The Vietnam war veteran in the Holyoke Soldiers’ Home’s dementia unit had been coughing for days. Finally, his coronavirus test results arrived: positive.
But instead of isolating the 78-year-old patient to protect the home’s other elderly veterans from the contagion, managers said they were short-staffed and needed to combine his unit with another. That left about 40 men crowded in a wing, with nearly a dozen sleeping in a dining room, according to five employees of the state-run elder care facility.
That decision, the employees said, was one of several grave missteps that allowed the virus to race virtually unchecked through a state-run home that had been placed on high alert to protect its elderly, infirm residents against a pandemic.
Managers also ordered caregivers to move between the infected unit and others without adequate protective gear, and threatened to discipline workers or dock their pay if they called in sick, the employees said.
The results were tragic, if all too predictable. Since late March, 21 veterans have died at the home, one of the largest fatal outbreaks in Massachusetts, and a grim echo of the contagion at a Kirkland, Wash., nursing home that killed at least 37 people.
In Holyoke, 15 of the deaths have officially been linked to COVID-19 to date, and at least 59 more veterans and 18 staff have tested positive. Results for dozens of others are pending.
“They infected the whole floor because they were understaffed — they made stupid decisions,” said a caregiver who worked in the infected unit and, like the other employees, spoke on condition of anonymity for fear of retaliation.
The lapses were not just born in the moment. They were years in the making, employees said, a legacy of understaffing and mismanagement that state officials did little to address, even as the medical needs of residents became far more complex, according to interviews with current and former employees and a Globe review of state records and published reports.
The systemic problems left the home for Massachusetts veterans — with 250 residents, one-third of whom are 90 or older and need substantial round-the-clock care — ill-equipped to handle a public health crisis of this magnitude, workers said.
“They were on very shaky footing,” said Cory Bombredi, with Service Employees International Union Local 888, which represents the home’s employees.
Since 2015, employees, union representatives, and former leaders have repeatedly warned the state that the home desperately needed more caregivers and nurses to keep veterans safe. In 2016, top leaders stepped down to protest the state’s lack of support.
“I resigned because of the failure of the state to truly understand the human, physical, and financial resources necessary to accomplish our mission to provide the best possible care for veterans,” said John Paradis, the home’s former deputy superintendent.
For years, records show, nurses have routinely been forced to work overtime shifts to cover staffing gaps, leading to high employee burnout and turnover.
“We’ve long had a staffing crisis. This just magnified it,” a nurse said this week while she was retrieving donated N95 masks from a friend. Managers tried to make her work an unscheduled double shift that day, but she refused.
As of March 14, the facility had 344 employees — 34 fewer than during that same time in 2015, according to state comptroller data.
In normal times, understaffing is linked to poor care that can result in bedsores and falls. But during an infectious outbreak, that dynamic turns far deadlier. Rushed staff may not have time to properly sanitize their hands and gear between patients. Quarantine areas require more aides.
“There’s a very direct connection: Understaffing can set things up for infection problems," said Robyn Grant, public policy director at the National Consumer Voice for Quality Long-Term Care.
State officials did not learn about the severity of the outbreak until five days after the first casualty on March 24, after an anonymous tipster and the union raised alarms. By then a 53-foot refrigerated truck had been placed in the home’s parking lot to accommodate the growing number of deceased.
On Monday, Governor Charlie Baker’s administration placed the facility’s superintendent, Bennett Walsh, on paid administrative leave and hired a former prosecutor to investigate the home, the events that led to the outbreak, and why the home failed to notify public health officials as conditions worsened.
Asked this week whether the state had properly overseen the facility, Baker did not directly answer. He said he expects the investigation to be conducted “by a trained professional who has an outstanding reputation who I believe will give us what we want, which is answers to what happened there, what went wrong and why, and to make sure that it doesn’t happen again."
Walsh did not respond to a request for comment but in a statement this week defended his leadership, saying the managers sought to follow federal and state coronavirus guidelines.
“Our focus then, and always, was on the veterans and their families,” Walsh said.
State officials said the home took steps since March 14 to prevent an outbreak by barring visitors from entering the facility and screening staff for fevers.
But workers said the measures fell short, as they had to ask permission to use personal protective equipment such as gloves, gowns, and masks — and managers often said no, even after the home tested its first veteran for COVID-19.
