When Dr. Kate Greenaway entered Tendercare nursing home amid a COVID-19 outbreak in December she was stunned.
“We’ve been in a pandemic for quite a number of months, at that point, it was pretty shocking to me that it was possible to seem so unprepared for an outbreak,” she said.
A family physician, she had answered an urgent call on social media that the home was in dire need of help. When she arrived at the home she raced from one resident to the next in a desperate attempt to provide assistance.
At least 81 people would die in the outbreak at the Toronto-area home. Management of the facility denies it was unprepared, but Greenaway said the outbreaks in the second wave were part of a larger “systemic failure.”
“I feel a sense of frustration, anger that outbreaks weren’t prevented in a second wave, when we knew exactly what happens with a virus in a long-term care home,” she said.
Documents obtained by Global News and interviews with more than 20 health experts, including physicians and senior’s advocates, reveal how the Ford government received repeated and pointed warnings about the looming dangers lurking in long-term care homes, and how it failed to deliver what was desperately needed in a sector already devastated by a deadly first wave of COVID-19.
“It was all just too slow, too late,” said Dr. Kevin Katz, medical director of infection prevention and control at North York General Hospital in Toronto.
Some of the documents included:
- An April 20, 2020 letter from infection prevention and control leaders at Toronto-area hospitals warned about the dire need to train and hire more infection prevention experts.
- An Ontario Health review Insights and Recommendations for Long-Term Care from July 24, 2020 warned that “LTC and public health are significantly under-resourced to meet IPAC standards to protect the basic needs of residents”
- A “lessons learned” list from the Ministry of Long-Term Care dated July 15, 2020 warned that the province knew it needed “1000s” of PSWs.
The Ontario Long-Term Care COVID-19 Commission’s final report as well as a damning new auditor general’s report underscored a months-long Global News investigation that found the Ontario government failed to provide homes with adequate infection prevention and control (IPAC) measures, didn’t hire staff fast enough and failed to take action on de-crowding older homes.
While provinces had months to prepare and learn from the catastrophe of the first wave, nearly all of Canada’s most populous provinces: Ontario, Manitoba, Alberta and B.C. saw higher death tolls in the second wave — 7,479 deaths between Sept. 1, 2020, and Feb. 15, 2021, according to Ryerson’s National Institute for Aging.
READ MORE: Ontario ‘completely ignored and bulldozed’ problems in long-term care, former inspector
Deaths in long-term care and retirement homes increased to 2,265 from 2,072 in Ontario during the second wave, Alberta saw its first wave numbers catapult from 153 to more than 1,000 in the second wave, and Manitoba’s jumped from just three deaths in the first wave to 480 in the second wave.
Over the course of the pandemic, nearly 15,000 residents in long-term care and retirement homes died across Canada.
“If you want to talk about high yield things that could have been done, it would have been to secure staffing, shore up infection prevention and control, and it would have been to de-crowd homes,” said Dr. Nathan Stall, a geriatrician and researcher at Mount Sinai Hospital in Toronto. “We failed to act meaningfully on either of those three issues.”
“Why was this sector so neglected and why did nobody act on what was learned in the first wave to prevent it from happening in the second wave?”
‘Significant deficiencies’
In April 2020, as long-term care homes were still reeling from the devastating first months of the pandemic, a group of physicians warned the Ontario government that it needed to rapidly build IPAC inside nursing homes.
Infectious disease experts called for the government to hire IPAC specialists for nursing homes at a ratio of one full-time specialist per 200 beds; one per 250 beds in retirement homes.
Known as a “hub and spoke model” these workers would be trained and managed by the specialized doctors based at nearby hospitals.
The proposal written up for Toronto — which could be expanded across the province — said the cost would be between around $5.5-million and $7.2-million a year.
“The dividends in resident and staff safety as well as future cost savings to the overall healthcare system will be substantial and will be felt immediately,” the document read.
READ MORE: A Toronto nursing home left isolation rooms empty as COVID-19 spread on crowded floors, killing 81
However, it wasn’t until November – as homes began reporting more COVID-19 outbreaks – when the Ministry of Long-Term Care formally outlined specific recommendations related to the “hub and spoke model,” which was first adopted in September. Nursing homes would get support from hospitals but not to the degree as IPAC specialists had called for in April, and the funding was just two-thirds of what hospital leaders had been asking for.
The funding letters for this life-saving IPAC measure didn’t arrive until January 2021, nine months after the first proposal was issued.
The province didn’t respond to questions about why the funding took months to arrive after it was announced.
Long-term care minister Merrilee Fullerton declined several requests for an interview.
The ministry said in a statement that specific recommendations related to the “hub and spoke model” proposal have been adopted.
“IPAC hubs have been established in Ontario Health regions provincewide, and most are housed in hospital sites with advanced expertise in IPAC,” said spokesperson Rob McMahon.
McMahon also said the ministry has “made significant” IPAC investments announced in September 2020 which included $61.4 million for repairs for homes to improve infection prevention and control and $30 million to allow long-term care homes to hire more infection prevention staffing, including $20 million for additional personnel.
Dr. Susy Hota, medical director of infection prevention and control at Toronto’s University Health Network, said the province needs to move faster to close the “gap” in the need for these experts in long-term care.
