An independent report on the Holyoke Soldiers Home and it response to the Covid 19 outbreak at the facility that claimed more than 75 lives has been released.
The 173 page report does not legally assign blame or fault but lays out some of the shortcomings. The report, written by former federal prosecutor Mark Pearlstein says that the Home “did not do everything right, in fact errors were made.
The report concludes only that the mistakes “likely contributed” to the outbreak of the Covid19 virus.
Among other things the report calls for better education and training of staff. It concludes that better planning was needed to deal with the outbreak. The report says that the decision to combine two units in which there were positive and negative ovid cases. The report calls that “opposite of infection control.”
The report says that it was incorrect that there were staffing shortages. The report says that within hours of its appearance at the Soldiers Home they assessed patients and sent the sickest ones to hospitals. The report says ”the same option was available to ....the staff.”
The report also says that the hospital did not adequately isolate patients. That it delayed closing common spaces. In addition the report says that it was a mistake to “float” nurses from position to position within the facility. And, the report also says that when asked about that protocol the director of the facility provided inaccurate information.
The report also takes issue with the availability of Personal Protective Equipment. The report says the practices were “inconsistent.”
In addition the report says that some nurses did not use the facilities computer system because it was--as the report quotes one nurses as saying “it was clunky.”
The report also reviewed the State Administration as it related to the facility. It says that the Department of Veterans Services did not take steps to address long standing problems with leadership.
The report says there were no material violations of any of the reporting requirements. It also says that the Home in the future should not be exempt from licensing and inspection requirements. Attorney Pearlstein says that the men and women who fought for their country deserve the very same quality as those at a long term care facility. The report also says that future directors at the home should licensed nursing home administrators.
Attorney Pearlstein ends his report:
“The Soldiers’ Home in Holyoke has a proud history of serving people who have given so much for this country. The tragic events described in this report cry out for reform, and it has already begun. We hope that the process of rebuilding the Home’s legacy will receive full support from the Commonwealth’s political leaders, so that veterans will once again be assured of receiving the high-quality care they so richly deserve.”
Attorney William Bennet who represents the Administrator Bennett Walsh has not commented yet.
(Photo Credit: John Baibak/WHYN News)