What happened at the Holyoke Soldiers’ Home was more than “gut-wrenching,” to use Governor Charlie Baker’s words. What happened there was sickening — and years in the making, on Baker’s watch.
A facility that is supposed to be a destination of comfort and honor for veterans turned into a death trap for 76 residents who died of COVID-19. Because of terrible decision-making by the facility’s superintendent, Bennett Walsh, the staff ended up “walking (the veterans) to their death,” as one nurse described it in the harrowing 174-page report prepared for Baker by attorney Mark Pearlstein.
That death march occurred as some 40 residents of two locked dementia units were crowded into one room; some had COVID-19, some did not. The results were “a catastrophe,” the Pearlstein report concluded, leading to one of the highest coronavirus fatality counts at a long-term care facility in the country.
“The choices that Mr. Walsh made or approved show that he was unqualified to lead the Soldiers’ Home. The clinical staff made the wrong clinical decisions and Mr. Walsh failed in his duty to oversee them and ensure a robust decision-making process,” states the report.
Yet from reading the report, it’s clear that the terrible chain of events started back in 2016, when Walsh, a politically connected veteran with zero experience in health care or long-term care administration, was hired for the superintendent’s job. Baker is blaming the Soldiers’ Home board of trustees for Walsh’s hiring. But Marylou Sudders, Baker’s secretary of health and human services, signed off on it, and the governor swore him in.
Within months, officials including Sudders began to receive reports of Walsh’s deficiencies as a leader, which included anger problems, absences from the office, and reluctance to allow unannounced visits from his supervisor. The administration got him executive coaching to help with anger management — but left him in the job.
The Baker administration also knew of long-term staffing deficiencies at the facility, including a 2019 report Sudders ordered that showed nurses struggled to find help moving disabled patients. But nothing was done about staffing.
The administration also allowed a key leadership position — a deputy with real health care experience — to stay vacant in the months before the outbreak. And the Baker administration’s decision to let the leadership problem fester, rather than find a new superintendent, set the table for the tragedy that unfolded in March.
Baker said this week that the administration is moving to fire Walsh, who was put on paid administrative leave when the deaths started mounting at the Soldiers’ Home. Meanwhile, Francisco Ureña, the secretary of veterans’ services, has resigned and is taking the fall for all that went wrong in March. But the Pearlstein report shows that during the pre-pandemic years, Ureña flagged problems about Walsh that should have triggered action by the Baker administration. For example, once when Ureña arrived at the Soldiers’ Home unannounced, Walsh called Sudders to object and suggested he must seek permission from Walsh before coming to the facility. Ureña also told Pearlstein that he and Sudders were concerned Walsh didn’t spend enough time at the facility.
Despite those red flags, plus a temperament that may have contributed to high staff turnover, Walsh still had some kind of strange power over the Baker administration. As disaster unfolded at the Soldiers’ Home, Sudders finally told acting HHS secretary Dan Tsai: “Just fire him. I’ll take the heat.” At that point, with bodies of veterans piling up in a refrigerated truck, what heat was there to take? From whom?
On Thursday, Baker announced reforms to strengthen oversight and governance at the Soldiers’ Home, including a stipulation that a new posting for the position of superintendent will include a “preference for hiring a licensed nursing home administrator.” The Baker reforms are important, but the administration didn’t heed the recommendations of Pearlstein’s report about making the relevant background a requirement for the administrator. That leaves the position open yet again for another purely political appointment.
The administration will also submit proposals to the Legislature to change the way the home is governed. Lawmakers should ensure that this and future governors appoint health care professionals to lead the institution, without regard to local political considerations.
Veterans who live there deserve no less.
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