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Factors Contributing to the Spread of COVID-19 in the Second Wave: Case Studies

Posted: November 23, 2020

(November 23, 2020)

Case Study: West End Villa, Ottawa

On August 30, 2020 a second wave of COVID-19 began with the declaration of an outbreak at Extendicare’s West End Villa in Ottawa. The outbreak quickly spread through the home and across Ottawa’s long-term care homes. Though there has been no public reporting about why the spread occurred, one member of the Ontario Health Coalition Board reports that his mother’s home care PSWs in Ottawa work in long-term care homes at the same time as agency staff. In a media report from September 29, it was revealed that among the 42 staff members who had tested positive at that point,one worked for an agency. It was not revealed at which other homes that agency staff person worked.[1] Notably, by mid-September eleven Ottawa long-term care homes were in outbreak.[2]

As of November 9, eighty-seven residents and 45 staff had contracted COVID-19 in the outbreak at Extendicare’s West End Villa that started August 30. At least 20 residents had died. In total, to date, one hundred and thirty-two residents and staff had contracted COVID-19 in this one home.

In our tracking reports we charted the spread of the outbreak as follows:
• Aug 30: 2nd outbreak started[3]
• Sept 16: 31 residents including 5 deaths and 5 staff[4]
• Sept 18: 46 residents including 6 deaths and 17 staff[5]
• Oct 18: 84 residents including 20 deaths and 43 staff[6]
• Nov 9: 87 residents including 20 deaths and 45 staff[7]

From the accounts of families, staff and the media, we have been able to piece together a picture of what happened as COVID-19 raged through this home. The reports are deeply disturbing and reveal just how little had changed from the devastating failures in the first wave. There were significant delays in getting testing done in the home itself, followed by a failure to cohort residents immediately upon development of symptoms. The provincial government’s failure to build testing, lab and contact tracing capacity during the summer for the reopening of businesses and schools resulted in fatal delays in obtaining test results. Inadequate policy, poor oversight and negligible enforcement of infection control guidelines by the province were apparent as staff reported inadequate access to PPE even after the home was in outbreak. Multiple accounts corroborate that the home operator did not ensure, even long after symptoms and/or positive test results, that residents who had not tested positive were protected from exposure. Staffing levels, which were reported in on line reviews as too low prior to the pandemic, crumbled during the outbreak. Care for residents, including those sick and dying with COVID-19, was horrifically inadequate. This long-term care home had been previously reported for poor and negligent care on numerous occasions. There was sufficient evidence not to trust the reports of administrators about conditions in the home. Yet Public Health and Ministry measures to assess the home’s response were inadequate. The measures to enforce provincial guidelines, directives and policy that had by that time been created to improve infection control were inadequate. And then, finally, measures for emergency intervention were too slow and also inadequate.

Delays in testing:

The provincial government’s failure to make a coherent plan to ramp up assessment/testing centre, laboratory and contact tracing capacity during the summer has had effects that can be accurately described as fatal. The lack of capacity once businesses, and particularly schools reopened, led to severe backlogs in testing and test results which were not only experienced in the general community, but also in long-term care homes. In West End Villa, reports throughout the month of September reveal a picture of late testing of residents and a failure to cohort symptomatic residents by the home itself, along with by slow test results resulting from the provincial planning failure. According to an Ottawa Citizen report on Friday September 18, sixty tests among staff were still pending and testing was continuing among residents with 48 results pending.[8] On September 29, a memo that was given to families from the home on September 28 was reported publicly in the media. According to this report, at that point there were pending test results for 121 residents and 149 staff members.[9] While inadequate laboratory capacity to process tests appears to be a factor, the delay in testing, cohorting of residents, and protecting residents from wandering into COVID “hot” zones that are the responsibility of the home operator also contributed to the spread of the virus.

A Postmedia report published on September 20 quotes a family member who reports lapses in testing and isolation in the home as follows:

“Lea Maurice, whose 76-year-old disabled grandmother lives in the home, says her grandmother was left in a room with a sick roommate for 24 hours after that roommate tested positive for COVID-19. The roommate had been showing signs of illness for several days before she was tested, they say. Even after the roommate tested positive, she was not immediately moved. Maurice says the home did so after family members complained. It took another eight hours, Maurice and other family members allege, before the room was sanitized, and even then it was done with her grandmother in the room. Maurice’s grandmother, who is not being named to protect her privacy, has now tested positive for COVID. She had to be tested twice. Officials with the home told family members that the original test was inadvertently cancelled by the lab where it was sent for processing. Maurice said she can’t understand why it took so long to move the roommate to protect her grandmother and two other residents with whom they shared a bathroom.”[10]

Poor care, poor infection control practices, Public Health and government surveillance and interventions inadequate and too slow.

On multiple occasions, Public Health Ontario, Ottawa Public Health and the Ministry of Long-Term Care claimed that the home had sufficient PPE, sufficient staff, and was following safety protocols: contentions that are directly contradicted by accounts from families and staff with immediate knowledge of the situation. These contradictory reports raise questions about whether inspectors and officials actually went into the home and spoke with staff and residents, or whether they relied on the accounts of the home’s administration alone.

