HOLYOKE — In 1989, Theresa King first came to work as a nurse at what she called “the best place in Western Mass. — the Soldiers’ Home in Holyoke.” The staff were proud of the care they gave, and the state-run home always had a waiting list of veterans wanting to live there.
But that was before higher-ups cut staffing levels, she said. That was before they forced the remaining staff to work mandatory overtime. And it was before COVID-19 swept through the facility for several months, beginning in March, killing at least 76 veteran residents and infecting at least 84 employees.
“We were failed by more than just our superiors,” King told state lawmakers on Tuesday. “We were failed by the state that failed to listen to (former Superintendent) Paul Barabani when he said the rooms were too small. We were failed when the staff reached out to report staffing levels well before COVID. We were failed when they mandated overtime, day after day after day, week after week.”
King was one of eight current and former employees of the Soldiers’ Home who testified Tuesday before a joint oversight committee of the state Legislature that is investigating the virus outbreak at the Soldiers’ Home. Those testifying spoke about the trauma that still impacts them today after watching those they cared for die, about management decisions that contributed to the outbreak and the home’s fall from a workplace with little turnover to an understaffed and demoralized facility.
“It was a disaster,” King said of the outbreak, explaining that as COVID-19 spread, families desperate for information had the facility’s phones ringing off the hook. But King said management barred staff from giving families critical information, and that shorthanded employees were often too busy running between dying patients to even answer the phones. “I want to apologize to the families for everything they went through.”
Testimony throughout the seven-hour hearing returned frequently to the topic of understaffing. Former employees described how years of cuts, and unfilled positions after retirements, left nurses and certified nursing assistants, or CNAs, with impossibly large workloads, leading to accidents and conditions that hurt residents’ health.
“We didn’t have enough staff from the beginning to take care of these wonderful veterans,” said Kwesi Ablordeppey, a CNA and president of his union, SEIU Local 888. He implored the officials: “Put more boots on the ground so we can take care of these veterans.”
Carol Konrad, a registered nurse at the Soldiers’ Home from 1984 until 2015, said when she first started at the facility, turnover was very infrequent because people loved working there. Employees used to take veterans to the movies or shopping, and when somebody died on the unit every staffer was able to be there to say goodbye. But over the years, she said, workers started to see vacations denied and overtime forced on them as staffing levels dropped.
“Our departments started getting privatized: PT, X-ray, pharmacy, everybody,” Konrad said. “Everything’s gone — take away, take away, take away. But everything gets taken from the nursing department, which takes care of the patients.”
Nurses described staffing so thin that they couldn’t provide adequate care and worried about putting their licenses at risk. They said the state used temp agencies and per diem employees to plug the gaps, but that wasn’t enough.
Nancy Harad, a nurse who retired in 2019 after 25 years working in every unit in the building, said bosses worked her and others relentlessly, but refused to listen to complaints. She said she knew it was time for her to leave when she had a patient dying and was so busy she couldn’t spend five minutes in the room with that veteran.
“You can’t continue to force people to work 16-hour shifts. It’s exhausting,” she said. “And when nurses and CNAs are exhausted, that’s when accidents happen, when mistakes are made.”
And those issues continue, some said, with more staffing needed to reopen to full capacity and more retirements on the way.
“Every day it’s something new — it’s more paperwork, it’s do more, do more, do more,” said registered nurse Francine Kapinos, who after 21 years on the job decided to retire early after the outbreak. “They have broken many of us.”
Some said that when they spoke up for their co-workers or patients, they faced retribution from bosses whose management style was intimidating. Ablordeppey said higher-ups laughed when staff asked about COVID-19 preparations in February, and that his manager wrote him up for wearing personal protective equipment on March 18.
“There are many people who aren’t here to testify, and the reason they’re not here is because they’re still afraid,” Kapinos said. “So many years of being afraid of retribution or of being targeted.”
Because of the crowding of veterans into rooms, some living in beds just 1 foot from other veterans, conditions were ripe for infection to spread, some said. Two nurses described how frequent outbreaks of scabies — mites that burrow under the skin and cause intense itching — pointed to a lack of protocols in the Soldiers’ Home for dealing with contagious patients.
Though many said the problems at the home were longstanding and systemic, many did place blame for the ferocity of the outbreak on senior management in charge at the time — in particular, then Superintendent Bennett Walsh, Medical Director David Clinton, Director of Nursing Vanessa Lauziere and Assistant Director of Nursing Celeste Surreira. Walsh and Clinton have been indicted on criminal neglect charges for their roles during the COVID-19 outbreak.
Joseph Ramirez, a CNA, said upper management removed personal protective equipment from supply closets as the outbreak began. He said he and other staff were forced to work unprotected around the first veteran who ended up testing positive, who himself was allowed to wander around his unit.
Ramirez soon caught COVID-19, and said it felt as though his entire body had been ripped apart, leaving him at one point wishing for death. While out sick, he said he heard from terrified co-workers who described the combining of two dementia units — a move that a state-commissioned investigation described as management’s “worst decision” from an infection control standpoint.
“I have numerous stories of people who came to me and told me how horrible it was, how shameful they felt, how some refused to do it and went home,” he said. Ramirez, like others who spoke, said he now has to take medication to deal with the anxiety he suffers after the outbreak.
Cindy Cormier, a floor nurse who has worked at the Soldiers’ Home for 17 years, said she was diagnosed with post-traumatic stress disorder after what she witnessed during the outbreak. She said she loved working with the veterans on the Alzheimer’s floor, in part because she took care of her mother who suffered from the disease. A self-described “military brat,” she said her father taught her to take care of veterans.
“We failed them, and I go to bed every night with guilt that I didn’t do enough,” Cormier said, weeping as she spoke. She was still wearing her pink scrubs, having just come from working a shift at the Soldiers’ Home.
Dusty Christensen can be reached at dchristensen@gazettenet.com.