COVID-19 deaths piled up as this LTC home missed deadlines to fix infection control, prevention problems. This was the government’s ‘pathetic’ response

In the midst of a COVID-19 outbreak that ended up killing 81 residents, the long-term-care home with the most deaths from the virus in Ontario was cited twice in two months for failing to comply with infection prevention and control measures.

A newly published provincial inspection report shows Tendercare Living Centre in Scarborough took more than two months to follow orders to comply with legislation designed to protect residents after inspectors found problems in December and January during the virus’ aggressive second wave.

The home was ordered by the Ministry of Long-Term Care on Dec. 17, 2020, to train and monitor employees to ensure proper infection control practices were being followed and to ensure an appropriate supply of personal protective equipment (PPE) was available. The order came after inspectors observed staff members going between residents’ rooms without proper PPE and some staff entering residents’ rooms without putting on gowns or gloves. Inspectors also found that many resident rooms and areas did not have PPE caddies available for staff. They gave the home until Christmas Eve to comply.

But the next month, inspectors once again found similar problems: a personal support worker (PSW) entering a resident’s room with a meal tray without wearing any gown or gloves, a housekeeper who punctured their gown to create a hole for their right and left thumbs, and a PSW feeding a resident a sandwich with bare hands. At this time, January 2021, residents were isolated in their rooms and droplet and contact precautions were supposed to be in place.

Instead of escalating the compliance failure to the director of the inspections branch, which is an option if homes do not comply with orders, and despite the fact that the inspectors found an “actual risk of harm to the residents” due to staff “not participating in the implementation of the (infection prevention and control) program,” the inspectors simply reissued their compliance order from December 2020 and gave the home until Feb. 26 to comply.

Tendercare, which is managed by Extendicare, says it was “in compliance by March 25, 2021” though it took inspectors until May — a full five months after the initial order — to verify this.

Candy Chan, manager of resident programs at Tendercare, told the Star in an email that “referencing reports alone will produce a misleading and inaccurate timeline of a home’s work to comply with inspectors’ recommendations or directives, as they do not outline the response time or ongoing work at the home level to respond.”

Chan included a statement from Tendercare in her email, which begins by saying the home “takes the ministry inspection report process very seriously and is glad to co-operate fully with each stage.”

“As you know, our home was battling a severe COVID-19 outbreak in December of 2020, that resulted in significant impact to our staffing levels, as large numbers of our team members tested positive for the virus. The scale of the outbreak greatly disrupted normal operations, as our full focus was on maintaining resident safety, stabilizing staffing levels with support from North York General Hospital, and clearing the virus from the home,” reads the statement, noting that infection prevention and control (IPAC) best practices were made a priority during the outbreak and in the weeks that followed.

The statement says that the home retrained all staff in infection prevention and control and created a team of 25 “IPAC Champions” in February to monitor and audit the work of their peers.

“We share in the sadness of each community and family that has been impacted by this pandemic. We will continue to follow all directives, guidelines and advice to protect our residents and continually improve our processes,” the statement reads.

Clorie Ng, whose 88-year-old mother,Yunsim Leung, is a resident of Tendercare, likened the inspection process to a “cat-and-mouse chase” between the home and the ministry.

“I’m not interested in reading all these reports about what went wrong anymore. I want to find out why all this went wrong. Let’s get to the root of the problem,” said Ng. “Do we have to wait until more people die?”

Clorie Ng, shown here with her mother, Yunsim Leung, says that Tendercare's handling of a COVID-19 outbreak was 'brutal.' Leung contracted COVID-19 at the home in December 2020 and nearly died, and the home misplaced her belongings during a move.

Ng says she received a call from the home on Christmas Day 2020 informing her that her mother, who uses a wheelchair and suffers from dementia, had tested positive for COVID-19. By that time, the 254-bed facility had 121 confirmed resident cases and 31 resident deaths.

