25 Investigates: Internal emails reveal lack of preparation for COVID-19 outbreak at Holyoke Soldiers’ Home

Internal emails reveal lack of preparation for COVID-19 outbreak at Holyoke Soldiers' Home

HOLYOKE, Mass. — For the first time we are getting a look at official communications between administrators and staff at the Holyoke Soldiers’ Home as they tried to contain the coronavirus from spreading. 25 Investigates has obtained internal emails, sent to workers, as the crisis was beginning to unfold.

Boston 25 News anchor and investigative reporter Kerry Kavanaugh obtained a series of emails sent to employees beginning in early March. They reveal concerns about a shortage of PPE and staffing. But as the weeks went on, Kavanaugh found little information about residents getting sick and no mention, at least in writing, of anyone dying.

For weeks staff members of the home have been telling 25 Investigates they raised concerns and they believe no one was listening.

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The earliest communication we have is dated March 4. Management told staff: “We are still considered to be low risk in our area.”

They added there was a worldwide shortage of masks and a very small supply at the home.

“We have a very small supply of masks left in the facility. I ask that you only use a mask if you have NOT had the flu vaccine, have a cough or are working with a veteran who is ill and coughing.”

For the next 10 days visitors were still coming and going from the Holyoke Soldiers’ Home with few restrictions.

By March 17, management stated every staff member was deemed necessary to operate the facility: “Beginning tomorrow, March 18, 2020, every staff member’s core function has been deemed necessary to operate the facility.”

And there was another reminder to be mindful of supplies.

“Please be mindful of supplies, we are keeping a watchful eye on all supplies during this time.”

Erin Saykin, an employee of the home, spoke with 25 Investigates in early April about her experience caring for sick veterans that led her to contract COVID-19 herself.

“They kept telling some staff people this is just like the common flu, it’s no biggie,” Saykin told Kavanaugh. “We go in and out of the room to care for them whether to feed them or change them and put them to bed, all we had were these yellow thin gowns and yellow surgical masks.”

Saykin and at least three other workers at the home told us they believe administration didn’t take this virus seriously enough, including one nurse who asked to remain anonymous for fear of retaliation.

“Everybody was asking questions and not getting answers. We went to our union after that and asked many questions and received no answers to their replies for help,” the nurse said.

On March 19, managers told healthcare workers to order tests for flu and RSV for sick veterans first and only, if deemed necessary, order a test for COVID-19.

And there was another reminder of lack of supplies: “Please use products thoughtfully as we need our supplies to last.”

On March 20, admins acknowledged there was national emergency and that staff was working out of their comfort zone: “Thank everyone for understanding this is a national emergency and working out of our comfort zone.”

It was only then the emails we obtained show any mention of a move to isolate sick patients: “2S has been temporarily closed to prepare for the isolation needs.”

On March 22, Superintendent Bennet Walsh wrote to staff that a resident tested positive for COVID-19. This was the first official written communication that anyone was infected in the home.

“I write this letter to inform you that one of our long-term care residents tested positive for COVID-19. The Veteran is currently in quarantine in a private room," Walsh wrote.

Three days later another letter from Walsh; the first written communication that an employee tested positive for the virus.

“I write this letter to inform you that an employee working at the Soldiers’ Home tested positive for COVID-19," Walsh wrote.

On March 26, staff was told to report to work, even if they were exposed to COVID-19: “All HCP exposed to a COVID-19 positive veteran or co-worker are expected to report to work as usual ...."

On March 27, management acknowledged an outbreak. They wrote eight residents tested positive for COVID-19 bringing the total case count to nine: “Today, the Soldiers’ Home has had eight residents test positive for COVID-19, bringing the Home to a total case count of nine residents and one employee.”

Yet on March 28, staff was told they should wear N95 masks for an entire week even if caring for a positive or pending COVID case: “N95 masks can still be worn for one week even if caring for a positive or pending COVID case.”

"I believe that in my heart that if one person would have listened to what we were saying, half of this wouldn't be happening right now,” said another staff member, Carmen Rivera, who spoke to 25 Investigates earlier this month.

According to the communications we obtained, there is never any mention of a single veteran’s death. Sources told us they only knew by word of mouth that veterans were dying.

