Nobody died in these nursing homes - what did they do right?
TORONTO -- Norma Sullivan is one of the lucky ones. At 91, she's been wheelchair-bound for the last eight years and lives at Chartwell Waterford Long Term Care Residence in Oakville, Ont., one of the hundreds of residential care homes in the province and across Canada that eluded a deadly outbreak of COVID-19.
Lynn Mucci, Sullivan's daughter, is grateful her mother's home has been a safe haven amid the fears over the quality of care at these facilities.
"Please know that the families of the Waterford residents appreciate all of you and are thankful for everything you do. Keep safe and hold your heads up high. You are my heroes!" She wrote in one email to staff.
Since COVID-19 was first reported in Canada on January 26, the disease has spread quickly and silently through nursing homes, leaving in its wake a devastating death toll. Stories from worried family members and reports -- including a damning one by the Canadian Armed Forces that alleged neglect and described overwhelmed, poorly trained, and ill-equipped workers hit by massive staffing shortages -- have shocked Canadians.
However, amid the alarming numbers, are the lesser-known stories of nursing homes that did not face a crisis. In interviews with several long-term care providers representing roughly two dozen long-term care facilities that had no or very few cases and were quickly contained, a combination of early planning, monitoring and timing seemed to have helped put these facilities on a different course.
This meant taking precautions and action before they were mandated or recommended by the government. Screenings as far back as January, sourcing extra personal protective equipment (PPE) before the shortages hit, reorganizing and beefing up staffing early were just some of the measures these homes say helped prevent an outbreak like the ones that ravaged numerous other facilities, especially across Ontario and Quebec.
In Quebec, centre d'hébergement Sainte-Dorothée, a 285-bed facility in Laval, reported 95 deaths, according to data collected by freelance journalist, Nora Loreto. The Notre-Dame-de-la Merci in Montreal reported 93 deaths in its 398-bed residence. The Quebec government operates both facilities and many other hard hit locations. The province’s coroner ordered a public inquiry into the deaths last week. More than 3,640 out of the more than 5,400 deaths in the province so far have happened at public long-term care homes (CHSLDs). Another 930-plus have been at private care facilities.
According to Loreto's database of deaths in residential care facilities -- collected through public health data, media reports, reports from homes, obituaries and families -- nine of the 10 worst-hit homes were in Quebec, all reporting more than 65 deaths each.
In Ontario, the Patient Ombudsman's office is launching an investigation into the province's facilities following more than 150 complaints. Orchard Villa Pickering, run by Southbridge Care Homes, had 78 deaths at its 233-bed residence, while more than 90 staff members were diagnosed with COVID-19. Camilla Care Community in Mississauga, a 237-bed residence had 68 deaths, while Altamont Care Community in Toronto had 53 deaths at its 159-bed home. Both are operated by Sienna Senior Living, which reported deaths due to COVID at nearly half of its 37 Ontario long-term care facilities, according to self-reported provincial data. Eight of Sienna's residences accounted for 260 deaths combined, while another eight reported under five deaths each. Its CEO resigned for "personal reasons" earlier this month.
Ontario and Quebec bore the brunt of the staggering number of deaths. More than 560 homes in Quebec and more than 430 in Ontario have experienced some level of outbreak, according to data compiled by the National Institute on Ageing. But other regions in Canada were not immune: 53 died at Northwood Manor, a 485-bed home in Nova Scotia, while 24 died at Langley Lodge, a 121-bed facility in British Columbia. And overall, Loreto's data shows that more than 7,100-- roughly 84 per cent -- out of the more than 8,400 deaths related to the coronavirus in Canada have been attributed to nursing homes.
"I think it's important to know that, yes, in long-term care, no one could have been prepared for this unprecedented pandemic. It's not like anything we've seen or experienced before," Wendy Beckles, the CEO of Shepherd Village in Toronto, told CTVNews.ca
As these homes recover, provinces across Canada are taking steps to slowly allow visitors again. But with a vaccine still far away and a resurgence in cases a constant possibility, homes that escaped the first wave unscathed are aware how easily the virus can still slip inside.
ON ALERT SINCE JANUARY
Shepherd Village is a seniors’ community of about 900 residents in Toronto’s Scarborough area. About 250 are in long-term care, and close to 150 reside in the retirement home. Most of those in retirement are on the waiting list to move into long-term care. Another 500 or so live independently.