Across the country, the pandemic has laid bare longstanding vulnerabilities in the elder-care system.
With a mission to provide “care with honor and dignity,” the Holyoke home has sought to provide a safe place for veterans to live out their final years. But in the chaos as the virus spread through the building, “all dignity has been thrown out of the window,” according to one nurse.
Back in February 2015, then-superintendent Paul Barabani cited that mission in a memo sent to Francisco Urena, the state’s secretary of veterans’ affairs, warning that “current staffing levels are inadequate and jeopardize patient safety and quality of care.” Barabani detailed how the current budget was insufficient to properly staff the units and meet the recommended national staffing standards. The home requested funds to hire 17 more full-time employees to “stop the bleeding" and 45 more to meet all the needs of the veterans and ensure quality care. But the home received no help, said Paradis, then the home’s deputy superintendent.
Within months, 48 seasoned employees, 26 of them in nursing positions, were gone after taking early retirement through an incentive program aimed at saving $170 million across state government.
The next year, Barabani, Paradis, and a third top administrator stepped down in protest.
“We continue to see an intense layer of challenges that require individualized care and greater numbers of nurses,” Paradis wrote in his resignation letter to the trustees.
Paradis said they warned state officials that the staffing situation would become more dire as residents — largely Vietnam War veterans — aged and their health needs increased.
The facility’s budget, which stayed relatively stable in recent years, has long been insufficient to handle those changes, he said.
Unlike its sister facility in Chelsea, where half of the residents live independently, the Soldiers’ Home is primarily a long-term medical care facility. Last year, 91 percent — or 232 — of its veterans needed help with daily activities such as eating and using the bathroom, according to a state report. Chelsea housed just 134 long-term patients in 2019, yet received $28.7 million in state funding. Holyoke received $23.9 million.
Baker appointed Walsh as superintendent in May 2016. Staffing issues continued. An audit released in 2017 revealed the facility lacked documentation that it had performed mandatory daily inspections of long-term nursing care areas, and raised concerns about nurses’ overtime.
Union members met with Secretary of Health and Human Services Marylou Sudders in December 2018 and blamed management for causing high turnover by allowing understaffing to persist, forcing excessive overtime, and creating a hostile work environment, employees said.
Sudders tapped Suffolk University to assess the facility’s staffing plan in interviews with roughly 75 employees.
In the study, completed last June, nurses reported struggling to find colleagues on their units who were free to help disabled patients out of bed and use the bathroom. Nursing assistants said they were forced to leave their units to help out in the dining room. All the while, management reported that staffing was sufficient and said nurses needed to increase their productivity, according to the study.
Management discussed the Suffolk report’s recommendations to ensure proper staffing levels at many meetings, but never acted on them, said Andrea Fox, an associate director with the Massachusetts Nurses Association, which represents 40 of the home’s nurses. The shortages persisted through March, when the worst-case scenario some had warned of was realized.
“They float us around the building to make up for shortages. So you might have been safe and then you had to go down into the unit where we have multiple positives and then the next day you’re in another unit,” said the nurse who refused the night shift.
She described veterans being crammed four to a room to compensate for absent staff. In recent days, she said, some beds were blocking bathroom doors. Patients who typically had private phones now had to share with roommates and couldn’t call their loved ones often, or at all.
“People are dying and they are dying alone,” she said.
Under ideal staffing levels, one nursing assistant would oversee five to six residents, employees said. But in reality, they said, each aide often oversees eight to 10 residents, even in the dementia units.
Cyndy Minnery, a long-term care administrator in California and expert witness in lawsuits against senior care facilities, said the industry standard for skilled nursing facilities, like Holyoke Soldiers’ Home, is to staff one caregiver for every six patients. Memory care units may require one assistant for every four residents, she said.
Now, staffers at the Holyoke home face the grim task of hauling the bodies of their beloved veterans to a refrigerated truck outside the building. Many break down in tears during their shifts, their sadness deepened by a sense of betrayal that the home’s leaders, and their state regulators, should have acted sooner to protect those who served their country.
“We have to go in and see those veterans we’ve grown to love because we’ve cared for them for so long and they’re suffocating,” said one caregiver, fighting back tears. “They can’t breathe, and that’s literally how they die.”
Naomi Martin can be reached at firstname.lastname@example.org. Hanna Krueger can be reached at email@example.com. Follow her on Twitter @hannaskrueger.