An independent report commissioned by Gov. Charlie Baker takes scathing aim at ousted Holyoke Soldiers’ Home superintendent Bennett Walsh, citing “baffling” decisions when COVID-19 first crept up on the facility — then killed a third of its residents over 11 weeks.
The report, authored by Boston attorney and former federal prosecutor Mark W. Pearlstein and released Wednesday, resulted in Walsh’s firing by the governor. Walsh, a decorated U.S. Marine Corps combat veteran who was paid $122,299 last year, had been suspended with pay since March 30.
In a statement Wednesday, Walsh’s attorney, his uncle and former Hampden County district attorney William M. Bennett, said, “We dispute many of the statements and conclusions in the report, to which we were never given the opportunity to rebut prior to publication. We are also disappointed that the report contains many baseless accusations that are immaterial to the issues under consideration. We are reviewing the report and will have more to say in the days ahead.”
He said legal action against the state is being considered as the firing “denies Mr. Walsh the opportunity for a fair and public hearing.”
Baker also sought and received the resignation of state veterans affairs secretary Francisco A. Ureña, himself also a Marine combat veteran. The report cited multiple failures by Ureña, who earned $131,716 last year, in his oversight of the Soldiers’ Home.
Within the 134-page analysis are vivid and disturbing accounts by staff who recounted a frantic afternoon on March 27. On that day, 40 veterans from two locked dementia units were crammed into one designed for 25. A single resident had tested positive for the virus nearly a week earlier and five more were awaiting results.
Some were ill. Some were well. Some were fully clothed. Some were not. Some were in the wrong beds, staff recounted. Employees worried they would lose track of which veterans were already sick or who remained healthy.
That hasty combination of two care units was held up as a “catastrophe” during a crisis response at the Soldiers’ Home that went wildly wrong, according to Pearlstein and his team of investigators. He called the decision “baffling” and “the opposite of infection control” in his report. He noted that every leader at the facility except chief nursing officer Vanessa Lauziere refused to take responsibility for the decision.
She blamed the decision on being short-staffed when employees began calling out sick, according to the report.
Some employees who were present for the combining of the dementia units said they were alarmed at the time and will remain haunted by what they saw there. “I will never get those images out of my mind — what we did, what was done to those veterans,” one staff members said, according to the report.
The report points the finger at inept management by Walsh, his senior nursing executive, and now-former medical director, Dr. David Clinton, who made $116,000 annually for a 20-hour a week job before recently being forced to resign. Along with Urena’s departure the night before the report’s release, the governor also received the resignation of the veterans’ affairs department’s general counsel, Stuart Ivimey, whose pay in 2019 was $111,250.
Pearlstein’s report was based on interviews with about 100 people — from Walsh to his senior staff, trustees, nurses, support staff and family members — plus an analysis of more than 13,000 documents.
The first veteran to test positive for COVID-19 began exhibiting symptoms in late February. By the time he was finally tested on March 17 — the results wouldn’t come in for another four days — he had been permitted to stay in a room with three other veterans, visit common areas and wander about the unit. By March 30, he and nine more had died in the space of a week; 66 more would die of the disease before the storm subsided. The report shows panic beginning to mount at the Soldiers’ Home in mid-March and eventually making its way to the governor’s office by month’s end.
Late-night and early morning texts and calls on March 29 and 30 were between Walsh, Ureña, officials with the Executive Office of Health and Human Services, Baker and Lt. Gov. Karyn Polito as more veterans died. There was confusion over the death toll, the report shows. At 7 a.m. on March 30, Walsh placed a phone call to Ureña, with whom he had never had the best relationship, according to the report.
“Mr. Secretary, I’m sorry I didn’t tell you about all these deaths,” Ureña, quoting Walsh, told Pearlstein of the brief conversation. Ureña told investigators he wished he kept Walsh on the line longer to determine “precisely what he was apologizing for.”
While general counsel Ivimey made a few cameos in the report, Ureña was strongly rebuked for looking the other way after, he told Pearlstein, he had years ago sized up Walsh as a bad manager who was “in over his head.”
Baker, at his press conference yesterday to discuss the report, confirmed Ureña had “gracefully agreed” to step down after Sudders asked for his resignation. The governor said his entire administration bore some responsibility for the collapse of the Soldiers’ Home while in the belly of the pandemic.
“The Department of Veterans’ Services and our administration did not do the job we should have done overseeing Bennett Walsh and the Soldiers’ Home,” he told reporters. “Veterans who deserve the best from state government got exactly the opposite.”
Baker signaled additional reforms with regard to staffing, capital improvements and some changes to the board of trustees to include members with medical expertise.
Kevin Jourdain, chairman of the Board of Trustees for the Soldiers’ Home, did not return a call for comment, although sources said he shared copies of the report with fellow trustees.
A group of grassroots advocates, including John Paradis, former deputy superintendent for the Soldiers’ Home, has renewed longstanding calls for reforms at the facility that predated the pandemic and some argue fell on deaf legislative ears for years.
“This must mean a path forward supported by a commitment to demonstrably improve the Home in three areas: staffing that ensures the utmost safety for veterans; the approval of a new or vastly improved facility in Holyoke that is state of the art and which meets the highest of standards in long-term care; and third a new governance and oversight model that is removed from politics and which truly serves the veterans,” Paradis said.
Family members of veterans who died of the disease said the release of the report placed them squarely back into a nightmare from which they had scarcely recovered. Susan Kenney, of Ware, emerged as a vocal advocate for families when she drove to the Soldiers’ Home on April 3 with a message scrawled on her car.
“Is my dad alive? Shame on the Soldiers’ Home, over 30 hours with no call back,” the message read. It was a period when families said they couldn’t visit the facility, but also couldn’t get through to staff, who were inside the walls and overwhelmed.
Her father, Charles Lowell, was alive on that day, she learned — but died eight days later. “His birthday was yesterday, and but for all this I don’t see any reason why he would not have made it,” Kenney said Wednesday.
She had been poring over the report all day. Some of the disturbing pictures painted by staff were familiar to her, through prior accounts from other families. Still, she hoped they weren’t true.
“This feels like it’s happening all over again, and we’re all exhausted again and it’s tough,” Kenney said. “But these are people who fought for our country and I want to see them get some kind of justice.”
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