BOSTON (CBS) – An independent investigation into the Holyoke Soldiers' Home found the facility's leadership team "made substantial errors" in preparing for and responding to the coronavirus outbreak that killed dozens of veterans.
A total of 76 veterans who tested positive for coronavirus died between March 25 and June 12. In addition, 18 veterans died and tested negative or weren't tested.
"The only thing we can say with certainty is that the death toll is tragic and unbearable," the report reads.
At least 80 staff members tested positive for coronavirus. The report finds that is likely because of the facility's failure to provide and require use of personal protective equipment.
Gov. Charlie Baker ordered the independent report as the death toll continued to rise at the facility.
The report concludes that it is possible "perhaps even likely" that if the home's leadership team did everything right, there still may have still been a deadly outbreak. But, the report concludes, major errors were made.
"However, as set out above, the Soldiers' Home leadership team did not do everything right – in fact, they made substantial errors in preparing for and responding to COVID-19," the report reads. "We conclude that these errors likely contributed to the scope of the outbreak, and its horrific toll. Likewise, we conclude that as a result of these errors, the Solders' Home fell short of its mission to provide 'care with honor and dignity.'"
According to the report, the "most substantial" error was a decision on March 27 to move all veterans from one of the two locked dementia units into the other locked unit, where they would be crowded with the veterans already living there.
Staff called the move "total pandemonium," "when hell broke loose," and "a nightmare."
A recreational therapist said she felt like she was "walking (the veterans) to their death," while a social worker "felt it was like moving the concentration camp – we were moving these unknowing veterans off to die."
A healthcare administrator sent in three days later said it looked like "a war zone" and some veterans were unclothed and "some obviously in the process of dying from COVID-19."
"The social worker's recollection of this consolidation is one of the most depressing and utterly shameful descriptions of what was supposed to be a care setting that I have ever heard of," Baker said during a Wednesday press conference.
Superintendent Bennett Walsh, the report found, was "not qualified to manage a long-term care facility, and his shortcomings were well known to the Department of Veterans' Services." Walsh declined comment on the report through his attorney.
Baker said "we are moving to end the employment" of Walsh.
The WBZ-TV I-Team first reported Thursday night that Massachusetts Secretary of Veterans Affairs Francisco Urena resigned.
Sec. Sudders on Holyoke Soldiers' Home Coronavirus Outbreak
A total of 111 interviews with 100 witnesses were conducted, and investigators reviewed more than 17,000 pages of documents. Baker issued a statement after the report, one of four that has been launched, was released.
"The subject matter and details of this report are nothing short of gut-wrenching. In fact, this report is hard to read," said Baker. "Some of the decisions that were made by those in charge of the Soldiers' Home in Holyoke are in Mark Pearlstein's words, utterly baffling."
Baker said he will be outlining Thursday several measures to address the trauma the staff experienced and their working conditions. He also said he plans to announce further reforms "very soon."
"The opportunity for our veterans to come live and be cared for in our Soldiers Homes is supposed to be a small token of our state's gratitude for their service," said Baker. "As this report reveals, the Holyoke Soldiers Home failed to provide a safe environment for our nation's veterans in the wake of COVID-19, during a particularly critical period."
Secretary of Health and Human Services Marylou Sudders called the environment at the home "chaotic" during the outbreak.
"Leadership is paramount during a time of crisis, and this absence at the Holyoke Soldiers Home created a chaotic environment for staff and devastating consequences for residents and their loved ones," she said.
There are no current cases of coronavirus at the home. Outdoor visits have since resumed for residents.
When asked if he believes his administration should have done more, Baker said "Our administration did not do what it should have done," but added he was not fully aware of the issues until late March. Baker was asked if he believes families are owed an apology.
"One of the things I would like to do, now that the reports is out there, is either do something virtually or, if we can figure out a way to do it in person, to meet with the families and to talk to them," he said.
Baker said he has "full confidence" in Sudders.
for more features.