The owners of a private long-term care home in suburban Montreal where dozens of residents died during the COVID-19 pandemic in March and April displayed “organizational negligence,” according to a new report.
The Quebec government released the report into Residence Herron on Wednesday, as well as a separate report that looked into a public long-term care home north of Montreal where 100 residents died.
In total, 38 people died at Residence Herron between March 26 and April 16, including 23 who died in less than a week between April 5 and 10, the report states.
Commissioned by the provincial government, the investigation concludes that authorities at Herron repeatedly failed to address shortcomings noted in prior inspection reports and in a coroner’s report, largely because of vacancies in key posts and a turnover rate that reached 20 per cent a year.
“It is clear with such a turnover of staff, things must continually be redone,” the report reads.
The report details the chaos that followed the discovery of a first case of COVID-19 on March 26, and its devastating effects on a residence that was described as ill-prepared to confront a pandemic.
The private facility was placed under government trusteeship after regional health authorities in late March found only three employees on site to care for 133 residents, some of whom were sitting in overflowing diapers and suffering from dehydration.
In the days that followed the first case, residents and staff began showing symptoms. There was no protective equipment until March 28, “except for a few masks,” the report reads. Staff began staying home, either out of fear or because they were told to go into isolation.
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On March 29, co-owner Samantha Chowieri texted the local health authority to inform them that the residence was short at least 27 people, including nurses, auxiliaries and care attendants.
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A team dispatched from the health authority found dirty floors, air that smelled of urine and feces and residents who were thirsty and dehydrated.
“Several (residents) were soiled, because their incontinence briefs had overflowed and the beds were dirty and the stains suggested it was several days old,” the report says. “When the incontinence briefs were changed, several residents had burns on their skin and the hygiene of the genital areas had not been done adequately.”
In a statement, Herron’s owners said they would take the time to carefully analyze the report before commenting.
The investigator commissioned by the health minister, Sylvain Gagnon, also criticized Herron’s owners for failing to collaborate with health authorities, who eventually sought a court order on the matter.
He concludes that the managers of the facility did not have “malicious” intentions but they did not have full control over their facility and they lacked understanding of what was required to respond to residents’ needs.
“As a result, I must conclude that in the present affair the authorities of the Herron CHSLD demonstrated organizational negligence,” Gagnon writes.
But the investigator reserved some of his harshest criticism for the province’s health-care system, which he says failed to address problems with long-term care and persistent staff shortages across the network.
He was highly critical of the former Liberal provincial government’s health-care reform of 2015, which was supposed to save costs and improve organization but had a negative effect on patient care, he said.
“Were our elders forgotten? Did the authorities at the time lack foresight? We have to answer in the affirmative,” he said.
He also recommended the province study whether private long-term care homes have the resources to adequately meet the needs of people who have serious health conditions or loss of autonomy.
The government also made public a report into the Ste-Dorothee long-term care home in Laval, which had the province’s highest death toll in the pandemic.
Investigator Yves Benoit found that pre-existing staff shortages were exacerbated when staff members had to self-isolate due to exposure and agencies refused to send their workers to hot zones.
Asymptomatic employees helped COVID-19 spread through the facility, throwing it into a crisis that resulted in more than 40 per cent of residents testing positive in early April.
Managers at the nursing home criticized health authorities for not setting foot on the site, leading them to feel abandoned.
The report concluded that the workers did the best they could, and the problems at Ste-Dorothee were largely the same as those faced by other long-term care homes: a lack of staff, ineffective management structure and shortages of personal protective equipment.
In a statement, Health Minister Christian Dubé said the government has already acted on many of the recommendations in the reports, which were submitted to the government in June and July.
“Not only did the major changes undertaken serve to prepare us for the second wave, our actions are sustainable and their benefits will continue after the pandemic,” he said in a statement.
Those changes include mandating that a manager be named to lead each long-term care home, raising salaries, hiring thousands of health-care staff and ensuring infection-control measures are in place in each residence.
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