A recently released inspection report alleges residents who tested positive for COVID-19 weren’t properly cohorted, with some observed to be out of isolation and coming into close contact with others at Roberta Place long-term care home in Barrie, Ont.
In the Jan. 18 report, an Ontario Ministry of Long-Term Care inspector said Jarlette Health Services, which owns Roberta Place, failed to ensure the home was a “safe and secure” environment for residents with respect to cohorting and isolation.
The inspector reported observing rooms that were shared by both COVID-positive residents and those who weren’t confirmed to be infected with the novel coronavirus. According to the report, a personal support worker (PSW) also indicated that residents within the shared rooms would “often come into close contact with each other.”
“Certain staff were providing care to both confirmed COVID-19 positive residents and residents not confirmed to have COVID-19,” the inspector said. “The administrator indicated that cohorting of staff on all resident home areas was not always possible.”
The ministry inspector also noted all residents at Roberta Place were required to be in isolation at all times, although some were seen out of isolation, touching high-touch surfaces and coming into close contact with other residents.
“Some of these residents were identified as COVID-19 positive,” the report said. “A registered practical nurse (RPN) indicated that they tried to keep residents isolated, but some residents refused to stay in their rooms.”
Staff and residents who weren’t cohorted or isolated placed other residents “at risk for disease transmission,” according to the report.
When the Roberta Place inspections took place on Jan. 12 and 13, Ontario’s long-term care inspector issued a compliance order to Jarlette, requiring the company to cohort staff and residents and to isolate residents “to the extent possible.”
Anatomy of the Roberta Place COVID-19 outbreak
On Jan. 8, the Simcoe Muskoka District Health Unit declared a COVID-19 outbreak at Roberta Place, a long-term care facility in Barrie, Ont. Since then, the virus has spread rapidly at the home, killing 49 people and infecting 128 residents and 86 staff members as of Wednesday afternoon. Three essential caregivers, one of whom has died, and three external partners have also tested positive for the virus.
On Saturday, the local health unit confirmed the U.K. COVID-19 variant, which is believed to be up to 70 per cent more contagious, played a role in the outbreak at Roberta Place. Health officials have said it’s unclear exactly how the variant made its way into the home but noted a staff member came into contact with someone who travelled internationally and tested positive for COVID-19.
On Jan. 16, the Simcoe Muskoka health unit issued an order that would allow the Orillia Soldiers’ Memorial Hospital to temporarily lead Roberta Place in controlling the COVID-19 outbreak. The Canadian Red Cross was also deployed to help.
“The home never successfully put in place the kind of cohorting … where you maintain a restriction on the movement of staff or the exposure of staff to cases and non-cases,” said Dr. Charles Gardner, the Simcoe Muskoka District Health Unit’s medical officer of health, when speaking to reporters Saturday.
“That was something that’s certainly the optimum practice in an outbreak, and that wasn’t established in part because of how quickly this spread and in part because the number of staff that became ill was such that they had difficulty maintaining adequate staffing in the first place.”
At the time Roberta Place was losing staff, it needed more to be able to cohort properly, according to Gardner, which it wasn’t able to do.
In an email Wednesday, a Roberta Place spokesperson said the home has “thoroughly” reviewed the Jan. 18 Ontario Ministry of Long-Term Care inspection report. The spokesperson said the home is working with the local health unit in regard to taking the necessary steps for resident and staff safety.
“The immediate impact on the Roberta Place team was significant despite proactive interventions and mitigation strategies in place at the time of the outbreak,” said Stephanie Barber, Roberta Place’s spokesperson, in an email.
“We identified the need to ensure that the home was suitably equipped with a leadership team skilled with the appropriate dexterity, skills and ability to support consistent compliance, which we promptly acted upon.”
In a statement Wednesday, the press secretary for Ontario’s long-term care minister said inspectors were on the ground during the early days of the COVID-19 outbreak at Roberta Place.
“They acted immediately by issuing a written notice and compliance order to the home to address their findings,” said Krystle Caputo, the press secretary for Ontario long-term care minister Merrilee Fullerton, in an email.
Other ‘non-compliances’ issued at Roberta Place since start of pandemic
Since COVID-19 was declared a pandemic by the World Health Organization in March 2020, inspectors with Ontario’s Ministry of Long-Term Care visited Roberta Place several times — in July, late-August and early-September, December, and most recently in January.
Since March, inspectors issued Jarlette five compliance orders, 15 written notifications and six voluntary plans of correction in relation to Roberta Place.
In a report dated Sept. 16, 2020, an inspector issued a written notice and compliance order to Jarlette for failing to ensure all staff at Roberta Place complied with the infection prevention and control program.
“The inspector observed signage outside two resident rooms, which indicated that isolation precautions were in place for these residents,” the report said.
“The inspector observed that staff went into both of these resident rooms wearing only a procedural mask and gloves. No other personal protective equipment (PPE) was utilized by the staff members.”
According to the report, staff were supposed to be wearing a gown, mask, gloves, and goggles or a face shield when coming within two metres of the two residents who were under isolation precautions. One of the two residents was sick, while the other had recently returned from another facility.
“The improper initiation of isolation precautions and improper use of PPE placed other residents in the home at risk of disease transmission,” the report read.
A ministry inspector also found that staff failed to separate and appropriately handle soiled items. The inspector reported observing soiled briefs and linens on carts that also contained clean supplies, such as towels. The inspector also saw a PSW helping a resident with soiled items in their hand.
“Staff should have promptly placed the soiled items in the appropriate bags or hampers,” the report read. “The improper handling and storage of soiled items increased the risk of contact surfaces becoming contaminated.”
In the September 2020 report, the inspector ordered Jarlette to retrain all Roberta Place staff on COVID-19 isolation precautions and the appropriate use of PPE, develop and implement an auditing process to make sure staff are using the proper PPE and introduce a process that ensures PSWs are handling soiled items correctly.
About three months later in December 2020, a follow-up inspection found Jarlette failed to ensure that all Roberta Place staff participated in the implementation of the infection prevention and control (IPAC) program.
“Although the home had completed the requirement within the compliance order, the home remained non-compliant regarding staff implementation of the IPAC program,” the December report said. “The scope of this non-compliance was widespread because concerns were noted during four of the five dates on site.”
In response, the inspector issued an order requiring Jarlette to prepare, submit and incorporate a plan that ensures all Roberta Place staff participate in the implementation of the IPAC program.
In a statement Wednesday, Barber said Roberta Place “constantly” strives and will continue to strive to achieve compliance to the “more than 1,000 requirements” within Ontario’s Long-Term Care Homes Act.
“We treat all inspections and their outcomes with the highest degree of importance to consistently identify opportunities for improvement while actioning strategies to achieve compliance,” Barber wrote.
“The home was subject to a follow-up and complaint targeted Ministry of Long-Term Care inspection from Dec. 7 (to) 11, 2020. The Ministry of Long-Term Care inspection report received Dec. 21, 202(0), returned two previously issued compliance orders related to the duty to protect and accommodation to compliance.”
Barber said all ministry inspection reports and Roberta Place’s corresponding action plans are posted within the home and made readily available to stakeholders “in an effort to inform and track measurable results.”