Class Action Alleges COVID-19 Outbreak at Mass. Soldiers’ Home Sparked by ‘Deliberate Indifference’ to Vets’ Needs [UPDATE]

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“Deliberate indifference” to the needs of residents at the Soldiers’ Home in Holyoke, Massachusetts by the facility’s operators is to blame for the deaths of 76 veterans and sickening of 84 others with COVID-19, a proposed class action lawsuit alleges. 

Filed by the estate of a Soldiers’ Home resident who died due to COVID-19, the 29-page lawsuit alleges the spread of the virus within the facility would have been preventable had it not been for the conduct of the five defendants. Cited in the lawsuit is an independent investigation commissioned by Massachusetts Governor Charlie Baker that found the defendants engaged in “unprofessional, unethical, and deliberately indifferent behavior” amid a “litany of ‘utterly baffling’ misrepresentations, misjudgments, mistakes, and blatant errors”—including combining two dementia units amid the outbreak—amounting to a “callous disregard for the health and safety” of Soldiers’ Home residents. 

Per the case, the Massachusetts and federal government issued guidance beginning in February 2020 that expressly directed institutions to identify patients with COVID-19 and isolate them from other patients and staff. The lawsuit, citing the governor’s report, stresses that “isolating cases of COVID-19 was epidemiology 101,” and says the Soldier’s Home received from authorities clear guidance pertaining to limiting staff movements between COVID-19-contaminated and non-contaminated areas, isolating asymptomatic individuals in assisted living facilities, utilizing facemasks on patients being examined for suspected COVID-19 infection and placing patients known or suspected to be infected in a single-person room with the door closed. 

Despite the abundance of guidance aimed at mitigating the spread of COVID-19, the defendants—who formerly held the roles of superintendent, medical director, chief nursing officer and assistant director of nursing at the Soldiers’ Home and Massachusetts Secretary of Veterans’ Affairs—did not utilize isolation rooms, the lawsuit alleges, claiming staff at the Soldiers’ Home also had inadequate access to and “were discouraged from using” personal protective equipment (PPE). 

According to the lawsuit, the first veteran diagnosed with COVID-19 at the Soldiers’ Home had “clear symptoms” he carried the virus as early as February 2020 yet was not tested until March 17. The case alleges that even after testing positive, the individual, identified in the suit as “Veteran 1,” was allowed by the defendants to continue living among other residents and staff. In the opinion the Soldiers’ Home’s former medical director, the decision of whether to isolate Veteran 1, who experienced weakness, fever and coughing, was a “moot point” given “everyone had been exposed [to COVID-19] already,” the case says, citing the governor’s report.

Even after Veteran 1 was tested for COVID-19, the defendants took “inadequate precautions” to mitigate the potential spread of the virus, the suit says. According to the complaint, the defendants “repeatedly made decisions” that only made the spread of COVID-19 at the Soldiers’ Home worse. From the governor’s report: 

“As soon as his positive test result was received (four days after Veteran 1 was initially swabbed for COVID19) Veteran 1’s three roommates were moved to a different room. Prior to this, one of Veteran 1’s roommates was “very mobile” and frequently visited other rooms. According to [one defendant], none of Veteran 1’s roommates were exhibiting COVID-19 symptoms at this time.

After testing positive, staff attempted to keep Veteran 1 in his room. The door to Veteran 1’s room was supposed to remain closed, but staff largely ignored this policy and kept the door open for faster access . . . .  

When Veteran 1 tested positive, [the defendants] again discussed whether Veteran 1 should be moved to the isolation unit. Dr. Clinton advised against doing so, as in his view others in 1-North had been exposed already, and the facility would be at risk if Veteran 1 got out of his room on an unsecured unit.”

Staff who worked near Veteran 1 continued to float around other areas of the facility, the suit continues, stating a nursing aide and laundry worker who worked between units tested positive for COVID-19 shortly thereafter. After Veteran 1’s positive COVID-19 test, a defendant falsely informed the former Soldiers’ Home superintendent that the individual had been isolated from others, the case says. 

On March 27, the suit alleges, the decision was made to combine two dementia units at the Soldiers’ Home despite the fact that several individuals residing therein had already been diagnosed with COVID-19 and were at a high risk of transmitting the virus to others. The governor’s report found that one of the Soldiers’ Home’s two locked dementia units, Unit 2-North, was closed and all of its 21 residents were moved into Unit 1-North, doubling that unit’s number of residents, the lawsuit says. 

“This required that veterans be crowded into rooms and common spaces, with their beds inches apart,” the governor’s report states, noting four of the defendants were involved in the decision to combine the dementia units. The lawsuit, again citing the report, relays the “devastating impact” that combining the two dementia units had on Soldiers’ Home veterans and staff: 

“Staff describe the move as ‘total pandemonium,’ ‘when hell broke loose,’ and ‘a nightmare.’ They reported that ‘all of a sudden they just started moving people.’ One staff member reported thinking: ‘How can they do this because this [is] the most insane thing I ever saw in my entire life?’ She ‘felt it was like moving the concentration camp—we are moving these unknowing veterans off to die. I will never get those images out of my mind—what we did, what was done to those veterans.’” 

Per the complaint, the first confirmed COVID-19 death at the Soldiers’ Home occurred on March 24, three days before the dementia units were combined, and Veteran 1 died on March 28 at 93 years old. The lawsuit alleges the spread of COVID-19 and spike in deaths at the Soldiers’ Home was anticipated by leadership, who had 13 body bags delivered to Unit 1-North on March 27, “shortly before the consolidation of the two units began.”

The governor’s report says the former superintendent of the Soldiers’ Home was placed on administrative leave on March 30 as a Massachusetts response team arrived at the facility to “take command of the rapidly devolving situation.”

The lawsuit looks to cover individuals and/or the estates of individuals who contracted COVID-19 while residing at the Soldiers’ Home in Holyoke, Massachusetts between March 1 and June 23, 2020.

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