BOSTON — Two former administrators of a Massachusetts veterans home where nearly 80 people sickened by the coronavirus died have been charged over their handling of the outbreak, the state attorney general said Friday.
It’s believed to be the first criminal case in the country brought against nursing home officials for actions during the pandemic, Attorney General Maura Healey said.
Former Holyoke Soldiers’ Home Superintendent Bennett Walsh and former Medical Director Dr. David Clinton were indicted by a grand jury on charges stemming from their decision in March to combine two dementia units, packing residents who were positive for the coronavirus into the same space as those with no symptoms, Healey said.
The veterans “risked their lives from the beaches of Normandy, to some the jungles of Vietnam, and to know that they died under the most horrific circumstances is truly shocking,” Healey told reporters.
A phone message was left Friday with a lawyer for Walsh. An email was sent to attorneys for Clinton. They could each face prison time if convicted of causing or permitting serious bodily injury or neglect of an elder, Healey said.
Relatives of veterans who died at the home said they hope “justice will prevail.”
“We now want our state to move forward and do the right thing to ensure this never happens again to any other veteran,” the family members said in an statement emailed by the Holyoke Soldiers’ Home Coalition, a group advocating for improvements.
The charges come three months after a scathing independent report said “utterly baffling” decisions made by Walsh and other administrators allowed the virus to spread unchecked. The “worst decision” was to combine the two locked dementia units, both of which already housed some residents with the virus, said investigators led by former federal prosecutor Mark Pearlstein.
Healey said Walsh and Clinton were the ones ultimately responsible for the decision to combine the two units, which she said led to “tragic and deadly results.” More than 40 veterans were packed into a single unit that usually had 25 beds, and space was so limited that nine veterans — some with symptoms and some without — were sleeping in the dining room, Healey said.
“This never should have happened. It never should have happened from an infection controls standpoint,” Healey said.
Since March 1, 76 veterans who contracted the coronavirus at the home have died, officials said. The first veteran tested positive March 17. Even though he had shown symptoms for weeks, staff “did nothing to isolate” him until his test came back positive, allowing him to remain with three roommates, wander the unit and spend time in a common room, investigators found.
When a social worker raised concerns about combining the two dementia units, the chief nursing officer said that “it didn’t matter because (the veterans) were all exposed anyway and there was not enough staff to cover both units,” investigators 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 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 sent to the combined dementia unit, investigators said.
The next day, a refrigerated truck to hold bodies that wouldn’t fit in the home’s morgue arrived, the report said.
Walsh has defended his response, saying state officials initially refused in March to send National Guard aid even as the home was dealing with dire staffing shortages.
He was placed on administrative leave March 30, and the CEO of Western Massachusetts Hospital, Val Liptak, took over operations. Walsh was fired after the release of the report, but a judge invalidated his termination this week after his lawyer argued that only the board of trustees could hire and fire the superintendent.
The Massachusetts U.S. attorney’s office and U.S. Department of Justice’s Civil Rights Division are also investigating whether officials violated residents’ rights by failing to provide proper medical care.
Attorneys general in other states, including Pennsylvania, have also launched investigations into coronavirus deaths at nursing homes. And earlier this month, federal agents searched two nursing homes near Pittsburgh, one of which had the worst outbreak of any nursing home in Pennsylvania.
Justice Department officials wrote wrote the governors of New York, New Jersey, Pennsylvania and Michigan last month seeking data on whether they violated federal law by ordering public nursing homes to accept recovering COVID-19 patients from hospitals.
The letters, sent from the head of the civil rights division, said the department hoped to determine whether the orders “may have resulted in the deaths of thousands of elderly nursing home residents.”
The Justice Department said it was evaluating whether to initiate investigations under a federal law known as the Civil Rights of Institutionalized Persons Act, which protects the rights of people in nursing homes and other facilities. But the law applies only to nursing homes owned or run by the states.