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Moving Beyond the Blame Game

Family members of veterans living at the Holyoke Soldiers’ Home didn’t need a 174-page review by a former federal prosecutor to tell them that something went terribly wrong at that facility in March and April, leading to the deaths of 75 residents.

But the report did what it was commissioned to do — analyze the facts concerning what happened at the home and come to a conclusion as to how this tragedy was allowed to play itself out and answer what was, for a time, the most pressing question about all this: ‘who is to blame?’

Indeed, in the wake of the deaths and hospitalizations at the Soldiers’ Home, Gov. Charlie Baker and the Legislature both used the phrase ‘get to the bottom of this’ (unofficially or unofficially) as the scope of the tragedy grew, as did the thirst for answers. And the report has certainly identified some people to blame.

Starting with state officials for not only giving the job of running the home to a veteran (Bennett Walsh) who had no experience leading a long-term-care facility, but then failing to provide adequate amounts of oversight to Walsh and others charged with the care of veterans. But Walsh is also singled out for triggering a series of decisions that allowed COVID-19 to race through the home, affecting residents and staff members alike.

With language that can only be described as heartbreaking, the report recounts the thoughts of one staff member after management merged two locked dementia units on March 27, a decision investigators described as a catastrophe: “[I] will never get those images out of my mind — what we did, what was done to those veterans … my God, where is the respect and dignity for these men?” Other staff members were quoted as saying, “all in this room will be dead by tomorrow.”

While the report is certainly a valuable document, the veterans who died, their families, and staff members who lived through this horrible tragedy want so much more than a document that chronicles what happened and assigns blame. They want and need for this catastrophe to lead to meaningful and permanent changes that will ensure that no one will ever say, ‘where is the respect and dignity for these men?’ again.

That is our hope as well, and while the governor and legislators sound sincere when they say this is their overriding concern with the regard to the Soldiers’ Home, we know from history that when stories disappear from the front pages of newspapers, the will to implement meaningful change dissipates.

We can’t allow that to happen in this case.

Changes proposed by the governor, including several not in the report, include creation of a consistent policy at Holyoke and its sister facility in Chelsea for the hiring of a superintendent; creating more oversight by hiring an assistant secretary within the state Department of Veterans’ Services who would serve as an executive director for the state’s two soldiers’ homes and report directly to the secretary of Veterans’ Services; expanding the board of trustees at both the Holyoke and Chelsea facilities from seven to nine and requiring that the two additions each have either a clinical or administrative background in healthcare; and, most importantly, perhaps, making immediate and long-term capital improvements to modernize residential units and furnishings to address infection control — renovations are currently underway on one floor, but a more comprehensive plan of modernization and improvements is certainly needed.

History also shows us that, following some of the worst tragedies in history — the Triangle fire in New York City, the Cocoanut Grove fire in Boston, and even the Titanic’s sinking — reviews that initially focused on laying blame eventually led to serious, and often historic, reforms.

If that can happen with the case of the Holyoke Soldiers’ Home tragedy, then perhaps those veterans who bravely served their country will not have died in vain.

COVID-19 Daily News

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.”

COVID-19 Daily News

HOLYOKE — Holyoke Medical Center (HMC) has welcomed 40 Holyoke Soldiers’ Home residents in response to a request for assistance from the Executive Office of Health and Human Services. In order to accommodate this request, the Birthing Center and the outpatient Cardiovascular Center at HMC have been converted to house these residents.

Holyoke Medical Center maternity patients will temporarily be delivering at the Family Life Center at Mercy Medical Center in Springfield. The outpatient Cardiovascular Center has also been temporarily relocated to 2 Hospital Dr., Suite 203, Holyoke.

“We were asked if we could accommodate Soldiers’ Home residents in our facility and are responding to the request to assist in any way we possibly can,” said Spiros Hatiras, president and CEO of Holyoke Medical Center and Valley Health Systems. “These are unprecedented times, and we have a duty to help any and all that need our assistance and an additional level of duty to assist our veterans.”

The Soldiers’ Home residents transferred to Holyoke Medical Center have screened negative for COVID-19.

“This request has been an opportunity for the staff at Holyoke Medical Center to once again shine,” Hatiras added. “I am incredibly proud of their efficiency and dedication to rise to any occasion, including their ability to convert two patient units within hours, accommodating 40 people to receive care.”

The Holyoke Medical Group obstetrics doctors and certified nurse midwives will be closely coordinating with their colleagues at Mercy Medical Center to maintain continuity of care for their patients while temporarily delivering at this alternate location.

Questions regarding labor and delivery through the Birthing Center can be directed to the outpatient office, Holyoke Medical Group Women’s Services, at (413) 534-2826. For questions regarding the Family Life Center at Mercy Medical Center, call (413) 748-7400.

COVID-19 Daily News

HOLYOKE — Gov. Charlie Baker announced on Wednesday that the Governor’s Office has hired attorney Mark Pearlstein to conduct an independent investigation of the Holyoke Soldiers’ Home and the events that led to the recent and ongoing deaths from COVID-19 within that facility.

The investigation will focus both on the events inside the facility that led to the deaths of veterans in the Holyoke Soldiers’ Home, and on management and organizational oversight of the COVID-19 response in the facility.

