An entrance sign is seen at the state run Menlo Park nursing home for veterans in Edison, N.J., Sept. 16, 2020. (Ed Murray, nj.com/TNS)
(Tribune News Service) — In a scathing new report, the U.S. Justice Department on Thursday found that New Jersey “systematically violated the rights of residents” of the Veterans Memorial Homes at Menlo Park and Paramus, the troubled state-run nursing facilities that care for veterans and their families.
The federal investigation, launched in October 2020 as COVID was spreading through many of the nation’s long-term care facilities, found that the state failed to implement adequate infection control protocols, provide adequate clinical care, and “provide oversight of the facilities in a manner that keeps the residents of the Veterans Homes safe from harm.”
During the first wave of the pandemic, the two veterans homes had some of the highest number of publicly reported resident COVID deaths of all long-term care facilities in New Jersey. Overall, COVID claimed the lives of more than 200 residents and staff in all Menlo Park, Paramus and a third facility in Vineland. Federal officials said the actual number of COVID deaths was likely much higher.
A 43-page report issued by the Justice Department noted that the pandemic devastated the facilities in Paramus and Menlo Park in Edison.
“One worker described the situation (during the height of the pandemic) in Paramus as ‘pure hell,’ ” the report noted. “Another described Menlo Park as ‘a battlefield.’ ”
Even by the standards of the pandemic’s difficult early days, it said the two facilities “were unprepared to keep their residents safe.”
Those problems continued even as the impact of the pandemic was winding down. Last year, inspectors concluded that residents at Menlo Park had been placed in “immediate jeopardy” over serious shortcomings in care — citing the nursing home for major medical mistakes, abuse of a resident who had not received medication, and improper infection controls to stop a new COVID outbreak.
In one incident, a registered nurse who apparently did not know how to remove a catheter — a skill taught in nursing school — simply cut it with a scissor. The resident ended up in the emergency room and then was transferred to a hospital to be treated for a urinary tract infection. When a certified nursing aide or CNA with experience in the procedure was asked why she had not spoken up, she replied: “She is an RN. She is supposed to know,” the inspectors said.
The new findings, sent to Gov. Phil Murphy earlier on Thursday by U.S. Attorney Philip Sellinger, found “reasonable cause to believe that conditions at the veterans homes violate the Fourteenth Amendment to the Constitution” and the civil rights of residents there.
“Those who served to protect this nation and their families are entitled to appropriate care when they reside at a veterans’ home,” said Sellinger. “The Paramus and Menlo Park veterans’ homes fail to provide the care required by the U.S. Constitution and subject their residents to unacceptable conditions, including inadequate infection control and deficient medical care. These conditions must swiftly be addressed to ensure that our veterans and their families at these facilities receive the care they so richly deserve.”
The governor’s office did not have an immediate response.
Sen. Joseph Vitale, D-Middlesex, chairman of the state Senate Health, Human Services and Senior Citizens Committee said the report “confirms my worst nightmares.”
He said the Legislature provided the necessary tools to provide the best care for the state’s veterans in the wake of COVID.
“But clearly, they’ve failed. Again,” Vitale said. “It’s time that we create a new cabinet level department or authority dedicated soley to veteran services with the very highest quality, tools and resources available. We have depended on our servicemen and women to protect us. It’s time we return the honor.”
Sen. Joseph Cryan, D-Union, who chairs the Senate Military and Veterans Affairs Committee, called the report’s findings “appalling and offensive to our cherished veterans and their service to our country.”
Cryan agreed with Vitale that it was time to create a separate agency that would focus on providing services to veterans. It’s an idea that they had proposed before but it was not welcomed by the Murphy Administration.
”I think (the report) will be the impetus for a change that has been needed for a long time,” Cryan said
Rep. Bill Pascrell, D-9th Dist., who led calls early on for an investigation into what was happening at the Paramus Veterans Home, said the report “lays out in exhaustive detail a chronicle of misdeeds at these homes that should enrage everybody in New Jersey.”
Too many times, he said, residents at the facilities — seniors who fought for our country — have been left in brutal conditions.