Since the virus was first detected in Canada, all but two staff members have tested negative at Shepherd Village, according to Beckles.
A number of the measures taken at Shepherd Village were implemented at other homes as well. "But what it came down to -- as we reflect on what we did -- was timing," she said.
"In many ways, it was -- how soon did we implement processes and procedures, together with the intensity and the consistency of our efforts?”
In a pandemic that has demonstrated time and again how quickly circumstances can take a dramatic turn for the worse within a few short days, early preparedness appeared to mean the difference between life and death at some of these facilities.
It is a sentiment echoed by Tracy Jones, the CEO of the Yee Hong Centre for Geriatric Care. However, she added, "You know, I'm not going to get on my high horse about this because it is an invisible enemy."
Yee Hong is a non-profit group that operates four long-term care homes across the Greater Toronto Area. The organization is self-described as "culturally appropriate" –they offer menus, spiritual, religious, cultural support and celebrations, and have linguistically trained staff that primarily serve Chinese and other Asian communities. Some 805 seniors call Yee Hong home, while some 400 others live in independent housing.
Both Jones and Beckles said they were monitoring the news closely in January as the disease spread in China. They knew they had to start planning because it was "just a matter of time."
"It was long before we even really understood what the impact would be on long-term care," said Jones, adding that they had a pandemic plan in place that was activated earlier than many other homes.
Screenings at both facilities began in late January as staff came back from the Lunar New Year holiday. A "command team" was created at each Yee Hong location to serve as backup should their leaders fall sick, while Shepherd Village created a COVID preparedness team. Both places implemented a one-employer policy before the government made it a requirement.
Vacations at Yee Hong were put on hold to mitigate worries about staffing shortages and employees were wearing masks and face shields well before they were mandated. They were also trained on proper usage. Social gatherings, including celebrating the Lunar New Year, which fell on January 25 this year, were cancelled at Yee Hong.
"Why we have been successful thus far is we did get a little bit of a head start from others in the sector. We've been watching what was happening in China. We have employees that were travelling, coming home," said Jones, who said their organization quickly decided that staff returning from their trip would be put on a 14-day, paid quarantine.
Scarborough, where Shepherd Village is situated, also has a large Chinese population, and Beckles knew many in the facility had families who went back to China to see loved ones over Christmas and New Year’s, and were coming home just after the Lunar New Year as well.
Meanwhile, the screenings became more comprehensive throughout February and into March, with temperature checks initiated weeks before it was mandated by the chief medical officer of health, Beckles said.
Shepherd Village, Yee Hong, and many others were completely closed within two days of the World Health Organization formally declaring a pandemic, with only staff and essential visitors allowed.
"It became really clear to us that we have got to limit access to our residence," said Beckles.
By the beginning of March, long-term care and retirement home residents at Shepherd Village had to stay on site, tray service began, and staff were not allowed to move from floor to floor or leave the premises for lunch.
Yee Hong also implemented a similar cohorting scheme for staff and residents "very, very early." Each of its homes had an isolation unit prepared so that infected residents could be moved off the floor and quickly segregated.
SECURING MORE PPE, MASS HIRING
Shepherd Village also started securing additional PPE in anticipation of the coming shortage, based on their experience with the flu season and extrapolating what that meant for a virus with no vaccine that also required 14 days of isolation. The early sourcing of new suppliers combined with donations from the community meant Shepherd Village maintained adequate levels of PPE at all times, Beckles said.
"We said, 'you know what? This thing's going to hit like a tidal wave.' I started sourcing suppliers in China to get our orders in well in advance of the shortage that then occurred," she explained.
Shepherd Village staff also increased their monitoring of residents for signs and symptoms of the virus. Even symptoms that were not on the list were treated with extreme caution. Both Yee Hong and Shepherd Village reported having two employees who tested positive early on that were immediately contained.
The two off-site cases at Shepherd Village put the community on high alert, Beckles said. “Hundreds of hours” of sanitizing were conducted. The whereabouts of the infected staff over the previous 14 days were also investigated: the shifts they worked, the residents they interacted with, and who also worked those shifts. The entire floor of residents and everyone who worked with them were immediately tested. All other staff and residents have since been tested as well.