On September 11 local public health officials told the Ottawa Citizen that things had changed since the first wave and that they had ensured that West End Villa had enough PPE, and the Ministry of Long-Term Care told the same newspaper that they had ensured that the home had enough staff and proper outbreak protocols in place.[11]

Yet on Saturday, September 19 a CBC news story quoted a staff person, who spoke on the condition of anonymity for fear of losing their job, as reporting that staff working directly with residents who have COVID-19 did not have N95 masks,[12] something that had been raised repeatedly as a problem with the provincial government and public health officials. The Ottawa Citizen further reported multiple claims from staff that care levels had dropped in September to two PSWs for sixty COVID-positive residents.[13] Maurice said she can’t understand why it took so long to move the roommate to protect her grandmother and two other residents with whom they shared a bathroom.”

On September 29 spokesperson Gloria Yip said Ottawa Public Health had been conducting daily on-site visits to West End Villa and it was also reported that the Ministry of Long-Term Care was meeting daily with the home’s licensee, the local public health unit and provincial health officials. From that surveillance, Ottawa Public Health said:

“The home has reported no critical personal protective equipment concerns or shortages at this time. The home is also addressing staffing challenges by using nurse practitioners, paramedic services and temporary staff.”

She said the provincial government has introduced “an aggressive testing, screening, and surveillance protocol, deployed specialized teams from hospitals, public health and the home care sector, recruited additional staff, and increased PPE. Long-term care homes enforce rigorous provincial standards for all public health concerns, including outbreak management systems for detecting, managing and controlling infectious disease outbreaks.”[14]

Yet, the daughter of another resident describes the conditions in which her mother Pierrette died on September 26 at West End Villa.[15]

Pierette’s room was dirty, she had excrement on her hands, there was excrement on the wall, and she had not been cleaned. Her tongue was dry, and although there were drink cartons on her table all but one had been left unopened: Pierrette, with dementia and COVID-19 was unable to open them. Despite being put into a private room for isolation as she had symptoms of COVID-19, other residents were wandering in and out, with no staff around to stop them from being exposed to the virus. There were not enough staff to provide hydration and nutrition, human company and basic care. These were the conditions in the second last week of September, three weeks after the outbreak was declared. Pierette died on Saturday September 26. Pierette’s daughter had been calling the home all morning. She finally got a call back from the nurse who apologized and said that the home was so short-staffed that she was covering two floors alone and had not been able to get into Pierette’s room until just before noon. Pierette’s family raced to the home just in time for her passing.

If Public Health officials relied on home administrators’ accounts as to what was happening in the home, which it appears they did, they should have interviewed staff and residents, and conducted on-the-ground surveillance to ascertain the condition of care and infection control. There was already plenty of evidence that the home had a documented history of inadequate care, as evidenced by inspection reports and a 2018 lawsuit.

In that 2018 lawsuit, the family of a resident alleged systemic, negligent treatment, including a report that the elderly woman’s bandaged wounds were infested with maggots. In the inspection report from June 27, 2017, the most recent comprehensive annual inspection, there were problems with housekeeping, medication errors, unsafe or rough transfers of residents, call bells not being heard, residents not being assisted to eat and offensive odours so bad that one resident was unable to have visitors in their room. Between October 2018 and August 2020, there were nine critical incident reports, 10 complaints and one follow-up inspection. According to one media report:

“They detailed everything from choking incidents to residents’ blood glucose levels not being checked, to falls resulting in significant injury, more unsafe transfers to lack of infection control.” There were further reports detailing falls, injuries, drugs administered not according to instructions and failure to immediately report allegations of abuse.[16]

The order for the Ottawa Hospital to take over the home was not made until the week of September 21 at which point more than 63 residents and staff had been infected and more than 6 had died.[17] Even after the order, the infections in West End Villa more than doubled by early November. Despite the evidence of a desperate inadequacy of staffing and care, only four residents at Extendicare’s West End Villa had reportedly been hospitalized by the end of September.

Case Study: Kennedy Lodge, Toronto

As of November 16, 2020, thirty-one residents had died and 128 residents and staff were infected by COVID-19 at Kennedy Lodge long-term care home in Scarborough. A spokesperson for the home, owned by Revera Inc., claimed that staffing levels were stable, staff were cohorted to specific units and there was an adequate supply of PPE.[18] His claims were echoed by the Minister of Long-Term Care Merrilee Fullerton in the Ontario Legislature on October 28. She said, “In wave 2, right now, there are no homes with critical staffing levels because we’re getting them the help that they need — including the PPE,”[19] and on Nov. 2, she said, “There are no critical situations with the homes. There are no critical staffing shortages.”[20] Regarding Kennedy Lodge in particular, the Minister told a journalist who was writing an investigative report into the conditions in the home that she had confirmed with Ministry staff that the home had sufficient PPE and they, “are in fact staffed over and above their regular staffing complement.”[21] Like in Extendicare’s West End Villa, these claims could not be more different than those of the staff working in the home.

A November 17 report includes descriptions by a PSW who works on a COVID floor in the home. The worker described critical staffing shortages that mean that infection control practices cannot be followed. Seven to eight staff are supposed to work on the floor, but sometimes only four show up to work and are not replaced. Staff are supposed to designated to specific floors but end up having to go between floors, including between COVID-positive and COVID-negative floors, because there are not enough of them. The PSW said that N95 masks are available but not in the specific fit-tested sizes that staff need. The staff person described shortages of PPE including gloves. The union president described the home as short staffed prior to the pandemic, but she described the situation under outbreak in the second wave as “horribly short-staffed”.[22]

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