BOSTON (WBZ NewsRadio) — An independent investigation into the COVID-19 outbreak at Holyoke Soldiers' Home has found "deplorable conditions," and an overall failure of leadership at the facility where at least 76 veterans have died from the coronavirus.
The first of three separate reports into the outbreak at the Holyoke Soldiers’ Home was released on Wednesday, twelve weeks after it was ordered by Gov. Baker.
“This report lays out, in heartbreaking detail, the terrible failures that unfolded at the facility, and the tragic outcomes that followed," said Gov. Baker. "The report finds that under the leadership of Supervisor Bennett Walsh, the Holyoke Soldiers' Home failed to prepare, even before the COVID-19 pandemic occurred."
According to the independent report by Attorney Mark Pearlstein, the Holyoke Soldiers' Home leadership team made several critical errors before and during the pandemic response.
That included either ignoring or failing to properly implement most of the guidance from the Department of Public Health, the Department of Veterans Services, the VA, and the Center for Disease Control and Prevention, on how to prepare and protect residents form the spread of COVID-19.
The report said there were delays in testing for veterans who were showing symptoms of the virus, and there were delays in closing common spaces to prevent the virus' spread.
There was also a failure to stop rotating staff among units, and a misrepresentation of those facts on the ground.
Baker said there were "inconsistent policies and practice" concerning the use of personal protective equipment, despite the facility having supplies, and there was a failure to keep adequate records and proper documentation for residents.
The report also disclosed "multiple errors in judgement about infection control and resident care," which needlessly exposed residents to grave risk.
"This is particularly true with respect to the decision by senior leadership to combine two units of veterans," said Baker, "only some of whom were known to be COVID-positive, into a single consolidated unit, under deplorable conditions."
Gov. Baker said one social worker's recollection of the unit consolidation was "one of the most depressing and utterly shameful descriptions of what was supposed to be a care-setting that I have ever heard of."
Finally, Baker said there was "a total failure of leadership and complete lack of compassion for these vulnerable heroes."
Health and Human Services Secretary MaryLou Sudders said the absence of leadership at the Soldiers' Home "created a chaotic environment for staff, and devastating consequences for residents and their loved ones."
Sudders said the weekend the fatal decision was made to combine the two units of infected and non-infected residents, the Superintendent was not present, and staff were left to deal with the crisis.
Pearlstein's report also pointed a finger at Baker's own administration, finding "the Department of Veteran's Services did not properly oversee the Superintendent and his team" at Holyoke. Baker said that lack of oversight "contributed to the tragic failure" at the Soldiers' Home.
The report found there were two crucial positions left unfilled, which Baker said contributed to the failed pandemic response. One position was at the Soldiers' Home, and the other was at the Department of Veteran's Services.
Before the report was released on Wednesday, Baker accepted the resignation of the state Secretary of Veteran's Affairs, Francisco Urena.
Sudders said she had also accepted the resignations of Holyoke Soldiers' Home former Medical Director Dr. David Clinton, and Department of Veteran's Services General Counsel Stuart Ivimey.
Superintendent of the Chelsea Soldiers' Home, Cheryl Poppy, has been named Acting state Secretary of Veteran's Services.
According to Baker, immediate action has already been taken to also remove other unqualified staff from their positions at Holyoke Soldiers' Home.
The Baker Administration said it plans to implement all the recommendations included in Pearlstein's report, and the Governor said extra steps will be taken to upgrade the governance of the facility "tomorrow."
There will also be several measures outlined to address the trauma experienced by staff at the Soldiers' Home.
Since Val Liptak took over leadership at the facility on March 31st, Baker said conditions have been stable. On Tuesday, zero veterans in the Home tested positive for COVID-19.
Baker said his Administration is also moving to end the employment of Superintendent Walsh, and he plans to announce further reforms at the Holyoke Soldiers' Home soon.
There are two other investigations still underway into the outbreak at the Holyoke facility; one led by U.S Attorney Andrew Lelling, and the other by state Attorney General Maura Healy.
(Photo: Getty Images)