Beckles said they began using disposable utensils, which pushed up the cost, and they implemented hand hygiene audits to remind staff on how to properly wash and ensure compliance.
Staff who worked at multiple jobs were asked to choose only one employer long before it was mandated. Shepherd Village, which typically employs about 460 full and part-time employees, initially lost 20 per cent of its staff as a result. The cumulative loss was up to 30 per cent after some could no longer work due to child or elder care responsibilities once the pandemic was officially declared.
But Shepherd Village said they began looking to hire additional employees early on, not just to fill the vacancies from staff who left, but due to additional staffing requirements as a result of their early pandemic safety measures. More help was needed for the additional screening and to fill in gaps created by staff having to cohort on a single floor. Even meals -- which usually entailed one staff member helping three or four residents at a dining table -- required more hands and one-on-one help after tray service was implemented. More help was also needed to facilitate phone calls, Skype, and FaceTime sessions between residents and family.
With assistance from the Ontario Long-Term Care Association, Beckles was hiring 30 people at a time, connecting with colleges to bring in nursing and personal support worker (PSW) students, getting retired nurses to come back and recertify, and hiring quickly outside the bargaining unit. They were able to return to their original staffing level and beyond, with managers going back to the frontline as new hires underwent training.
Yee Hong also lost some of its 1,350 staff members. Still, they were ultimately able to maintain between 90 and 100 per cent of their staffing level, Jones said, as the organization made similar hires as those made at Shepherd Village.
At Yee Hong, when the adult day programs for the community were shut down, those staff were redeployed to its long-term care homes, cohorted, specifically to focus on virtual visits with family members and provide one-on-one time with seniors.
It’s not perfect, Jones said. The sense of isolation and confusion does happen -- "it does not replace the face-to-face of a family. We know that."
"THEY DIDN’T MAKE HER FEEL LIKE SHE WAS ALONE"
Over the last few months, Norma Sullivan's daughter, Mucci, has witnessed the difference in care these kinds of early measures have meant for her mother at Chartwell Waterford,compared to the horror stories she was hearing elsewhere. They had not been overwhelmed by staffing shortages, and importantly, she said she felt "100 per cent confident" in her mother’s care and never felt she was being neglected. Waterford had its own minor outbreak, Mucci said, but "they really contained it -- they didn't fool around."
Mucci, who is 65, says she and her friends are fortunate enough to still have a parent alive, but many of them are on waiting lists to get into long-term care. Sullivan, who had suffered several falls, had been waiting four and a half years before a spot opened in the spring of 2018 at Waterford, Mucci's top choice. But now, her friends are worried.
"(They're) stressing out going, 'Oh my God, I don’t want to put my parents in a long-term care facility,' and I said, 'they’re not all like that.'"
While separation from loved ones could be lonely for residents, the staff tried hard to maintain a semblance of normalcy in the absence of family, Mucci told CTVNews.ca. From her daily phone calls to emails and photo attachments with subject lines like, “Norma wants to say hi,” Mucci said Waterford put in extra effort to help reassure families and make them feel connected with their loved ones.
"When this whole scenario came up - it's difficult to watch their morale because they're just kind of all painted with the same brush as ... these long-term care facilities that are having major issues," she said.
Norma Sullivan poses for her birthday in this photo taken May 8, 2020. Photo provided by Lynn Mucci.
For Sullivan’s birthday last month, Mucci asked staff to bring her to a window so her family could sing happy birthday from outside. Gifts had to be delivered the day before, to allow them to sit for a period of time, out of an abundance of caution.
"I really felt that they really made an effort, you know, to celebrate mom's birthday," she recounted. By the time she got home, there was already an email waiting in her inbox from one of the staff members who had brought Sullivan to the window: they had stayed with her afterward while she opened her presents.
"They’re in the middle of a stressful time with lots to do, but they took that extra time and sent me a picture of her with her balloons and the flowers and everything. I felt like they made an effort. How many more birthdays is she going to have? They didn’t make her feel like she was alone."
