An independent investigation at the Soldiers House in Holyoke, Massachusetts, a government agency where more than 90 residents have died since death. coronavirus pandemic he began, discovered that the “material errors” and the “completely incomprehensible” decisions of the leadership of the house probably contributed to the tragedy.
The investigation report, however, states that house management, including the ousted superintendent Bennett Walsh, did not hide the situation.
“Our analysis of the preparation of the House to respond to COVID-19 in the light of the existing public health the recommendations identified significant errors and disruptions on the part of the leadership of the Ministry of the Interior, which probably affected the death toll during the outbreak, “the report said Wednesday, signed by lawyer Mark Perlstein, a former federal prosecutor.
“Indeed, some of the critical decisions made by Mr. Walsh and his management team during the last two weeks of March 2020 were completely incomprehensible in terms of the fight against infection and did not correspond to the mission of the House to treat their veterans with dignity and dignity “report added.
Ninety-two veterans died in the soldier’s house – nearly 40 percent of the population. 76 of those who died gave a positive result on COVID-19.
The investigation was ordered by Governor Charlie Baker.
The report describes the “most significant mistake” of management – the decision of March 27 to transfer all veterans from one closed unit for dementia to another.
At that time, there were several veterans in each unit who were found to have positive COVID-19, some of whom were suspected of having the virus, while others showed no symptoms, according to the report.
Instead of isolating people with COVID-19 from those who did not have symptoms, more than 40 veterans “gathered in a place designed for 25 people,” the report said.
“This overpopulation was the opposite of infection control; instead, he was exposed to an asymptomatic risk of becoming infected with COVID-19, ”the report said.
The employees who were interviewed for the report spoke of a difficult situation.
A recreational therapist assigned to help relocate said she felt she was “walking” [the veterans] until their death ”and that the veterans were“ terrified ”.
The social worker said she “felt like a concentration camp move — we [were] take out these unknowing veterans to die. Another described the unit as resembling a “war zone”, some veterans were dressed, some were stripped, and some were clearly dying from COVID-19.
Other errors in the house included delays in closing common areas, inability to stop staff rotation between units, inconsistent personal protective equipment and practices, and malfunctioning of records and documentation.
“Even the best drugs and the most thorough response cannot eliminate the threat of COVID-19. But this does not justify the inability to plan and implement on the basis of long-term principles of infection control and to seek outside help when necessary to ensure patient safety – indeed, the extreme danger of COVID-19 makes these steps even more important. ” The report said.
The report helped answer a long-standing question about what happened so tragically wrong in the house.
Staff previously told ABC News that in the early days of the pandemic, employees were not given face masks. They also said that some residents were moved to other rooms, leading to overcrowding and possible further spread.
Family members said they were struggling to contact someone at home when the virus began to spread in late March.
One daughter is a veteran of the house, Susan Kenny, told ABC News she waited several days to hear about her father’s condition after she found out about the first COVID-19 case in the house.
She said that in the end she decided that she would go home herself. Kenny made sure the staff noticed her, so she drew 12 words in her car: “Shame on you, soldiers house. 30 hours passed without a callback. ”
Kenny’s father eventually tested positive for COVID-19 and died on April 15th.
Bennett Walsh, a lawyer for the ousted chief of Soldiers House, said at a May press conference that Walsh was not keeping anyone “unaware” of the growing crisis inside.
Attorney William Bennett, who is also Walsh’s uncle, repeatedly insisted that Walsh took several steps to notify state and local officials of the growing number of cases of COVID-19 infection among veterans, but that Walsh’s medical requests for the institution were rejected .
Bennett wrote in a statement released Wednesday evening that he and his client were “disappointed that the report contains many unfounded allegations that are not relevant to the issues at stake.”
The lawyer added that he and his client “dispute” the findings of the report, arguing that they “were never given the opportunity to refute before publication.”
He noted that the investigation “establishes the initial allegations that Mr. Walsh did not tell government officials anything and tried to keep everyone in the dark, is false.”
Walsh was placed on paid administrative leave on March 30 after government officials visited the facility.
A report released Wednesday found that Walsh was not “qualified” to run a long-term care facility. The report also noted that its “shortcomings were well known to the Department of Veteran Services”, but the agency was not able to effectively control the house during his tenure, despite the statutory responsibility for this.
There are three other investigations ongoing into the house and its response to the COVID-19 pandemic.