“The incompetence, negligence and outright recklessness by facility management led to loss of life,” Pascrell said. “We have learned much about the deadly problems that happened early in the pandemic. But that issues as critical as infection control, quality standards of care, and proper oversight have not been remedied by now and continue into 2023 is beyond disturbing. Those responsible must be held accountable, and held accountable now.”
The pandemic hits
COVID officially arrived at the veterans homes in late March 2020.
The report noted that Menlo Park sent two residents to the hospital on March 28 and 29, 2020. By March 31, 2020, both had tested positive for COVID. One of those residents died in the hospital on March 31, 2020. The other returned to Menlo Park and died in early April. The leader of Veterans Healthcare Services notified his supervisor of the March 31 COVID death on April 1, inexplicably reporting the cause of death as pneumonia and writing that the facility had “0 death[s] COVID related.”
By April 12, 2020, 25 more Menlo Park residents had died. Thirteen of those residents had tested positive for COVID. The resident population, which was approximately 300 before COVID began, dropped dramatically the next month. By April 25, 2020, 63 more residents had died, of numerous recorded causes.
Gov. Murphy later announced a major shakeup at the facilities, ousting members of the top leadership. Among them were Brig. Gen. Jemal J. Beale, the adjutant general who oversees the New Jersey Department of Military and Veterans Affairs. He was replaced on an interim basis by Deputy Adjutant General, Col. Dr. Lisa J. Hou, a surgeon.
In discussing what went wrong with managing the outbreak, the report said inadequate infection control practices and inadequate medical care at the homes were compounded by a lack of effective management and oversight.
“Such deficiencies expose residents to uncontrolled, serious and deadly infections,” said federal officials, noting that both the New Jersey Department of Military and Veterans Affairs, or DMAVA, which operatives the facilities, and the individual veterans homes drafted separate infection control policy documents.
Regardless of policy source, DMAVA leadership viewed implementation of policy as the responsibility of the individual veterans homes, led by their CEOs. But the CEOs appeared to view themselves largely as intermediaries, passing new policy guidance from DMAVA’s central office to facility staff without assuming ownership over the successful implementation of that policy. Likewise, DMAVA’s central office did not exercise significant oversight to ensure the facilities implemented policies safely and correctly, said the report.
“This multi-level leadership failure placed Veterans Homes residents at serious risk of harm,” investigators wrote.
The failures were big and small. The report found the facilities were filthy and no one was washing their hands consistently in both veterans homes.
“By late April, there were serious cleanliness issues at both facilities. Housekeeping staff in Paramus had not been properly trained on disinfecting resident areas, including the ‘terminal cleaning’ of rooms required after a COVID-positive resident is transferred or discharged, or tracking which beds were clean and which were dirty. In Menlo Park, the nursing stations were dirty and there was no cleaning of common areas,” the report found.
One U.S. Veterans Affairs staffer reported “ants and bugs everywhere.”
There was no segregating the sick from well patients, resulting in the co-mingling of residents and staff and allowing the virus to spread throughout the facilities.”
And there was a widely publicized incident involving the switch of the identification bracelets for two Paramus residents that resulted in a heartbreaking mix-up for their families.
Both residents were COVID-positive and had been transferred from the facility’s secure dementia unit to the same room in the Valor Unit. Staff told the family of one resident that he was recovering well from COVID when he had in fact passed away on April 11, 2020. The family of that resident’s roommate was incorrectly told he had died. The family of the resident who died on April 11 learned from the funeral home that their loved one was wearing his roommate’s identification bracelet. The other resident — whose family was incorrectly told that he had died of COVID on April 11 — died of COVID five days later, on April 16, 2020.
The report criticized the state for its missed opportunity to keep residents safe. Early in the pandemic, investigators noted U.S. Veterans Affairs offered to house Veterans Homes residents in federal facilities, which had additional space.
“DMAVA declined the offer and asked for additional staff instead,” investigators said. “When U.S. Veterans Affairs arrived at the Veterans Homes in April of 2020, it was clear that the facilities needed not just staff but additional direction and infection control planning.”
Earlier this year, Menlo Park was hit with more than $340,000 in federal penalties over the findings of improper care and abuse that had threatened a shutdown of the facility in 2022.
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