An independent report on the coronavirus outbreak at the Holyoke Soldiers’ Home describes “the opposite of infection control,” as administrators combined wards of infected and uninfected patients.
BOSTON — An investigation of 76 deaths linked to the coronavirus at a state-run veterans’ home in Massachusetts paints a picture of a facility in chaos, as traumatized nurses carried out orders to combine wards of infected and uninfected men, knowing that the move would prove deadly to many of their patients.
Workers at the facility, the Holyoke Soldiers’ Home, remembered the days in late March as “total pandemonium” and a “nightmare.”
One social worker told investigators, in a report released on Wednesday, that she “felt like it was moving the concentration camp, we were moving these unknowing veterans off to die.”
Another recalled sitting in a makeshift ward that was crowded with sick and dying patients, some unclothed or without masks, and trying to distract a man who was “alert and oriented,” chattering about the Swedish meatballs his wife used to make.
“It was surreal,” she said. “I don’t know how the staff over in that unit, how many of us will ever recover from those images.”
Nursing home deaths have accounted for more than 60 percent of the fatalities from the coronavirus in Massachusetts, a state that prides itself on its health care system. None of those deaths have received more attention than the cluster at the Holyoke Soldiers’ Home, which housed frail veterans of World War II and other conflicts.
The 174-page independent report, led by the former federal prosecutor Mark Pearlstein, blasts decisions made by the facility’s superintendent, Bennett Walsh, as “utterly baffling from an infection-control perspective.”
The report was especially scathing on the decision to combine crowded wards. But it catalogs a series of other errors, including failure to isolate infected veterans, failure to test veterans who had symptoms, and the rotation of staff members between wards, accelerating the spread of the virus.
“In short, this was the opposite of infection control: Mr. Walsh and his team created close to an optimal environment for the spread of Covid-19,” the report said.
Gov. Charlie Baker of Massachusetts said on Wednesday that the accounts in the report were “one of the most depressing and utterly shameful descriptions of what was supposed to be a care system that I have ever heard of.”
The state is acting to fire Mr. Walsh, a retired Marine Corps lieutenant colonel with no previous nursing home experience, the governor said. A lawyer for Mr. Walsh was not immediately available for comment.
Mr. Walsh’s supervisor, Francisco Urena, resigned from his post as the state’s secretary of veterans’ services on Tuesday in anticipation of the report. Mr. Baker said the secretary was asked to step down.
“Our administration did not do the job we should have done overseeing Bennett Walsh and the Soldiers’ Home,” Mr. Baker said.
“I’m very sorry,” Mr. Urena told a reporter for WCVB, a local television station. “I tried my best.”
Staff members told investigators that they were initially discouraged from wearing protective equipment, in an effort to conserve a limited supply, and that they felt “annoyed, paranoid and fearful for their lives because they could not find masks,” the report said.
The most troubling portions of the report describe the weekend of March 28 and 29, when staffing was so short at the home that two wards were hurriedly combined, a decision one employee described as “the most insane thing I ever saw in my entire life.”
A social worker described listening to the chief nursing officer say “something to the effect that this room will be dead by Sunday, so we will have more room here.” Another social worker recalled seeing a supervisor point to a room and say, “All this room will be dead by tomorrow.”
Several staff members told investigators that, in the confusion, some of the dying men did not receive adequate pain relief medication.
None of the facility’s top administrators acknowledged taking part in the decision to combine the two wards, and its medical director, David Clinton, told investigators he was not consulted.
“We find this not to be credible, and at the very least, that Dr. Clinton was aware (or should have been aware) of the move and did nothing to stop it,” the report said.
Val Liptak, the interim administrator brought in to manage the crisis, told investigators that, though she and her team had a “collective 90-plus years of nursing” among them, “none of us have ever seen anything like this.” The overcrowded ward, she said, “looked like a war zone.”
Among the disturbing revelations in the report was that supervisors had instructed social workers to call the families of sick veterans and try to persuade them to change their end-of-life health care preferences, so that the veterans would not be transferred to a hospital.
One social worker said she stopped making those calls because “it felt wrong,” as she put it, “in the pit of my belly and heart.”
