Report: ‘Hell broke loose’ after series of leadership errors at Holyoke Soldiers’ Home

BOSTON — The leadership team at the Holyoke Soldiers’ Home made a series of catastrophic errors that lead to an unthinkable death toll at the facility from a COVID-19 outbreak, according to a damning report released Wednesday morning by the state.

The report, compiled by a team of independent investigators hired by the governor’s office, indicates a COVID-19 outbreak may have been unavoidable at the facility, but the errors made by a small leadership team led to a “horrific toll” of 76 veteran deaths.

The first major error, and most egregious, according to the report, involved combining two dementia units due to low staffing on March 27. That decision was made by Chief Nursing Officer Vanessa Lauziere, who took sole responsibility, the report states.

This decision was a catastrophe. Staff described the move as “total pandemonium,” “when hell broke loose,” and “a nightmare.” One staff member remembered thinking, “How can they do this because this [is] the most insane thing I ever saw in my entire life.” She “felt it was like moving the concentration camp—we are moving these unknowing veterans off to die. I will never get those images out of my mind—what we did, what was done to those veterans.” Other witnesses, including the Interim Administrator brought in three days later to stabilize the situation, described the combined unit as resembling a “war zone.”

—  The COVID-19 Outbreak at the Soldiers’ Home in Holyoke Final report

“In short, this was the opposite of infection control: [Superintendent Bennett] Walsh and his team created close to an optimal environment for the spread of COVID-19,” the report states.

According to the report, the combination of units was not necessary and many of the patients could have been transferred out of the home for acute care elsewhere.

“Within hours of arriving on March 30, 2020, the Commonwealth’s emergency response team assessed the acuity of the patients and quickly sent many of them to hospitals and other acute-care facilities. The same option was available to Mr. Walsh and his team,” the report states.

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The second error came when staff failed to “promptly isolate patients suspected of COVID-19 using the rooms set aside for isolation.”

We conclude that the leadership team at the Soldiers’ Home made a number of serious errors during the COVID-19 outbreak that likely contributed to the scope and severity of the outbreak. Our investigation has determined that Superintendent Bennett Walsh, Chief Nursing Officer Vanessa Lauziere, and Medical Director Dr. David Clinton were the primary decision-makers during this period—and that Mr. Walsh and Ms. Lauziere excluded others (including the designated Infection Control nurse, Vanessa Gosslin) from participating in critical decisions.

—  The COVID-19 Outbreak at the Soldiers’ Home in Holyoke Final report

According to the report, Superintendent Walsh was notified as early as March 12 that anyone with symptoms should be isolated. But the isolation rooms created after that notification were never used -- even when the first veteran with apparent COVID-19 symptoms was tested for the disease on March 17.

Further testing was then delayed until after that first veteran’s test results came back positive, according to the report. This delay led to the unfettered spread of the virus as leadership at the home made its third grave error, the report notes.

It had been recommended on march 13 that all nursing home facilities close all common areas, but veterans at the Holyoke Soldiers’ Home were allowed to congregate in common recreational spaces through March 16, just a day before the first veteran was tested for COVID-19.

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Additionally, “the leadership of the Soldiers’ Home failed to prevent the rotation or “floating” of staff members from unit to unit.” Guidance stating that staff should refrain from rotating through units was distributed as early as March 6 and the report states, “this guidance was never implemented, and that the Soldiers’ Home made no serious effort to implement it.”

Further record-keeping failures and inconsistent policies related to personal protective equipment led to more spread of the disease, according to the report.

“When the response team arrived to take command of the Soldiers’ Home on March 30, 2020, they found an organization in staff member was disciplined in writing for using personal protective equipment while treating a sick veteran, the day after he provided care to Veteran 1,” the report stated.

The report outlined the ways the leadership of the Holyoke Soldiers’ Home was unprepared and unqualified.

“We find that the Department of Veterans’ Services and its leader, Secretary [Francisco] Urena, should have responded to a series of warning signs and concerns about the administration of the Soldiers’ Home in the years and months leading up to the COVID-19 outbreak,” the report states. “We find that the Department of Veterans’ Services did not take steps to address substantial and long-standing concerns regarding the leadership of the Soldiers’ Home.”

In a noon address to the media Wednesday, Gov. Charlie Baker said his administration had begun taking steps to remove unqualified staff from leadership teams at veterans homes. That began when Baker accepted the resignation of Secretary Urena Tuesday evening.

The Soldiers’ Home leadership team did not do everything right—in fact, they made substantial errors in preparing for and responding to COVID-19. We conclude that these errors likely contributed to the scope of the outbreak, and its horrific toll. Likewise, we conclude that as a result of these errors, the Soldiers’ Home fell short of its mission to provide “care with honor and dignity.

—  The COVID-19 Outbreak at the Soldiers’ Home in Holyoke Final report

Massachusetts Attorney General Maura Healey is also investigating to determine if legal action is warranted, she said. And the U.S. attorney’s office in Massachusetts and Department of Justice’s Civil Rights Division are looking into whether the home violated residents’ rights by failing to provide them proper medical care.


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