Here are five key takeaways from the report.
1. The “worst decision” - The 174-page report, compiled by a team led by former federal prosecutor Mark W. Pearlstein, found the “worst decision” at the home came Friday, March 27, when staff combined two locked dementia units containing veterans with a mix of COVID-19 statuses.
The decision, which the report called a “catastrophe,” created “close to an optimal environment” for the deadly disease to spread. The decision was made in the afternoon after several workers called out sick for the evening shift, the report said.
Witnesses indicated veterans on the combined unit didn’t receive “sufficient nursing care, hydration, or pain-relief medications” that weekend. In addition, the report said, several days before and after the units were combined, Chief Nursing Officer Vanessa Lauziere told social workers to call veterans’ families to “persuade them to change their end-of-life healthcare preferences, such that they would not be transferred to the hospital.”
2. Failure to quickly isolate patients suspected of having COVID-19 - According to the report, staff failed to promptly isolate compromised patients in “rooms set aside for isolation.” Investigators cited a “perception” that the Home didn’t have enough “dedicated nurses or nursing aides” to monitor veterans if they were placed in a designated isolation unit.
Between March 17 and March 30, the report said, “dozens of residents of the Soldiers’ Home were tested because they were suspected of COVID-19, but in every instance they were allowed to remain in their units, posing continued infection risks to their asymptomatic neighbors. Even positive test results did not prompt meaningful changes in approach, as such residents were still allowed to remain in their units.”
3. Troubling staff rotations - The report found the Home failed to keep staff members from rotating or “floating” from unit to unit, which poses a “substantial and obvious transmission risk.” On March 29, the report said, state Veterans’ Secretary Francisco Urena sent a series of text messages to Home Superintendent Bennett Walsh asking whether he ensured staff in the infected units weren’t being floated to other areas.
Walsh, the report said, replied that staff had “done that for two weeks, attempt to keep same staff on same unit.” Not true, according to the report, which cited a nurse who “recalled that even after Veteran 1 tested positive, nursing aides would be scheduled to work two hours on 1-North and then directed to complete their shift on the third floor. ... A number of staff members who floated from unit to unit later tested positive for COVID-19.”
Walsh was placed on paid administrative leave shortly after the crisis publicly surfaced. Urena abruptly resigned Tuesday.
The report said investigators found Governor Charlie Baker and Lieutenant Governor Karyn Polito first learned of the “evolving crisis” at the Home on the evening of Sunday, March 29, after Holyoke Mayor Alex Morse informed Polito, who alerted Baker. Walsh was placed on leave the following day and Val Liptak was named acting administrator of the Soldiers’ Home.
4. Inconsistent protocols and practices surrounding personal protective gear - Investigators said the interim administrator who arrived at the Home on March 30 observed “some staff with gowns but no masks; some with only masks; and some with only gloves on. Her initial assessment was that there was ‘no understanding of what the infection control guidelines were.‘“ In addition, the report said, workers reported inconsistent policies on gear, especially masks and gowns, and that the Home “took steps to make it more difficult to access such equipment.” At least 80 staffers contracted COVID-19, the report said, “likely due at least in part as the Home’s failure to provide and require the use of proper protective equipment.”
5. Walsh was unqualified to run the Home and the Department of Veterans’ Services failed in its oversight - State law requires people who run long-term care facilities to be licensed nursing home administrators, but the Mass. Department of Public Health considers the Soldiers’ Home to be exempt since it’s a state-run entity, according to the report.
Walsh, the report said, lacked the appropriate license “or any experience whatsoever in managing a healthcare facility.” After a distinguished military career, the report said, he initially sought a job as a security consultant at MGM Casino in Springfield but changed his mind after a state legislator “suggested he apply to run the Soldiers’ Home, and assured him that his lack of clinical experience would not be an impediment.”
The report also said the Department of Veterans’ Services “did not take steps to address substantial and long-standing concerns regarding the leadership of the Soldiers’ Home.”
“A key oversight function is to make sure the right people are in important jobs. ... The Department of Veterans’ Services leaders did not believe Mr. Walsh was the right person for the job, but they did not take action to assure that there was competent leadership in place at the Soldiers’ Home,” the report said.
Globe Correspondent Jeremy C. Fox contributed to this report.