But, the mayor of Holyoke, Alex Morse, said the first residents began dying on Wednesday, March 25, but the home didn’t notify anyone until Sunday, March 29. On Tuesday, March 31, Massachusetts Health and Human Services Secretary Marylou Sudders shared a grim update with the state, 11 veterans had died at that time.

It was then the state took over control of the Soldiers’ Home and placed Superintendent Bennet Walsh on leave.

We asked Walsh to comment on these emails; his attorney referred us to a previous statement:

Governor Baker has initiated a full review of my actions as Superintendent of the Holyoke Soldiers’ Home. I am cooperating with this investigation and thus far I have been interviewed on two occasions by investigators. I am committed to full participation in the process.

There have been widespread reports in the media that state officials were kept in the dark about what was happening at the Soldiers’ Home during the COVID-19 crisis. These reports are false.

We provided updates on a daily basis, sometimes multiple times a day. These updates were by phone, text, email, conference calls and official report forms. These updates were made at various times to the staffs of the Secretary of Veteran Services (DVS), the Executive Office of Health and Human Services (EOHH) and the Department of Public Health (DPH).

Specifically, as of Friday afternoon March 27, we had notified state officials that:

28 veterans had exhibited symptoms of the coronavirus and samples had been collected and sent for testing

These 28 veterans were living in different locations

Test results for 13 had been received

10 veterans were positive and three were negative

Test results for 15 veterans were pending

Two veterans had died; one with a positive test result and one with test results pending.

Events were happening rapidly and these statistics were again updated in the early evening when the test result for the second veteran who had died was determined to be positive. There were now two confirmed coronavirus related deaths.

The first veteran who showed symptoms resided in North 1. The first veteran who died with a confirmed positive resided in North 2. These veterans were on different floors and physically separated from each other. It was clear that the virus was not confined to one area but was infecting veterans throughout the facility and our medical resources were stretched to the limit.

At mid-day Friday, March 27 I requested that National Guard medical personnel be sent to the Soldiers’ Home to assist our staff. That request was denied.

We also notified state officials that we were in a crisis mode regarding staff shortages. 25% of the workforce was not reporting to work. These work shortages, and the knowledge that our veterans were extremely vulnerable to the virus, were taking a toll on the staff who had reported for duty. I requested trained grief support counselors to assist our staff who were dealing with the hardest hit units.

The staff shortage was so acute, and the number of veterans with known or suspected COVID-19 so large, that the medical staff was forced to close some areas and place these men in the same unit. This action to “cohort” the veterans was reviewed with the Department of Public Health on Wednesday, March 25 and accomplished on Friday, March 27.

Between Friday night and Sunday morning, six more veterans died bringing the total number of deaths to eight. By Sunday afternoon we had determined that four deaths were positive for the coronavirus and four deaths had test results still pending. The delay in getting test results was frustrating to all. This information was reported to state officials on Sunday afternoon at about 4:30 p.m.

It is very disappointing to me that during this time of unspeakable horror the staffs at EOHH, DVS and DPH have remained silent and have let the lie that they didn’t know what was going on persist.

State officials knew that Holyoke needed as much help as possible. No one was kept in the dark.

It is gut-wrenching to observe the devastation the virus has caused my fellow veterans. These are men I helped to care for with affection and respect. I again express my sincere sympathy to their families.

In it, Walsh claims he requested the assistance of the National Guard on March 27 and was denied. And he claims he warned the state that staffing levels were so low that they had to combine units and risk exposing more veterans.

We also asked the state about what we found. In an emailed statement, a spokesperson with HHS responded:

“It is imperative that the Holyoke Soldiers’ Home provide a safe environment for the veteran residents, and the dedicated staff who serve them. Superintendent Bennett Walsh was placed on paid administrative leave effective March 30, and Val Liptak, RN, currently the CEO of Western Massachusetts Hospital, has assumed responsibility for the administration of the Soldiers’ Home. An onsite clinical command team comprised of medical, epidemiological and operational experts has been instituted, and they have assertively responded to the emergency situation and are continually making necessary changes on the ground to protect resident safety. The circumstances that led to the heartbreaking situation at Holyoke Soldiers’ Home are the subject of a full and impartial investigation ordered by the Governor, led by Attorney Mark Pearlstein.”


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