“I kind of knew that she would get it, the way (the home) was handling it … totally brutal. Like the worst nightmare,” Ng recalled. “She was on the verge of dying.”

Adding to the family’s stress of dealing with the outbreak, Tendercare managed to lose all of Ng’s mother’s personal items, including her clothes and the family pictures on her walls, while temporarily moving Leung to a new room.

“That was so devastating,” Ng said.

Loading…

Loading…Loading…Loading…Loading…Loading…

Remarkably, despite requiring oxygen to breathe and people to feed her, Leung recovered. She received her first COVID-19 vaccine in February.

With regard to Ng’s mother’s lost belongings, Tendercare’s Chan said “we deeply regret that personal photos and clothing items were misplaced” and that “this is below the standard of resident care quality we hold ourselves to.”

At the time of the January inspection, North York General Hospital had assumed temporary management of Tendercare to assist the home in meeting the required standards. A statement from the hospital to the Star said progress was made in January to improve compliance, including “rigorous staff education, training and retraining on IPAC and outbreak management best practices,” and to address the severe staffing shortage by bringing in about 40 physicians, and increasing nursing and PSW staffing to a higher level than Tendercare had before the outbreak.

While inspectors visiting Tendercare in May found that the home did eventually comply with the December order to ensure proper infection prevention and control practices, they made yet another finding that the facility “failed to ensure that the home was a safe environment related to infection prevention and control measures.” Inspectors cited the home for failing to follow a May directive issued by Ontario’s chief medical officer of health to address outbreak risks in the wake of the COVID-19 pandemic.

Specifically, the inspectors found Tendercare failed to ensure a visitor to the home wore proper eye protection due to a risk of “transmission of infectious agents,” and failed to actively screen all staff, visitors and anyone else entering the home for COVID-19. In this case, it was in fact one of the inspectors that the home neglected to screen.

Despite the fact that the home failed to follow the chief medical officer of health’s directive, the inspectors did not order the home to comply. Instead, they asked the home to come up with a written plan “to ensure that the home is a safe and secure environment for its residents” in the form of a “voluntary plan of correction.”

A Star investigation published in May highlighted how provincial inspectors have in recent years been asking homes to come up with voluntary plans of correction, considered an essentially powerless sanction, for serious compliance failures, such as failing to report an allegation of staff-on-resident abuse to police, failing to test a resident for COVID-19 after they developed symptoms (the resident later died), and insufficient supplies of blankets and bedspreads. Critics call voluntary plans of correction “absolutely useless” because homes are not required to submit their plans to the ministry.

“What does it take to finally get compliance to something as important as infection prevention and control? It seems that what is happening is that the inspection branch almost has to beg and plead to get some compliance, rather than having some teeth and forcing the compliance,” said Patricia Spindel, co-founder of Seniors For Social Action Ontario (SSAO), a group of social activists calling for in-home and residential care in the community as an alternative to institutions.

“This should not be a negotiation. This should just be a requirement that they need to follow because it’s the law,” she added. “The public deserves protection, not a pathetic response.”

In a statement to the Star, the Ministry of Long-Term Care said its inspection system “exists to keep residents safe.”

“The ministry continually assesses information and re-prioritizes inspections daily based on harm or risk of harm to residents,” said ministry spokesperson Aslan Hart, noting that actions or sanctions when non-compliance is found are based on the risk presenting to residents.

Hart said inspectors take into account a number of factors when deciding what actions to take, including the severity of the non-compliance, and in cases where there has been harm or risk of harm to residents, the severity of that harm or risk of harm. The ministry also looks at the scope of non-compliance, as well as the licensee’s history of compliance, he said.

“The ministry is in the process of evaluating our inspection system,” Hart said. “The goal is to develop an improved, standardized inspection process that aligns with addressing risk in reactive and proactive inspections and consider the appropriate use of and balance between supportive and compliance-focused mechanisms and tools.”

TORONTO STAR