The state announced the deaths of two additional veterans at the Soldiers’ Home on Wednesday, bringing the total deaths of veteran residents to 15. Six of the deceased have been confirmed with COVID-19 so far, with other tests pending. In addition, 11 other veteran residents and seven staff members have tested positive.

Pearlstein has substantial experience in the investigation and trial of complex white-collar criminal cases and other government enforcement matters. He practiced as a federal prosecutor in Boston’s U.S. Attorney’s Office, where he served as chief of the office’s Economic Crimes Unit from 1994 to 1996, and was the first assistant U.S. attorney from 1996 until 2000, where he supervised the Civil and Criminal divisions of the U.S. Attorney’s Office. Currently, Pearlstein is a partner at McDermott, Will & Emery, where he concentrates his practice on white-collar criminal defense, defense of U.S. Securities and Exchange Commission actions, complex commercial litigation, arbitration, and internal investigations.

COVID-19 Daily News

HOLYOKE — The death toll at the Holyoke Soldiers’ Home is up to 13 veteran residents in the past week, at least six from COVID-19, while another 10 residents have tested positive for coronavirus, and 25 more are waiting for test results.

Holyoke Mayor Alex Morse called the situation at the Soldiers’ Home “unacceptable” and “a disservice to everyone who lives there.” 

In a statement, he noted that, “while I am grateful that the state is now taking swift action to ensure residents and staff get necessary care and treatment, I am grief-stricken for those we have already lost, and my heart goes out to their families and friends.”

Meanwhile U.S. Rep. Richard Neal is calling for accountability for what happened, noting that he has spoken to Massachusetts Secretary of Health and Human Services Marylou Sudders and the Massachusetts Nurses Assoc. to share his concerns about the conditions at the home and to learn more about their plans to move forward.

“I am heartbroken by the sudden loss of life,” Neal said when the first 11 deaths were reported earlier this week. “While the Commonwealth of Massachusetts manages the healthcare facility, I have always worked hard to secure federal assistance for the home because of the importance of their mission. The residents of the Soldiers’ Home have served their country with honor and distinction, and their health and safety, along with that of the staff, has always been top priority. This is even more personal to me because I have an uncle who is a full-time resident there. I was shocked to learn of these deaths.”

Bennett Walsh, the home’s superintendent, has been placed on leave, and Val Liptak, CEO of Western Massachusetts Hospital, has assumed responsibility for the administration of the facility. The state also assembled an on-site clinical command team comprised of medical, epidemiological, and operational experts responsible for rapid response to the outbreak.

COVID-19 Daily News

HOLYOKE — Eleven veterans at the Holyoke Soldiers’ Home have died between March 1 and March 30, at least five due to COVID-19. Eleven other veterans and five staff have tested positive for the virus, and 25 veterans are awaiting test results. Bennett Walsh, the home’s superintendent, has been placed on leave.

“It is imperative that the Holyoke Soldiers’ Home provide a safe environment for the veteran residents and the dedicated staff who serve them,” Health and Human Services Deputy Secretary Dan Tsai said on Monday. “Superintendent Bennett Walsh has been placed on paid administrative leave effective immediately. Val Liptak, RN, currently the CEO of Western Massachusetts Hospital, will assume responsibility for the administration of the Soldiers’ Home at this time.

“We have also implemented an on-site clinical command team comprised of medical, epidemiological, and operational experts responsible for the comprehensive and rapid response to the outbreak of COVID-19,” Tsai added. “All of these enhancements will build upon the existing protocols and work that align with Centers for Disease Control and Prevention, Department of Veterans Affairs, and Massachusetts Department of Public Health guidance. Today’s actions underscore the state’s commitment to our veterans and frontline healthcare employees during this unprecedented public-health crisis.”

In a tweet Monday, Gov. Charlie Baker said that, “as someone who has visited the Holyoke Soldiers’ Home on many occasions to catch up with staff and residents, I am heartbroken by today’s news. The loss of these residents to COVID-19 is a shuddering loss for us all.”

Holyoke Mayor Alex Morse issued a statement as well, noting that “this is a difficult day for our city, and it is almost certain that more difficult days will follow. Today is a painful reminder that, while many people will experience mild symptoms or no symptoms at all, there are those among us who are at much higher risk, and we must be vigilant in our care for ourselves to ensure the safety of all. I call on all Holyokers to consider your actions, to be sure to follow social distancing to the best of your abilities, to contact your friends and loved ones, and to take care of yourselves both physically and mentally. While we need distance from each other now, we are in this fight together.”

He added that Holyoke is receiving frequent updates from state health officals as the situation at the Soldiers’ Home unfolds, and he will continue to update the public with what he learns.

“It is in large part thanks to the outreach of staff from the state-run facility to my office on Saturday that I was alerted to the growing issues at the Soldiers’ Home,” Morse added. “I want to thank Lieutenant Governor Polito and Secretary of Health and Human Services [Marylou] Sudders for taking immediate action upon my request, but, most importantly, thank you to the nurses and staff at the Soldiers’ Home who cared for those whom we have lost, and who continue to care for those in need.”