Waterford is one of more than 200 retirement and long-term care homes run by Chartwell Retirement Residences, one of Canada’s largest senior living operators. Like Shepherd Village and Yee Hong, Chartwell said it moved quickly to strengthen infection control protocols across all its facilities and launched a recruitment campaign that saw over 1,300 new hires during the pandemic. Like the others, they enacted screening and monitoring measures across the board and made PPE mandatory for staff before government directives were issued.
While no COVID-19-related deaths were recorded at the majority of Chartwell’s long-term care facilities according to provincial government figures, a number of them did have outbreaks -- defined as one or more positive cases. Data showed that five facilities also suffered a number of deaths, which Chartwell says were concentrated in older buildings.
"While some of our retirement residences have experienced COVID-19 outbreaks … the impact of such outbreaks in long-term care residences has been much more profound," Chartwell’s CEO, Vlad Volodarski, wrote in a message on its website in early June. Volodarski said older Chartwell residence buildings that had a large number of two- and four-bed rooms "made infection control much more challenging."
Yee Hong has single and double rooms, for example, while Altamont, one of the worst-hit homes in Ontario, and Pinecrest Nursing Home in Bobcaygeon, Ont., have a number of rooms across their single-floor buildings that were shared by four residents separated only by a curtain.
TRAINING AND COMMUNICATION
The long-term care operators say they’re not perfect and that they are learning as they go as well, mindful of the need to be even more prepared if and when a second wave strikes.
"COVID unfortunately raises a lot of challenges that long-term care homes have had already anyway," said Jones, adding that the industry should be sharing best practices with one another and that proper training is essential.
"Really, it's your staff that is your foundation. And if you don't have a good foundation, you're going to start to crumble once you see this crisis hit."
Shepherd Village tried to communicate regularly with staff, residents and family, to ensure everyone was on board, Beckles said. This helped everyone respond quickly, cooperatively, and as a team whenever directives were issued, because of the trust that had been established. Even housekeeping staff offered to help, asking to learn how to feed residents, she said.
From February onwards, those working at Shepherd Village were given extensive training and education on infection control, what to do outside the community, how to handle their own clothing and sanitization, for example, and encouraged to go straight home after work and reduce all social activities in the community.
It was a similar scene at Yee Hong, according to Jones. "I think that training and readiness really prepared us so that our staff felt a lot more confident."
"That's really what the impact has been in the other homes -- the other staff don't feel confident, they don't feel protected, there's no ongoing communication … Also, our leaders are on the floor, including myself."
This was especially evident at CHSLD Résidence Herron, in Quebec, where the home’s co-owner told the Montreal Gazette that over the course of three days at the end of March, staff began deserting the home, too “scared to come in.” Media reports said Herron staff complained there was not enough PPE and common areas like the dining room were kept open. One employee told CTV News Montreal that staff did not receive training on how to wear or remove PPE.
In contrast, discussions around self-quarantine, being mindful of their social activities and going out, and wearing masks started early on at Yee Hong, some of it initiated by staff themselves, who saw what their peers, family and friends in China were going through.
"So I did have that advantage that I wasn't trying to convince -- I was just making sure I was putting in the right measures in, in a timely fashion," said Jones, adding that staff were reassured that mask and shield protocols were implemented before the government required them. "It doesn’t mean they weren’t scared. But I think they just felt supported."
All this preparation and planning are a stark contrast to the Canadian Armed Forces report, which detailed serious concerns about PPE shortages, staffing shortages, inadequate training and communication, and severely deficient isolation measures. Military members say they witnessed residents "crying out for help" and ignored for as long as two hours at one home, and a "significant number" of seniors with pressure ulcers, with many residents having been bed bound for several weeks at another. One home reportedly had a "culture of fear" among staff with respect to using supplies due to costs. Several homes reportedly had key supplies locked away and inaccessible.
As a non-profit organization not beholden to shareholders, Jones wondered whether that also made a difference in how a home operated.
Beckles too recognized the costs of the preparation, and support from Shepherd Village’s board meant she was able to reallocate capital reserves well before emergency funding was provided by the government, in order to support and implement the measures and staffing they needed.
"Our evolving response to COVID started well in advance of Ontario declaring its emergency and then followed by Toronto. So it really was that early start," said Beckles.
"By March 11, when the World Health Organization declared the coronavirus an actual pandemic, we had already planned, prepared, and started the implementation of our pandemic plan."
Edited By CTVNews.ca Producer Adam Ward