BOSTON — An independent report on the outbreak COVID-19 at the Soldiers' Home in Holyoke that cost the lives of 76 veterans is "gut wrenching" to read and "utterly shameful," said Gov. Charlie Baker on Wednesday. 

 

"Today the loss of life is difficult to even think or speak about. The events that took place at the Holyoke Soldiers' Home in March, are truly horrific, and tragic," Baker said at a press conference on Wednesday. "COVID-19, as we all know, has claimed the lives of thousands of people in Massachusetts, and has been particularly devastating for long-term care facilities. ...

 

"But as this report reveals errors were made at the Holyoke Soldiers' Home before COVID-19, more errors were made in preparation for COVID-19, and still more errors were made during the home's initial clinical response to the pandemic in March."

 

The 174-page report by former federal prosecutor Mark Pearlstein was commissioned by the Baker-Polito administration as the full scope of the tragedy occurring at the nursing home became apparent in March. 

 

Superintendent Bennett Walsh was put on immediate administrative leave on March 29 and Secretary of Veterans Services Francisco Urena had been asked to resign by Baker ahead of the report's release on Wednesday. Baker called it an "abject failure of leadership" starting with superintendent and said steps are being made to remove Walsh permanently.

 

He also admitted that his administration and the Department of Veterans Services failed to properly oversee the facility.

 

The report found numerous failures in action and decisionmaking in the days before and after the first case of the novel coronavirus was identified. 

 

According to the report, "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 despite a statutory responsibility to do so."

 

In total, at least 76 veterans died from complications of COVID-19 at the 300-bed nursing facility and 84 veterans and more than 80 staff tested positive. 

 

Val Liptak, a registered nurse and chief executive officer of Western Massachusetts Hospital, was appointed as interim administrator.  

 

"Val and her team have done a tremendous job of creating a safer long-term care facility for students and staff," said Baker. "Yesterday, zero veterans across the home tested positive for COVID-19."

 

Secretary of Health and Human Services Marylou Sudders said many of those "responsible for this tragedy" have been off the job for months now.

 

The report notes that at least 80 nursing homes had more than 20 cases of COVID-19 and that the Soldiers' Home has a mortality rate of 10 to 12 veterans a month. These facts point to the vulnerability of nursing home patients. 

 

"Our analysis of the Home's preparations for and response to COVID-19 in light of existing public health recommendations has identified substantial errors and failures by the Home's leadership that likely contributed to the death toll during the outbreak," the report states. "Indeed, 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, and were inconsistent with the Home's mission to treat its veterans with honor and dignity."

 

Sudders said a lack of leadership at the home "created a chaotic environment for staff and devastating consequences consequences for residents." She particularly pointed to a decision to consolidate units that exacerbated the crisis.

 

The investigation by Pearlstein was done for free with the state funding $26,000 for a staffing study. 

 

Pearlstein and and his team conducted 111 interviews with 100 witnesses and reviewed more than 17,000 pages of documents.

 

"I want to thank Mark and his team. Their exemplary work, the subject matter and details of this report, are nothing short of gut wrenching," the governor said. "In fact, this report is hard to read some of the decisions that were made by those in charge of this Holyoke are in Mark Pearlstein's words, 'utterly baffling.'

 

"Today the loss of life is difficult to even think or speak about the events that took place at the Holyoke Soldiers' Home in March, are truly horrific, and tragic."

 

The report also outlines recommendations that are being or have already been instituted. Officials said further legislation will be filed to reform governance of the facility.

 

"We'll also be outlining several measures to address the trauma the staff have experienced their working conditions," said Baker. "There are very dedicated group of individuals and other professionals at that facility, who haven't had the support that they deserve to do their jobs."