Sick resident left behind in evacuation
Family call led to discovery that senior with COVID-19 was still in Hamilton seniors home
HAMILTON— A resident ill with COVID-19 was inadvertently left behind during the evacuation of the Rosslyn Retirement Residence and went without care for 18 hours.
“We’re extremely sorry this happened and we absolutely have learned from it,” said Winnie Doyle, executive vice-president of clinical operations at St. Joseph’s Healthcare, which was involved in the evacuation. “It was something that nobody would have ever wanted to have happen.”
Two seniors have now died in the outbreak that saw all but one resident at the 64-bed retirement home get COVID-19 in the span of less than a week. An 84year-old man who died in hospital May 18 brought Hamilton’s overall death toll to 28. A 70-year-old resident also died in hospital May 14.
Rob MacIsaac said “extensive meetings” were going on Tuesday to determine how the resident was missed when 52 others from the home on King Street East were taken to Hamilton General and St. Joseph’s Friday night. A debriefing is expected Thursday.
“It’s a shocking thing that it did happen,” said MacIsaac, who is CEO of Hamilton Health Sciences and represents hospitals on a regional committee overseeing aid for long-term care and retirement homes.
“But I also think the operator of the home certainly has a responsibility in all of this.”
Who was thought to be the last resident was removed from the home at 12:50 a.m. Saturday and staff from St. Joseph’s left by 1:30 a.m.
It wasn’t until concerned family called Doyle at 7 p.m. Saturday that it became clear a resident was still at the empty home. Doyle said she believes security and cleaning staff were on-site during that entire time but none of them knew there was a resident still there.
“The family, of course, all day had been trying to sort out what had happened,” said Doyle. “This was a very worrying time for them and it must have been difficult for the resident.”
Doyle described a chaotic situation at the home Friday that led to the resident being left behind. By the time the evacuation started at 4:45 p.m., there were no Rosslyn staff left at the home due in large part to 20 being infected with the virus themselves, including five who had been called in from temporary agencies.
The last two Rosslyn staff who had been working that morning had to leave when they got positive test results, said Doyle.
“There wasn’t a clear list of the number of patients who were in the home so that was a difficult circumstance with no staff there who were familiar with the patients,” said Doyle. In this sort of a crisis situation where you don’t have the usual people, who know who is who, it does introduce some risk.”
Adding to the confusion was a false report that this resident had been among nine transferred to hospital prior to the official evacuation.
“We’re all dealing with pandemic for the first time and this is the first time in Ontario where everybody has needed to be transferred because of the risk that was in the home,” said Doyle. “The patients were sick, some of the patients are unwell beyond being sick with COVID, the usual staff in the home to provide cleaning and food were not there. Our team had many, many things they were addressing at the same time.”
Doyle said a search of the home was done after the evacuation that included rooms, cupboards and bathrooms.
“A mistake was made,” said Doyle. “Somehow either the person wasn’t in their room or the person was in their room and it wasn’t searched.”
It’s not clear if the resident knew the home had been evacuated. Before the pandemic, the resident was able to look after themselves by and large. However, the resident was ill with COVID-19 while alone and was taken to St. Joseph’s around 7:30 p.m. Saturday.
“The resident was alert” when found, said Doyle.
Doyle said the home was known to be at risk as early as May 12, prompting a group that included St. Joseph’s, public health and LHIN Home and Community Care to help with staffing as well as infection prevention and control. Paramedics also did testing there.
“Things started to escalate rather quickly,” said Dr. Elizabeth Richardson, medical officer of health. “They are not really well set up to manage outbreaks and have PPE (personal protective equipment) supply in these facilities. They did not appear to be effectively monitoring the residents in terms of illness.”
Public health issued orders twice — once before the outbreak and once during — aimed at stopping the spread of COVID-19. But the number of confirmed cases still went from one resident on May 10 to 49 residents and 13 staff May 15.
By that time, eight St. Joseph’s staff were working at the Rosslyn. They are now self-isolating at home for at least seven days and require a negative COVID-19 test to return to work.
“All of those staff are volunteers and their courage and commitment to their work, I think they’re heroic,” said Doyle.
Ultimately, the decision to evacuate the Rosslyn Friday was made by the home’s operator at the urging of MacIsaac and others involved including St. Joseph’s and Paul Johnson, director of Hamilton’s Emergency Operations Centre.