“It’s not like there are infection prevention and control practitioners waiting in the wings through this pandemic,” Hota said. “They’re all employed and they’re all very much in shortage.”
READ MORE: Ontario’s LTC sector not ‘sufficiently positioned, prepared’ to respond to COVID-19 in effective way
Dr. Katz said Ontario missed a crucial window between the first and second waves to bolster defences inside the long-term care homes against the virus.
“There was a long period of time there between the first wave and the second wave, six months where the cavalry should have been called in. Resources should have been put in place,” he said. “But those activities really only started later into the fall.”
More warnings about the need for infection prevention came in September. Ontario Health documents obtained by Global News show that on Sept. 10, 2020, there were still major concerns about IPAC measures and staffing in every region.
“Many homes were unable to comment on whether or not they were expecting more staff to return to work compared to Wave 1 for various reasons,” read the document titled Ontario Health Regional Preparedness Assessment Summary.
‘Iron ring’ was farce, says physician
As more outbreaks began to emerge at homes that had escaped the first wave, crippling staffing shortages became a key contributor to some of the worst crises.
For Stall, it was “unthinkable” that Ontario’s second wave would be more deadly given the months Ontario had to prepare and said Ford’s promise to build an “iron ring” around nursing homes was a “farce.”
“We didn’t act on the lessons learned to prevent another tragedy from happening during the second wave,” Stall said. “The iron ring never existed.”
In Quebec, as the provinces’ long-term care homes, known as CHSLDs (Centres d’Hébergement de Soins de Longue Durée) were dealing with its own crisis that killed over 4,600 residents during the first wave, Premier François Legault vowed to hire 10,000 new orderlies who would play a supporting role.
Just over 8,000 orderlies were trained over the summer, according to Quebec’s Ministry of Health, with 7,600 still in place and 800 more in training.
In Ontario, however, a patchwork of hiring programs launched in the fall has failed to produce the additional workforce needed in long-term care.
“What we didn’t do was take the big steps forward like Quebec did to do mass hiring and training over the summer to meet the needs in the fall,” said Laura Tamblyn Watts, president of Can-Age, a seniors’ advocacy organization. “The efforts were minimal.”
And the government knew many of its 626 homes were in dire need of help.
The months-long calls for help didn’t just come from public health experts, but also from Ontario’s Long-Term Care Association (OLTCA), the advocacy group that represents the majority of long-term care homes in Ontario.
“We know the government did make attempts to help us recruit staff. Nobody came,” said Donna Duncan, CEO of the OLTCA.
“We needed help and we still need help.”
On June 19, 2020, the OLTCA advised the government it needed to “train, certify and hire an army of Infection Prevention and Control (IPAC) Specialists.”
“Our challenge was that there isn’t an army of those people. We needed to build the army,” Duncan said.
Duncan said while there is some staff IPAC training in homes, there are no dedicated specialists and they usually have “20-30 other different roles” in the home.
The province said it provided enough funding to hire “over 150 IPAC staff” for Ontario’s 626 homes, but did not say how many had actually been hired.
Crowded homes
Ontario’s aging long-term care homes were not a problem created by the pandemic. There are more than 24,000 beds built to design standards of 1972, many with three or four people to a room.
For Stall, the problem of crowded homes was something the government didn’t work quickly or creatively enough to address.
“This is a deadly risk factor. And it was very foreseeable that we were going to have a large number and large meaning thousands of deaths during the second wave,” Stall said.
Some hospitals and regions got creative.
The Salvation Army-run Toronto Grace Health Centre created a plan for up to 90 beds inside a convention hall. And Windsor Regional Hospital, in conjunction with the province, set up a 100-bed field hospital inside the St. Clair College Sportsplex to house long-term care residents who have tested positive.
READ MORE: Staffing shortages, absentee leaders linked to high mortality in Ontario LTC homes
But experts say these were the exceptions and most infected residents had nowhere to go.
“Our premier in Ontario talked about moving heaven and earth to protect long-term care residents,” Stall said. “There were expensive, complex innovations that could have been done to protect residents.”
The Long-Term Care COVID-19 Commission’s final report found the sector was completely unprepared for the pandemic, as well as a government response that “lacked urgency.”
“Many of the challenges that had festered in the long-term care sector for decades — chronic underfunding, severe staffing shortages, outdated infrastructure and poor oversight — contributed to deadly consequences for Ontario’s most vulnerable citizens during the pandemic,” the commissioners wrote.
In March, the Ontario government announced $933 million in new funding to create more beds in long-term care and upgrade facilities and pledged to ensure long-term care residents get an average of four hours of direct care each day.
It’s part of a $2.6-billion plan to create 30,000 beds over the next decade.
The ministry also said in a statement it has established the Response and Recovery Advisory Committee which is “expected to discuss IPAC capacity in the sector and to make recommendations for priority actions going forward.”
However, for public health experts, the more than 3,700 nursing home residents who died between March 2020 and March 2021 was a “collective” failure that could have been significantly mitigated.
“At each opportunity over the course of the pandemic, when it came to long-term care home residents, we really never missed an opportunity to let them down,” Stall said.
“What most families want is probably an apology. And some acknowledgment that things could have been done better.”
Part 3: This is the final story of a three part investigation into Ontario’s long-term care crisis amid COVID-19
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