Report: 'Baffling' errors at vets home amid deadly outbreak

The leadership of a home for aging veterans in Massachusetts where nearly 80 residents sickened with the coronavirus have died packed dementia patients into a crowded unit as the virus began spreading, one of several “utterly baffling” decisions that helped the virus run rampant, investigators said in a report released Wednesday.

The superintendent of the Holyoke Soldiers’ Home was not qualified to run a long-term care facility and “substantial errors and failures” he and his team made likely contributed to the high death toll there, investigators found. Among them was a decision prompted by staffing shortages to combine two locked dementia units, both of which already housed some residents with the virus.

“Rather than isolating those with the disease from those who were asymptomatic — a basic tenet of infection control — the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25. This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19,” the report said.

When a social worker raised concerns about the move, the chief nursing officer said “it didn’t matter because (the veterans) were all exposed anyway and there was not enough staff to cover both units,” the report said. One staffer who helped move the dementia patients told investigators she felt like she was “walking (the veterans) to their death.” A nurse said the packed dementia unit looked “like a battlefield tent where the cots are all next to each other.”

As the virus took hold, leadership shifted away from trying to prevent its spread, “to preparing for the deaths of scores of residents,” the report said. On the day the veterans were moved, more than a dozen additional body bags were...