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Inspection reports from Hamilton’s biggest and deadliest COVID outbreak

Posted: January 29, 2021

(January 28, 2021)
By: Joanna Frketich, The Hamilton Spectator / Maria Iqbal, The Hamilton Spectator

Public health inspections revealed issues with Grace Villa’s staffing, cleaning and infection control during the city’s worst and deadliest outbreak of COVID-19.

But ensuring residents had proper care was beyond the department’s scope, so public health services says it met with the Ministry of Long-Term Care on Nov. 27 — two days after the outbreak was declared at the home at 45 Lockton Cres. on the east Mountain.

“We called in the authorities saying we need you to look at this home,” said Hamilton’s medical officer of health, Dr. Elizabeth Richardson. “Throughout those early days, all the way through, we were definitely pressing to say they need support, they need more guidance.”

No provincial inspector went into the home until Dec. 15, despite the ministry also saying it was involved in the outbreak from the beginning. The inspection was prompted by a complaint and it’s not clear if public health’s call for help had anything to do with it.

The public inspection report dated Dec. 22 shows no problems found with compliance and no orders or other corrections issued at the home, where 234 people were infected and 44 died over the course of the outbreak that was declared over Jan 20.

“There needs to be some accountability around that for sure,” said provincial NDP Leader Andrea Horwath. “It’s absolutely impossible to believe that there was nothing found in an inspection and yet the voices of the front-line workers say exactly the opposite. “

Letters from staff to their local MPP that became public Monday detailed disturbing allegations about conditions inside the outbreak, including residents lying on bare mattresses soaked with urine, others waiting 30 minutes for help when choking, as well as allegations of preventable deaths from neglect.

“The images of residents, some hanging out of beds moaning, vomiting, crying, it is all too much to bear,” read one of the anonymized letters from staff. “I still can’t sleep at night.”

The scathing reports have led to calls to revoke the operator’s licence from union SEIU Healthcare, NDP Hamilton Mountain MPP Monique Taylor, the Ontario Health Coalition and McMaster University professor Dr. Amit Arya.

Grace Villa’s operator, APANS Health Services, did not respond to The Spectator’s request for comment on the inspections Wednesday. However, CEO Mary Raithby said in an email Tuesday that the workers’ statements are “deeply concerning.”

“Our leadership team is working tirelessly to ensure everyone has the knowledge, training and resources to safely care for our residents now and in the future,” Raithby said.

Public health held the first inspection amid the outbreak Nov. 27, two days after it was declared. It found several issues, including staff with masks “pulled down, not covering the nose.” They also noted that the staff member who screened the inspectors at the entrance was not wearing either goggles or a shield.

Personal protective equipment (PPE) was not readily available outside residents’ rooms nor garbage bins to dispose them in. At the time of the inspection, the COVID-positive residents were restricted to the third floor.

The inspectors noted missing signage and that they did not see records that the home was auditing staff compliance with COVID-19 precautions, though the home said its leadership team was doing checks “regularly” and correcting issues.

A day after that inspection, public health ordered Grace Villa to “immediately” allow Hamilton Health Sciences (HHS) to enter the home and to follow its direction with a penalty of up to $25,000 for noncompliance.

It also ordered that the home ensure proper infection prevention and control, and buy any recommended resources.

Public health confirmed Wednesday it did not issue any fines against Grace Villa.

Inspectors returned Dec. 11 and found even more issues. There were so many cases by then that COVID-19 patients were no longer limited to the third floor. But inspectors saw a resident wandering into a common area without wearing PPE and coughing.

HHS staff were working on the first floor, but Grace Villa was short on cleaning staff, resulting in high-touch surfaces only being sanitized once daily instead of twice.

Again, there were staff without shields or goggles, missing signage, and one missing record of a staff member’s temperature check when leaving their shift, the report said.

Yet the provincial inspector lists no infractions in a public report of the Dec. 15 tour of the home during which residents and meal service were observed, and interviews took place with staff and residents.

“The ministry takes long-term-care home accountability and compliance with the act very seriously,” spokesperson Mark Nesbitt said in a statement Wednesday. “Inspectors support homes on the ground through staff, supply, and care co-ordination, serving as point-people with local public health, helping homes to prevent and contain infections, and assisting with many other tasks necessary to the safety and security of residents. As professionals, inspectors are required to report on their concerns to the ministry.”

The statement doesn’t explain why the inspection differs so greatly from staff accounts and public health findings. It also doesn’t say what the complaint was that led to the inspection or who raised the concerns, citing privacy.

“Since the start of the outbreak on Nov. 25, the ministry has worked continuously with the local public health unit, Hamilton Health Sciences and all our health-sector partners to support the home and its residents,” says Nesbitt.

The day after the ministry inspection, the province approved HHS’ temporary takeover of management at Grace Villa and public health found continued problems with cleaning.

The public health inspection from Dec. 16 says agency staff didn’t have a guide of which areas to clean and said they should be assigned duties so high-touch areas could be sanitized twice daily.

It noted six more cleaning staff had been brought on as of Dec. 13, though four of them were working in dietary.

Inspectors added dietary staff had not been included in infection prevention and control checks to date. They also called for more signage and for sanitary supplies to be placed at appropriate spots.

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