Just a few pages into a report on the Holyoke Veterans’ Home... it’s hard to read. “A social worker ‘felt it was like moving the concentration camp—we [were] moving these unknown veterans off to die.’” @NBC10 the full report: https://www.mass.gov/doc/report-to-governor-baker-re-holyoke-soldiers-home/download

“While decisions made by the Home’s leadership team contributed to this tragedy... we do not find a failure of reporting or an effort to conceal cases or deaths from the Department of Veterans’ Services or EOHHS.”

The independents investigators wrote the worst decision made by the Holyoke Soldiers’ Home was made 3/27 — combining two locked dementia units ahead of a staff shortage. “The decision was a catastrophe.”

“There were ‘chairs of people lined up, some were clothed, some unclothed, some were wearing masks, some weren’t.’ A number of witness accounts suggest that veterans on the combined unit did not receive sufficient nursing care, hydration, or pain-relief medications.” (Page 11)

Report: the Department of Veterans’ Services did not take steps to address substantial & long-standing concerns regarding leadership. Supt. Bennett Walsh had no healthcare administration experience when appointed. High turnover & didn’t spend enough time there.

The report states the department saw “massive turnover” in Walsh’s staff and hired and executive coach to work on anger management & had to extend this appointment in response to more complaints.

Secretary of Veterans’ Affairs Francisco Urena resigns: https://www.nbcboston.com/news/coronavirus/secretary-of-veterans-affairs-resigns-ahead-of-holyoke-soldiers-home-report/2148148/

“It is possible—perhaps even likely—that even if the leadership of the Soldiers’ Home in Holyoke
had done everything right, and administered the Home consistent with public health guidance and long- standing infection control principles, COVID-19 would have nonetheless infected..

and event potentially claimed the lives of some veterans residing at the Home,” Mark Pearlstein wrote, along with the team at McDermott Will & Emery. The report wrote leadership’s errors “likely contributed to the scope of the outbreak, and its horrific toll.”