure,” the report states. Walsh was suspended with pay at the start of the outbreak.

On Tuesday evening, Veterans’ Services Secretary Francisco Urena confirmed he had been asked to resign ahead of the report’s release and complied.

The 176-page report, authored by Boston attorney Mark Pearlstein, was commissioned by Gov. Charlie Baker in early April as the death toll from the outbreak rose. The report reviews actions taken over a several-day period, but zeroes in on critical decisions made on March 27 to herd dozens of men into one unit that was staffed by employees who did not use proper personal protective equipment.

“Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report states.

The outbreak ultimately left 76 veterans dead and 80 others sickened, along with many staff members.

“The Soldiers’ Home leadership team made substantial errors in responding to the COVID-19 outbreak,” the report notes. “Even the best preparations and most careful response cannot eliminate the threat of COVID-19. But this does not excuse a failure to plan and execute on long-standing infection control principles and to seek outside help when it is required to keep patients safe — indeed, the extraordinary danger of COVID-19 makes these steps all the more important.”

In addition, “the worst decision made during the Soldiers’ Home’s response to COVID-19 occurred on the afternoon of Friday, March 27, 2020. On that afternoon, a number of staff members had called in sick for the evening shift that was about to begin. Because of the looming staff shortage, the chief Nursing officer, with Mr. Walsh’s approval, decided that one of the home’s two locked dementia units (2-North) would be closed and consolidated with the other (1-North). One social worker recalled raising concerns with the chief Nursing officer about the risk of COVID-19 spreading, and the chief Nursing officer responded that “it didn’t matter because [the veterans] were all exposed anyway, and there was not enough staff to cover both units.

“This decision was a catastrophe,” the report continues. “Staff describe the move as ‘total pandemonium,’ ‘when hell broke loose,’ and ‘a nightmare.’ One staff member stated that she ‘will never get those images out of my mind — what we did, what was done to those veterans,’ and ‘thought, my God, where is the respect and dignity for these men?’ Other witnesses, including a command-response leader brought in three days later to stabilize the situation, reported that this ‘hot’ unit had veterans ‘crammed in on top of each other,’ some of whom ‘were clearly dying.’”

In a statement Wednesday announcing the report’s release, the governor pledged to take “immediate action to deliver the level of care that our veterans deserve.”