Report: ‘A very great many things’ caused COVID-19 tragedy at Holyoke Soldiers’ Home

HOLYOKE, Mass. (WPRI) — A new report says management and staffing issues were among some of the top contributing reasons a deadly COVID-19 outbreak occurred at the Holyoke Soldiers’ Home last year.

The 186-page report was released by the Massachusetts Legislature’s Special Joint Oversight Committee on Monday evening.

The committee says it was charged to ask not only “how” the tragic COVID-related deaths of 77 veterans occurred at the Holyoke Soldiers’ Home, but also “why” it happened.

According to the report, “a very great many things over the course of several years caused the great tragedy that occurred at the Holyoke Soldiers’ Home,” with “numerous” points of long-term and short-term failures.

The committee detailed 14 findings with recommendations, in an effort to understand the reasons why the outbreak occurred.

According to the report, a decision on March 27, 2020 to combine two locked dementia units, allegedly because of insufficient staffing, was “the most consequential decision that was made.”

The oversight committee also said there were “many instances of unexplainable and harmful clinical and leadership decisions” that also “contributed substantially to the deaths of 77 veterans.”

Other immediate causes of the outbreak, according to the committee, included:

• Possible delays in responding to calls for additional assistance and support from the National Guard
• Understaffing during the crisis and as it escalated
• COVID-19 reporting structures and requirements not clearly defined by the Baker Administration
• The absence of the medical director
• A lack of implementation of infection control protocols
• Inability for staff to track patients’ conditions due to lack of adequate record-keeping and electronic records

The committee made several recommendations, including that the governor be given the power to hire and fire the superintendent of the home.

The committee also recommends the home get inspections by the Massachusetts Department of Public Health twice a year, and that a hotline be available for staff and family to report time-sensitive and serious concerns directly.