Could this Pa. veteran’s death have been prevented?
Ed Horowitz is one of about 11,000 Pennsylvanians who died of the coronavirus this year.
Could his death have been prevented? We likely will never know, but it’s clear that the state-run veterans home where he lived could have done more to try to protect Horowitz. He served his country for six years as a military policeman in the Army.
The circumstances of Horowitz’s death were highlighted in a new report by the state auditor general that questioned whether an outbreak at the Southeastern Veterans’ Center in Spring City, Chester County, was properly handled.
The answer is a resounding no. Horowitz, 81, of Philadelphia, died in May, not long after his roommate succumbed to the virus.
They were among 42 residents at the facility who died. The center is operated by the state Department of Military and Veterans Affairs. The center’s commandant and nursing director were suspended in May, following reports by the Philadelphia Inquirer about the death toll. The governor launched an outside probe that is ongoing.
That investigation is in addition to Auditor General Eugene DePasquale’s review, which was released Wednesday.
Some of DePasquale’s findings are disturbing, including the circumstances of Horowitz’s death.
In April, Horowitz’s roommate became sick with COVID-19 symptoms, including a bad cough. Horowitz asked to be separated from his roommate but his request was denied, his son, Ian Horowitz, told the auditor general’s office.
“Instead, when (his roommate) complained that he was cold because of his fever, they just kept turning up the thermostat and throwing blankets on him,” Ian Horowitz said, according to the report. “And his cough just kept getting worse.”
After 10 days, the roommate was taken to a hospital, where he died. That same day, Horowitz developed COVID19 symptoms. He died 10 days later.
“We couldn’t even have a funeral for him,” Ian Horowitz told the auditor general. “We could only have a burial … and everybody had to stay in their cars and just watch the casket go into the ground.”
The coronavirus still was new in April and May. A lot about the virus was unknown, and nursing homes were hit hard. Knowing what we know now, including how common it is for coronavirus patients to be asymptomatic, it’s easy to second-guess decisions that were made in the first few months of the pandemic.
Still, much of what the auditor general found happened at the Southeastern Veterans’ Center indicates a disregard for how dangerous the virus could be in close quarters among older people who may have underlying health conditions.
A nurse who was interviewed wept as she described for investigators the center’s slow response.
“When COVID first started, we had no masks available,” she said, according to Wednesday’s report. “And even once we got them, we were told not to wear them because it would scare the residents … I know one maintenance worker who was sent home three times early on because he refused to take his mask off.”
Staff rotated through the facility, “working with residents who were positive for COVID-19, then healthy residents, then residents who showed COVID symptoms and were awaiting test results — all during the same shift,” according to the report.
The nurse recounted how residents dined communally even after displaying symptoms.
“One day, a resident … showed all the symptoms (of COVID) around lunchtime but she was still eating in the dining room … Two days later, she went to the hospital and tested positive for COVID, and she died three days later.”
The auditor general’s research built on an inspection by the state Department of Health in June that found “questionable actions by the facility’s leadership put 83 percent of its residents in immediate, serious jeopardy,” DePasquale said.
The Health Department determined the commandant and nursing director “did not effectively manage the facility to make certain that proper infection control procedures were followed to protect residents from cross-contamination, infection, virus and disease in the facility.”
An outside contractor has been running the Southeastern Veterans’ Center since June. The facility passed subsequent Health Department inspections in August and September.
More about how the center responded to the pandemic should be known after the ongoing investigation ordered by the governor’s office is completed. DePasquale urged Wednesday that those findings be released publicly.
“Our veterans and their families deserve the best quality of care available, as well as full transparency about any failures that may have put veterans’ lives in jeopardy,” he said.
Sadly, that will likely be of little consolation to the family of Ed Horowitz.