DOJ Says New Jersey Veterans’ Care During Pandemic ‘Systematically Violated’ Constitution

New Jersey Army National Guard combat medics enter the New Jersey Veterans Home at Paramus, N.J., April 9, 2020. Mark C. Olsen/New Jersey National Guard

The residents of two state-run veterans’ homes in New Jersey had their Fourteenth Amendment rights “systematically violated” by the state, according to the Department of Justice.

The department, in a Sept. 7 report, said it had found “reasonable cause to believe” that the state failed to provide adequate care to residents of the Menlo Park and Paramus Veterans Memorial Homes during the COVID-19 pandemic and that those failures are ongoing.

Poor quality of care, the department contends, constitutes a violation of residents’ Fourteenth Amendment right to conditions of “reasonable care and safety” while in state custody.

“We owe the veterans who served our nation our deepest thanks, and those veterans and their family members who live in these facilities have the right to appropriate care,” said Kristen Clarke, assistant attorney general of the Justice Department’s Civil Rights Division, in a statement.

“Based on our investigation, we have found that these facilities have provided inadequate protection from infections and deficient medical care, which have caused these veterans and their families great harm,” Ms. Clarke said.

“We look forward to working with the New Jersey Department of Military and Veterans Affairs (DMAVA) to improve the conditions in these homes they operate and ensure these veterans and their families receive the care they need and deserve.”

The Justice Department notified New Jersey officials in October 2020 that it would be investigating the conditions in the two veterans’ homes under the Civil Rights of Institutionalized Persons Act.

The state’s third such facility, Vineland Veterans Memorial Home, was not included in the probe.

‘Pure Hell’

Dozens of witnesses were interviewed in the process, including the facilities’ staff members and management, DMAVA leadership, and residents and their family members.

U.S. Veterans Affairs personnel who assisted the facilities early in the pandemic were also questioned.

When interviewed, one Paramus staff member reportedly said the scene there was “pure hell.”

Another at Menlo Park described it as “a battlefield.”

“Even by the standards of the pandemic’s difficult early days, the facilities were unprepared to keep their residents safe,” the report notes.

“A systemic inability to implement clinical care policy, poor communication between management and staff, and a failure to ensure basic staff competency let the virus spread virtually unchecked throughout the facilities.”

In 2020, COVID-19 was the second-leading cause of death in New Jersey. But according to the report, the true number of COVID-19 deaths in the state’s veterans’ homes that year was likely “substantially higher” than what was publicly disclosed.

“The facilities reported the cause of death as COVID only when there was a positive COVID test. But, COVID tests were not readily available during March and April 2020. And residents often died before they were tested,” the report notes.

The facilities’ failure to systematically track probable COVID-19 deaths meant that such deaths were excluded from the early death data.

Another key failure the report cites was the facilities’ poor implementation of basic infection control policies like masking, using personal protective equipment (PPE), handwashing, and proper cleaning practices.

At Paramus, housekeeping staff did not know how to properly disinfect resident areas.

At Menlo Park, the nursing stations were dirty, common areas weren’t being cleaned, and one Veterans Affairs staffer reported seeing “ants/bugs everywhere.”

Meanwhile, neither facility properly adhered to the state Department of Health’s orders to group residents based on their level of exposure, and no standard protocols existed for symptom monitoring.

In the case of one Menlo Park resident, a former Marine whom the report calls “Resident C,” his health began to deteriorate shortly after the death of his roommate.

His roommate had been hospitalized with suspected COVID-19 and tested positive at the hospital, where he died shortly after.

Yet even as Resident C’s condition declined over the following weeks, the facility’s staff never moved him to a COVID-19 unit or noted any possibility of infection on his chart.

Instead, without explanation, they took his scooter and shut the door to his room, making it impossible for him to leave or reach his buzzer to call for assistance. The next day, they noted “confusion” on his chart, and started treating him for pneumonia. Within hours, he was yelling for help, and days later he was “observed in bed screaming.”

Resident C died 10 days after his roommate’s death. His death certificate lists “respiratory failure” as the cause. And when his family members later asked the facility if his roommate had COVID-19, they were told, “No.”

Ongoing Failures

According to the Justice Department, the infection control problems that plagued the facilities early in the pandemic persist today, including a lack of proper training, contact tracing, PPE usage, or adequate cleaning practices.

“These failures are substantial departures from generally accepted standards of care in long-term care facilities and inhibit the Veterans Homes’ ability to stop the virus from spreading inside the facilities, creating a serious risk of harm.”

Other ongoing deficiencies exist in COVID-19 testing, clinical care, health monitoring, care planning, and staff competency, among others.

The report attributes those problems to the DMAVA’s failure to ensure appropriate oversight and accountability.

While the report noted that the Justice Department would work with the state to determine the appropriate remedies, it added that Attorney General Merrick Garland may soon file a lawsuit on the matter if state officials do not adequately address the listed concerns.

Responding to the report in a statement, Democrat Gov. Phil Murphy called it a “deeply disturbing reminder” that the treatment New Jersey’s veterans received was not only unacceptable but “appalling.”

He said his administration implemented policy changes to improve conditions, including securing private management and assistance for the homes, but added that more work was still needed.

“We are open to exploring all options to deliver for our veterans the high level of care they deserve and are entitled to under the law,” he said.