DLC initiated a monitoring of Tewksbury State Hospital on April 23, 2020 due to reported concerns regarding the spread of COVID-19 at the facility, which houses units run by the Department of Public Health (“DPH”) and the Department of Mental Health (“DMH”). In addition, DLC received a complaint to the system regarding the hospital’s COVID-19 practices and procedures. DLC found probable cause on June 9, 2020 to open an investigation. At that time, the COVID-19 Weekly State Facility Report stated that 180 staff tested positive, 154 patients tested positive, and 18 patients had died from COVID-19. As part of its monitoring and investigation, DLC interviewed hospital leadership, and reviewed records related to COVID-19 infection controls and the records of the 18 patients who died from causes related to COVID-19. In addition, DLC conducted remote interviews with 32 DMH and DPH patients.
Per a letter dated July 6, 2021, DLC found that failures and delays in implementing appropriate COVID-19 protocols at Tewksbury did not adequately protect patients at the onset of the pandemic. DLC also found that once the infection control assessments were completed and the recommendations were implemented, the hospital successfully reduced facility COVID-19 transmission. DLC recommended the immediate development of a pandemic preparedness plan, including the following:
- Detailed safety procedures concerning prevention of the spread of COVID-19 and other infectious diseases at Tewksbury and detailed criteria regarding when and how such procedures shall be implemented;
- Detailed plans on how each unit will safely continue to provide services, recreation, exercise, fresh air and treatment when the pandemic preparedness plan is in place, rather than halt access to program and services;
- Continued conversion of all quadruple and triple patient rooms to single and double rooms; and
- Assessment of Wi-Fi dead spots and plans to immediately improve Wi-Fi access across the hospital.